Texas Health and Human Services Commission

Texas Health and Human Services Commission

Medicaid Disease Management Program OverviewMedicaid Disease Management Program Overview

Texas Association of Community Health Centers Annual MeetingTexas Association of Community Health Centers Annual MeetingOctober 26, 2004October 26, 2004

Maureen Mangotich MD, MPHMaureen Mangotich MD, MPHMedical Director, Provider and Community OutreachMedical Director, Provider and Community Outreach

McKesson Health SolutionsMcKesson Health Solutions

Agenda

Medicaid DM Program History

DM Program Overview

Opportunities for Collaboration with

Community Health Centers

Legislative Mandate

The Texas 78th Legislative Session (2003)

mandated State agencies to focus on the

healthcare needs of the underserved and

needy

The legislation mandates measurable

financial and clinical results, and

proactively reduced budgets

State RFP for Medicaid FFS DM Program

Program GoalsProgram Goals Improve health statusImprove health status

Increase adherence to national evidence based guidelines

Reduce overall medical costs Reduce overall medical costs Savings expectations – a minimum of 5%

of total expenditures for the eligible population served

Why Disease Management?

Clinic visitClinic visit NextNextClinic visitClinic visit

Treatment PlanTreatment Plan1-12 months

Late Rx Refill

Acute Sx – ER visit Avoidable

IP admit

State RFP for Medicaid FFS DM Program

Program Objectives Program Objectives Improve continuity of care Improve continuity of care Increase access to preventive care Increase access to preventive care Enhance clients’ relationship with their primary Enhance clients’ relationship with their primary

caregiver and other providerscaregiver and other providers Improve coordination and collaboration among Improve coordination and collaboration among

healthcare providers and other community healthcare providers and other community resourcesresources

Reduce unnecessary hospital admits, total Reduce unnecessary hospital admits, total hospital days, ER visitshospital days, ER visits

DM Vendor Selection

Multiple bidders summer ’03 for 1/04 awardMultiple bidders summer ’03 for 1/04 award Initial plan to award South and North separatelyInitial plan to award South and North separately

2 Finalists 7/1/04 McKesson chosen for entire state7/1/04 McKesson chosen for entire state

Major reasons:- Guaranteed savings

- Risk contract – 100% of fees

- 60 day implementation

McKesson Health Solutions Profile

Six care centers Six care centers 4 in Mainland USA, 1 in Puerto Rico, 1 in Westlake TX Employ ~ 400 nurses in N. America

Nurse Advice Line (Triage Services)Nurse Advice Line (Triage Services) ~ 25MM covered lives in Triage

Disease Management ProgramsDisease Management Programs Asthma, COPD, Diabetes, CAD, Heart Failure 80 DM clients (MCO, Medicaid, Employers, Pharma 8 Medicaid Contracts: Colorado, Florida, Mississippi, Montana,

New Hampshire New Jersey, Oregon, Puerto Rico, Washington Accredited by JCAHO, NCQA, URAC

Heart Failure ProgramHeart Failure ProgramHeart Failure ProgramHeart Failure Program

McKesson DM Program Results

Diabetes ProgramDiabetes Program Diabetes ProgramDiabetes Program

Asthma ProgramAsthma ProgramAsthma ProgramAsthma Program

•89% increase in ACE-inhibitor prescriptions

•24% increase in annual flu vaccinations

•114% increase in pts weighing themselves daily

•155% increase in pts keeping a weight record

•44% increase in pts following a low-salt diet

•33% increase in pts who do SMBG monitoring

•70% increase in aspirin use

•22% reporting lower blood glucose levels

•20% show improved functional status

•91% increase in patients with action plans

•85% in asthmatics who own peak flow meters

•34% increase in asthmatics using spacers

Economic Impact

Behavior changes lead to improvements in Behavior changes lead to improvements in compliance, functional status, symptom controlcompliance, functional status, symptom control, , andand reduced service utilizationreduced service utilization

Claims-based studies show:Claims-based studies show: Range:Range:

• Reduction in inpatient hospitalizationsReduction in inpatient hospitalizations• Reduction in ED visitsReduction in ED visits• Gross savings per person per annumGross savings per person per annum• Return on investmentReturn on investment (Dollars saved for every dollar spent)(Dollars saved for every dollar spent)

15% – 53%15% – 53%

5% – 31%5% – 31%

$279 – $2,560$279 – $2,560

$1.55 – >$3.00$1.55 – >$3.00

The Texas Medicaid Enhanced Care Program

Disease Management Disease Management

Care CoordinationCare Coordination

24/7 Triage Services24/7 Triage Services

Who is eligible to participate?

