Chronic care management options for vermont
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Chronic Care Management: Options for Vermont. Kenneth E. Thorpe, Ph.D. Robert W. Woodruff Professor and Chair Department of Health Policy and Management Rollins School of Public Health Emory University [email protected] Key Facts.

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Chronic Care Management: Options for Vermont

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Chronic care management options for vermont

Chronic Care Management: Options for Vermont

Kenneth E. Thorpe, Ph.D.

Robert W. Woodruff Professor and Chair

Department of Health Policy and Management

Rollins School of Public Health

Emory University

[email protected]

November 14-15, 2005 Montpelier, VT


Key facts

Key Facts

  • Cost of treating chronically ill patients accounts for 75% of health spending in Vermont (over $3 Billion per year)

  • Rise in chronic illnesses and obesity key factors in driving growth in spending

  • Chronically ill patients receive about 50% of the clinically recommended care

  • The IOM and others have highlighted the need to dramatically restructure how we deliver services

    • Patient focused/central

    • “integrated” multi-disciplinary approach

    • Proactive not reactive model

November 14-15, 2005 Montpelier, VT


Chronic care model ccm

Chronic Care Model (CCM):

  • Does It Work?

    • Yes. Interventions that contain 1 or more elements of the chronic care model improve clinical outcomes and processes and to lesser extent quality of life according to RAND findings.

  • Implementation Challenges Facing The State: Can Vermont Build the CCM?

    • Change how Medicaid pays for care—key challenge for existing Blueprint.

November 14-15, 2005 Montpelier, VT


Disease states commonly targeted by dm industry

Disease States Commonly Targeted by DM Industry

  • CHF, Cardiovascular disease

  • Asthma

  • Chronic Obstructive Pulmonary Disease (COPD)

  • Diabetes

  • Cancer

  • Maternal/Neonatal

  • Rare Diseases

  • ESRD

November 14-15, 2005 Montpelier, VT


Components of dm products

Components of DM Products

November 14-15, 2005 Montpelier, VT


Full integration population based and chronic care case based model

Full Integration: Population Based and Chronic Care Case Based Model

HEALTH IMPROVEMENT

DISEASE MANAGEMENT

Lifestyle interventions

Low risk

At risk

Early Signs

Symptoms

Disease

Disease

Management

Preventive Services

Case Management

Screening

Acute

treatment

Disease

Management

Primary and Secondary

Prevention

HEALTH MANAGEMENT

POPULATION-BASED

CASE-BASED

November 14-15, 2005 Montpelier, VT


Disease management targets for vermont

Disease Management Targets for Vermont

  • Medicaid, could be effective approach for managing global commitment

  • State employees

  • Dual eligible (Medicaid/Medicare)

  • Commercial market

November 14-15, 2005 Montpelier, VT


Managed care organizations mcos play key role in medicaid dm nationally

Managed Care Organizations (MCOs) Play Key Role In Medicaid DM Nationally

  • Some MCOs manage directly, others outsource and pay vendors on performance (e.g. % reduction in hemoglobin A/C levels among diabetics, % reduction in hospital days among asthmatics)

  • Disease states typically targeted in Medicaid

    • depression- anxiety disorders

    • psychosis - diabetes

    • hypertension - asthma

    • CHF, CVD

November 14-15, 2005 Montpelier, VT


Chronic care management options for vermont

Other states are implementing disease management programs to provide beneficiaries with higher quality care at a lower cost

  • Florida – runs in AIDS, Congestive Heart Failure (CHF), End Stage Renal Disease (ESRD), diabetes, hemophilia and asthma. Five of these programs reported successful results

  • Washington state runs programs in ESRD, diabetes, asthma and CHF and has also published favorable results.

  • Montana started recently with five common chronic diseases and a highly popular nurse call in line to help beneficiaries coordinate care.

  • Indiana is building its own program rather than outsourcing to disease management vendors.

  • Wyoming, Texas, New Hampshire, Georgia, Tennessee, and South Carolina are in various stages of RFPs with disease management vendors and will likely begin operations soon.

November 14-15, 2005 Montpelier, VT


Selected examples of dm in medicaid ffs

Selected Examples of DM in Medicaid FFS

November 14-15, 2005 Montpelier, VT


Dm contracting examples

DM Contracting Examples

  • Washington - full risk

    • 80% payment at risk based on projected savings

    • 20% payment at risk based on performance/quality

    • Has been effective in Washington

  • Financial and clinical goals need to be clear

  • Need methodology for program evaluation

November 14-15, 2005 Montpelier, VT


Based on other states experience and vendor guarantees significant savings can be achieved e g

Based on other states’ experience and vendor guarantees, significant savings can be achieved, e.g.,

  • Disabled and Blind – 4%

  • Aged – Community & Custodial Care

    • Acute Care Medical – 25%

    • Drugs – 10%

    • Aged in Skilled Nursing – 20%

    • TANF – Neonates – 6%

    • ESRD – 8%

      Contracts typically include performance guarantees. States typically pay base administrative fees to DSM vendors. At the end of the reporting period (Usually a Fiscal year), savings are measured. If the net savings “guarantee” is not met, the vendor will reimburse the state up to 100% of their administrative fees.

      SOURCE: COMPUTER SCIENCES CORPORATION

November 14-15, 2005 Montpelier, VT


Vermont can expect challenges to implementing these programs

Vermont can expect challenges to implementing these programs

  • Need continuous enrollment (at least 12 monthly enrollment by Medicaid / SCHIP) populations

  • Need to define business model:

    • Per member, per month adjusted for risk (i.e. Medicare Advantage Methods).

    • Contracts with physician groups based in cost savings / quality / clinical measures

November 14-15, 2005 Montpelier, VT


Inside the black box key implementation issues

Inside the “Black Box”: Key Implementation Issues

  • How to identify candidates

    • Registry

    • Claims data

    • Physician referral

  • How to enroll beneficiaries

    • “opt-in” (low enrollment ≈ 30%)

    • “engagement or opt-out model” (are enrolled unless they decline – up to 95% participation)

November 14-15, 2005 Montpelier, VT


Inside the black box key implementation issues1

Inside the “Black Box”: Key Implementation Issues

  • How to pay for DM – Perhaps the Key Issue

    • Full insurance risk (PMPM risk adjusted payment using Medicare Advantage Model)

    • P4P – Performance Risk

      • Define evidence based guidelines

November 14-15, 2005 Montpelier, VT


Inside the black box key implementation issues2

Inside the “Black Box”: Key Implementation Issues

  • P4P (continued)

    • Bonus pool distribution at practical network level based on

      • HEDIS measures(50% weight)

      • Patient satisfaction(30% weight)

      • IT investment(20% weight)

November 14-15, 2005 Montpelier, VT


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