ILLINOIS DISEASE MANAGEMENT ILLINOIS DISEASE MANAGEMENT MEDICAL HOME INITIATIVEMEDICAL HOME INITIATIVE

State Coverage Initiatives Summer State Coverage Initiatives Summer Workshop for State OfficialsWorkshop for State Officials

San Francisco, California

July 30 – August 1, 2008Stephen E. Saunders, M.D., M.P.H

Medicaid Medical Advisor

Illinois BackgroundIllinois Background

2.3 Million beneficiaries in HFS programs

Primarily fee-for-service

Voluntary managed care in Cook and seven other rural counties (170,000 members)

Program Program GoalsGoals

• Goal– Improve health outcomes & reduce avoidable

costs

• Program Design Concepts– Reduce inappropriate and unnecessary

utilization, especially ED use– Reduce avoidable medical admissions through

better community-based care– Establish a medical home to minimize

fragmented care and improve continuity of care

Program Goals (2)Program Goals (2)

– Improve coordination of care– Increase member compliance with

treatment plan and improve self-management skills

– Improve adherence to national, evidence-based clinical practice guidelines

– Use data and IT tools to better monitor, report and improve clinical outcomes

OverviewOverview

Primary Care Case Management PCCM Administrator responsible for provider

recruitment, client enrollment, quality and EPSDT compliance.

Program designed to ensure Medical Home 1.7 million beneficiaries eligible

Disease Management population is a subset 220 beneficiaries eligible Targets disabled adults and children with

asthma

Program StatusProgram Status

PCCM Network development began in Fall 2006

Started member enrollment for Cook County in February 2007

Current status Statewide enrollment complete 1.6 million members enrolled 5,300 medical homes (physicians and

clinics) with over 5 million member capacity

DM program administrator started July, 2006.

Disease ManagementDisease Management

Eligibility

Disabled Adults: All eligible irrespective of disease or condition – 122,000

Persistent Asthma: Children and adults who have persistent asthma (utilizing the HEDIS definition) - 75,000

Frequent ER Users: Children and adults who are frequent emergency room users (defined as 6 or more visits a year) - 32,000

Participation in Your Healthcare PlusTM is voluntary, and statewide. Individuals can “opt out.”

Disease State of Eligible Disease State of Eligible MembersMembers

Other Conditions29.2%

Asthma6.1%

Back Pain1.2%

Bipolar7.1%

Cancer2.1%

Chronic Fatigue Syndrome0.1%

Chronic Kidney Disease0.6%

Chronic Obstructive Pulmonary Disease

5.8%Coronary Artery Disease3.3%

Depression1.4%

Developmental Delay NOS2.3%

Diabetes4.3%

Dyslipidemia3.8%

End Stage Renal Disease1.6%

Fibromyalgia0.1%

HIV-AIDS3.1%

Headache0.6%

Heart Failure7.1%

Hemophilia0.0%

Hypertension3.8%

Osteoarthritis0.9%

Other / Substance Abuse0.7%

Other Psychoses0.5%

Schizophrenia13.8%

Transplants0.5%

Traumatic Brain Injury0.0%

• Disease state shown by primary diagnosis:– Over 26% of members

have a primary diagnosis within the core five conditions (Asthma, Diabetes, COPD, CAD, CHF)

– Over 22% of members have a primary diagnosis of a behavioral health condition

– A significant portion of members suffer from multiple co-morbidities

DM Patient Activation DM Patient Activation StrategyStrategy

Community based teams of professional and lay educators – 170 local staff

Teams are comprised of individuals who are indigenous to these communities, culturally diverse

Staff is also placed in high volume sites (hospitals and clinics)

Other special projects to augment this effort

DM Program ModelDM Program Model Community Staff

Nurse

Lay community educators

Social workers

Behavioral health workers

Hospital based case managers

Clinic based staff

Special Projects

LTC initiatives

Pharmacy

Behavioral health

Services to HFS ClientsServices to HFS Clients

• Health Risk Assessment - to determine disease severity and knowledge of self-management and care practices

• Care Plan - to identify problems, goals and interventions specific to each client

• Ongoing Case Management - dependent on risk level with highest risk receiving monthly nurse case manager assistance

• Health Education - relative to medical conditions

• Level of Services – dependent on Risk stratification

PCP Support for Disease PCP Support for Disease Management MembersManagement Members

Support providers care plan by facilitating patient compliance.

Nurses to provide education to patients with chronic conditions to help them better understand their disease, follow care plan and medication requirements.

Nurses to provide intensive care management to most complex patients.

Support provider in post ER and hospitalization follow-up.

Notify provider of any urgent medical problem or medication management/compliance issues.