Eligible Fee-For-Service Medicaid clients with asthma, diabetes, heart failure, CAD and COPD

Opt Out Program Clients are automatically enrolled

unless they choose not to participate

Identification of Program Enrollees

State DataState Data

ClaimsClaimsEligibilityEligibility ProvidersProviders

Client- Client- Provider Provider

LinksLinksTarget Target ClientsClients

Medical Home

DM Services Support Pts Between Office Visits

24 x 7 24 x 7 nurse nurse triage triage

serviceservice

Proactive Proactive Outbound Outbound

Nurse CallsNurse Calls

Community Community Support Support

Services Services

Promotora Promotora outreach/ outreach/

enrollment enrollment contactscontacts

Face to face Face to face nurse nurse

contactscontacts

Provider Provider mailing with mailing with patient list patient list

Care Care coordination coordination

services services

Pt mailings: Pt mailings: educational educational materials, materials, reports, reports,

remindersreminders

Audiohealth Audiohealth

Library Library (English (English

and and Spanish)Spanish)

Coordinate

Triage &Navigate

R.N.M.D.Patient

MD Reports: MD Reports: Clinical Clinical alerts, pt alerts, pt updates updates

Primary Care 60% of visits are for information and reassurance rather than treatment (7) Our triage service directs 40% to home/self care

ER Care 53% of visits are not urgent; (3)

Our triage service directs more than 86% away from ER and Urgent Care facilities

Select High Cost Surgical Procedures/Bed DaysSignificant variation of surgical treatments for common diseases (8)

Chronic IllnessChronic illnesses drive 60% of the nations medical care costs (1) 1 out of 3 callers have a chronic /catastrophic or mental health condition – 75% elect to enroll (2)

Sources (1) The Robert Wood Johnson Foundation, Annual Report, 2000 (2) Internal McK Research, 2001 and 360 pilot results, March, 2002

(3) National emergency care utilization report -NCHS, 2001 (4) Harris Interactive and Harvard School of Public Health Research Study, 2000(5) Cyber Dialogue and Deloitte & Touche, Strategy and E-Health, 2001 (6) Health Affairs Article, 2001 and Agency for Healthcare Research and Quality

(7) Modern HealthCare, June, 2000; source: Agency for Healthcare Research and Quality(8) The Dartmouth Atlas, 2000

Evidence supporting nurse triage

Avoidable Admissions1 out of every 9 admissions is avoidable with improved access to care (6)

Member ParticipationIn Medical Decisions90% of consumers want greater participation in decision making. (4) 50 mm online health users (5)

A recent ground breaking RCT just competed by the Geffen School of Medicine at UCLA compared McKesson nurse triage of symptoms to a panel of Board Certified Pediatric

Emergency Medicine Specialists from a major Academic Institution … the result no significant differences in care recommendations

Randomized control studyN = 3,193 medical advice pediatric callsStudy period was 11 monthsReferred to 3 categories ED/Urgent Care, Office Care, Self CareCallers were randomly routed to either a physician or nurse. The caller was then triaged and the result were recorded. There was no significant difference in where the physician recommended the caller seek care vs where the nurse recommended the caller seek care

0

10

20

30

40

50

60

70

80

ED/Urgent Care Office Care Self Care

Physician

Nurse

11.4% 10.7%

19.0% 18.7%

69.6% 70.6%

Proof that our triage clinical content and nurse quality management processes are working….

