Virginia Medicaids Search for

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Virginia Medicaids Search for
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True Loves Kiss
A Tale of Virginias Disease Management Chronic
Care Management Programs

• Cheryl Roberts, Deputy Director of Operations
• Department of Medical Assistance Services
• July 24, 2008

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Once Upon a Time.
in a Land Not Too Far, Far Away

• Nationally
• More than 75 of the 1.4 trillion spent on
  health care in the U.S. was on care for chronic
  diseases
• Chronic conditions account for 88 of all
  prescriptions filled, 72 of all physician
  visits, 76 of all inpatient stays
• Medicaid is 25 of a States budget
• In Medicaid, 30 of population expends 75
• Virginia Medicaid
• Spent nearly 825M on health care expenses
  related to Chronic Illness (CI) in FY05
• Estimated that those with CI will increase by
  more than 1 per year by 2030 locally nationally

• Commonwealth of Virginia

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There Lived a Princess

• Virginia is a mandatory enrollment, capitated
  full risk managed care program
• Total Virginia Medicaid and SCHIP MCO enrollment
  - 462,517 (61)
• Unmanaged care for fee-for-service population

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True Loves Kiss

• Disease Management
• Health Management Corporation (HMC) approached
  DMAS in 2004 proposed a pilot disease
  management (DM) program at no cost to Virginia
• Pilot was successful and in 2005, Virginia issued
  a RFP to expand its DM initiatives HMC awarded
  contract
• Expanded DM program was implemented on January
  13, 2006

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My First Princes Characteristics

• No-risk Program
• Quality Focused
• Voluntary Program (Opt-In Model)
• Condition Driven (CHF, CAD, asthma, diabetes,
  COPD)
• Telephonic Mailing Interventions
• 24/7 Nurse Line
• Evidence-based Treatment Guidelines

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Chipmunks,
Poison Apples,
Dragons ?
Oh My!
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Chipmunks

• The Good Things
• Provide technical assistance
• Share lessons learned best practices

• Facilitate beneficial partnerships
• Other State Medicaid agencies
• Center for Health Care Strategies
• Agency for Healthcare Research and Qualitys
  Learning Network

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Designing and Implementing Medicaid Disease and
Care Management Programs A Users Guide

• In 2005, AHRQ, with The Lewin Group as the lead
  contractor, began the Medicaid Care Management
  Learning Network.
• 17 States share their experiences, lessons
  learned, and best practices with operating
  disease and care management programs within FFS
  or PCCM

• Using the experiences of the first 13 Learning
  Network States, the Users Guide
• Provides States an overview of each step in
  developing a care management program, from
  planning to evaluating a program
• Highlights best practices and lessons learned
  from States within the Learning Network
• Offers an evidence base for implementing a care
  management program that improves quality of care
  for people with chronic conditions

The Guide is available online at
http//www.ahrq.gov/qual/medicaidmgmt/
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Poison
Apples
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Dragons

• Entities that want to control the design
  direction of your program
• May not have your best interests at heart

Beware!!
Beware!!
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How Do I Know He Loves Me??

• Subjective outcomes have merit (e.g.,
  self-reported outcomes, satisfaction scores)
• Difficult to isolate financial savings
• Proactive monitoring
• Accountability
• Ask a lot of questions
• Timely accurate reports

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He Has a Lot to Offer Me
Let me Count the Ways.

• Increase in members receiving flu vaccines
• 68 of members with diabetes perform blood
  glucose monitoring, up from 58 42 report A1C
  values of 7 or less, up from 32, and 80 report
  LDL values of 130 or less

• Prescriptions for beta blockers among members
  with congestive heart failure increased to 62,
  up from 58

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He Has a Lot to Offer Me
And More.

• Improvements in mental and physical functioning
  and a decrease in the average number of days of
  lost activity

• High participant satisfaction

- Source Preliminary Data from HMCs Draft 2006
Annual Report
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He is Wonderful, but could there possibly be
someone else.

• ?

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What is a Date?
(Finding a Bigger World)

• High risk high cost fee-for-service individuals
  still unmanaged
• Focus on cost savings
• Decided to pursue a Chronic Condition Care
  Management program

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My Second Princes Qualities

• Chronic Care Management (CCM)
• Two-tiered Case Mgt Approach
• Face-to-Face, Telephonic, Mailing
  Interventions
• Targets High Cost, High Risk Population

• Holistic Approach
• Vendor at Risk
• Voluntary Program (Opt-In)
• Predictive Modeling

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What We Have Seen and Done

• Tasks Completed
• Vendor Presentations
• Drafted RFP
• Submitted SPA to CMS

• To Do
• Release RFP
• Select Vendor
• Start-up Activities
• Implementation
• (Anticipated end 2008)

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Inner Conflicts
With Dating
Two Princes

• How to avoid duplicating enrollment?

• Does it make sense to have two vendors providing
  similar services to overlapping populations?

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Lessons
Learned

• DM CCM are needed services
• Accountability
• Objective subjective data serve a purpose
• Independent evaluations
• Alliances are key

There are advantages to dating two princes
simultaneously
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• It is

Possible
to Live
Happily Ever AfterWith the Best of Both Worlds
Forever and Ever
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But if You Want More
Information, Contact...

• Disease Management
• - Meredith.Lee_at_dmas.virginia.gov
• Chronic Care Management
• - Jeff.Beard_at_dmas.virginia.gov