Physicians receive support in identifying patients with unusual drug utilization patterns

PCCM Program PCCM Program Provider ReimbursementProvider Reimbursement

PCPs are paid a PMPM month for every person whose care they are responsible to manage: $2.00 per child $3.00 per parent $4.00 per disabled or elderly enrollee

The monthly care management fee is paid even if the enrollee does not get services that month. PCPs will continue to receive their regular

fee for service reimbursement for services from HFS.

PCP RequirementsPCP Requirements

Maintain hospital admitting and/or delivery privileges or have arrangements for admission

Make medically necessary referrals to HFS enrolled providers, including specialists, as needed

Provide direct access to enrollees through an answering service/paging mechanism or other approved arrangement for coverage 24 hours a day, 7 days a week. Automatic referral to an emergency room does not qualify

Maintain office hours of at least 24 hours/week (solo practices) or 32 hours/week (group practices)

Follow recognized preventive care guidelines Manage chronic disease Appointment scheduling guidelines.

PCP SUPPORTPCP SUPPORT• PCP access to secure web portal which contains

PCP support materials

• Patient roster

• Mailed monthly but also available electronically

• Provides information on needed preventive services

• Well child visits

• Pap smears

• Mammograms

• Electronic version sortable

Provider PortalProvider Portal

Provider RosterProvider Roster

PCP SupportPCP Support Provider profiles

20 HEDIS and HEDIS-like metrics

System and provider specific performance

Listing of members with chronic diseases and their level of metric compliance.

Historical claims

2 years Medicaid claims

Pharmacy

Immunizations (7 years of data)

Office visits

Hospitalization

Diagnosis

Procedures

Provider ProfileProvider Profile

Provider ProfileProvider Profile

Claims HistoryClaims History Prescription Summary

Prescription Date Prescription Quantity Prescription Description

Immunization Summary Immunization Date Immunization Code Immunization Description

Claim Summary Service Date Claim Date Provider Name Diagnosis Code Procedure Code Claim Type

Claims HistoryClaims History

PCP SupportPCP Support

Pay for Performance

Bonus payment for meeting National 50th HEDIS percentile.

Measures

Immunizations

Developmental Screening

Asthma Management

Diabetes Management (HbAIC)

Mammograms

EPSDT (Well Child)

PCP Support - (continued)PCP Support - (continued) Provider Services Representatives

11 Provider Services Reps in field

Provider Services Help desk – 1-877-912-1999

Outreach and Education to support Providers and their staff

Site Visits

Training Sessions

Billing

EPSDT Support

Quality Assurance

Monthly Webinars

Specialty Resource Database

Provider Newsletter and web site

Provider Continuing Provider Continuing EducationEducation

Education program provided by AAP and AFP under subcontract.

Continuing Medical Education programs on evidence-based evaluation and management of common chronic conditions.

Chronic Care Model

Asthma

Depression

Diabetes

COPD

Substance Abuse

Topics also include preventive health

Immunizations

Developmental Assessment

Medical Home

In-Office training for physician and staff in addition to traditional CME.

Measures of DM Program Measures of DM Program SuccessSuccess

Patient and provider satisfaction (survey)

Reductions in avoidable hospitalization, ED visits

Calculated cost avoidance relative to preprogram cost trends

Improvements in state defined clinical indicators

Heart Failure: Percent of pts on ACE/ARB medication

Diabetes: Retinal exam, HgbA1c testing rates

CAD: Cholesterol testing rates, Statins,

ACE/ARB

Asthma: Use of controller medications

COPD: Use of spirometry for dx, corticosteroids

post exacerbation

PCCM Quality MeasuresPCCM Quality Measures Childhood immunizations

Lead testing

Developmental screening

Appropriate medications asthma, diabetes

care (HbA1c)

Well baby/well child visits

Cervical cancer screening

Breast cancer screening

PCCM Quality Measures PCCM Quality Measures (Continued)(Continued)

Adolescent well care Prenatal care frequency/timeliness Post partum care Depression treatment Adult access to preventive care ER visits/1000 Ambulatory care sensitive hospital visits

Lessons LearnedLessons Learned

• Difficult to find high risk members – especially Chicago

• Mental Health is a significant problem both as a primary diagnosis and as co-morbidity

• Behavioral health component requires specialized focus and outreach

• Importance of interagency coordination, especially behavioral health

• Importance of physician buy in and need for provider input

Lessons Learned (2)Lessons Learned (2)

• Delayed launch of PCCM program made launching DM program more difficult

• Need ability to analyze claims data rapidly

• LTC community very different and more difficult to engage

• Interventions, program components staggered during program launch – some components take longer than anticipated

• Avoid promising significant savings in year one

RESULTS: Year 1RESULTS: Year 1

• $34 million net savings• Reduction in hospitalization costs (9%)• Provider and patient satisfaction

• 94% members satisfied or very satisfied• 65% providers report program useful and 70% would recommend

their patients participate• Modest improvement in clinical metrics• Disease specific hospital admission rate decreases

• CAD - 20%• CHF - 19%• Asthma - 19%