Tiered Interventions based on risk

Proprietary Risk StratificationProprietary Risk Stratification

STABLE STABLE (Level 1)(Level 1)

Audio health Library

Educational Mailings

24x7 nurse line

Provider AlertsProvider Alerts

AT RISK(Level 2)

Proactive callsProactive calls Level 2 services

Case mgmt referralsCase mgmt referrals

HIGH RISK(Level 3)

In-person visitsIn-person visits

Home Monitoring Home Monitoring DevicesDevices

Level 1 services Level 1 services

DM Program Launch – November 2004

Physician Communications

Patient Patient CommunicationsCommunications

DM Program IntroDM Program IntroPt List, Guideline Pt List, Guideline info. Program info. Program brochurebrochure

DM Welcome letterDM Welcome letterToll free numberToll free numberBusiness reply cardBusiness reply cardCalling card Calling card incentiveincentive

Enrollment ContactsEnrollment Contacts

Physician CommunicationsIntroductory Mailing

Cover letter with list Cover letter with list of physician’s of physician’s patients eligible for patients eligible for enrollment enrollment

Program InformationProgram Information Clinical guidelines Clinical guidelines Stepped Inserts:Stepped Inserts:

Program benefits to pts, provider

FAQs

Introductory Materials Provided to All clients Eligible to Participate

Personalized letterPersonalized letter 44thth grade reading level grade reading level Magnet with Toll Free Magnet with Toll Free

numbernumber Easy to read educational Easy to read educational

pamphletpamphlet Mail or hand deliveredMail or hand delivered

Personalized Patient Education

Assess: Maslow's hierarchy of needs, Prochaska/ readiness to change, clinical, functional, utilization, knowledge level, risk metrics and QOL

Teach: Condition knowledge, self-management skills, medication compliance, prevention, proactive management

Reinforce improvement: Action plans, monitoring, 24/7 nurse advice line, health counseling and fulfillment

Modify Goals: Re-assessment 6 and 12 months, re-

education, monitoring, etc.

Personalized Support: Action Plans Developed for All Program Enrollees

Prevention

Education

Screening and testing

Medication reminders

Warning signs and symptoms

Provider partnering

Personalized Support: Special Needs Coordination and Physician Alerts

Compliance and adherence

Three Severity Levels

Level 3 alerts faxed to office/clinic after nurse call

Access concerns

Utilization issues

Financial issues

How do Providers Benefit?

Improvement in patient self-mgmt skills:Improvement in patient self-mgmt skills: Better adherence to medical regimen Earlier recognition of decompensation and

PCP contact for urgent evaluation Improved continuity of care Improved continuity of care

Reduced “no-shows” for office appts Fewer after-hours calls Fewer calls to nurse staff during office hours

Program Launch (first 90 days)Program Launch (first 90 days) Orient CHC staffOrient CHC staff to new programto new programReview lists of identified DM enrollees Review lists of identified DM enrollees

Validate identified cases and provider linkages Recommend appropriate level of DM

services/support Identify CHC clients not currently on DM program

rolls who might be eligibleRecommend CHC Representative to serve on Recommend CHC Representative to serve on

Statewide Provider Advisory BoardStatewide Provider Advisory Board

Opportunities for Collaboration with Texas Community Health Centers

Opportunities for Collaboration with Texas Community Health Centers

Post Launch PeriodPost Launch Period Coordinate resources to optimize Coordinate resources to optimize

appropriate access to primary care appropriate access to primary care servicesservices Promote 24x7 telephone triage service to

reduce office/ER visits for c/o appropriate for self-care

Expedited appt access for DM managed clients with urgent clinical issues

Opportunities for Collaboration with Texas Community Health Centers

Longer Term GoalsLonger Term GoalsDemonstrate value of collaborative careDemonstrate value of collaborative care

Number of similarities between DM program and CHCs in mission, approach, services offered

Share tool kitsShare tool kitsEducate clinicians in population Educate clinicians in population

management tools, techniquesmanagement tools, techniques

Program Contact Information

In-State Program Manager

Barbara Ramsey – (866) 645-0312

HHSC Senior Policy Analyst

Geri Willems– (512) 491-1460