The Disease Management Care Blog Gets Quoted

.....but that's not the only reason to read this article in the Texas Tribune by Emily Ramshaw. This is well written as well as interesting and is a good example of the difficulty in evaluating the economic outcomes associated with disease management. In this instance, it deals with the McKesson contract with Texas Medicaid.

So which is it? DM is a waste of money? It's too difficult to measure savings in an insured population? We need different metrics? We need a single industry standard? This year's DM is different than last years' and comparisons are unfair? It's not savings, but value? Read this and decide for yourself......

Care Management Can Help As Medicaid Enrollment Increases Nationwide

The Disease Management Care Blog got this submission from one of its colleagues who helps coordinate McKesson's ubiquitous disease management programs. As noted in prior DMCB posts, the value of these kinds of population-based initiatives is not being questioned by commercial insurers or in State sponsored managed care or Medicaid fee-for-service settings. Jim presents a convincing argument about why the taxpayers and their elected representatives cannot afford to not have disease management programs as part of the solution to increasing enrollment, escalating costs and serious concerns about quality.

By Jim Hardy

One percent doesn’t seem like a lot.

But every time the U.S. unemployment rate increases by 1%, about 1 million more Americans join state Medicaid programs, our country’s health insurance program for children and adults in low-income families, the elderly and people with disabilities.

This is always a cause for concern, but is potentially catastrophic in today’s economy.

As more people become eligible for Medicaid, the revenue to fund a state’s share of Medicaid and other services shrinks by 3%-4%, according to the Kaiser Commission on Medicaid and the Uninsured. Even so, in fiscal 2007 Medicaid accounted for a whopping 21% of all state expenditures, tying for first place with elementary/secondary education as the largest portion of state spending, according to the National Association of State Budget Officers.

In Colorado, for example, the Department of Health Care Policy and Financing reports that its overall Medicaid caseload increased 13% since January 2008. In February 2009, the caseload increased by more than 3,900 bringing the total number of cases to 440,274.

Because Medicaid programs are funded by tax dollars, states now face significant challenges as revenues plummet because of rising unemployment. A recent Rockefeller Institute of Government report shows that during the end of 2008, tax revenues declined 3.6% nationwide.

States aren’t about to cut Medicaid completely. But with the country’s economy in bad shape, what can we do?

Tough Choices Next?

As the Deputy Secretary for Medical Assistance Programs at the Pennsylvania Department of Public Welfare, I faced similar dilemmas. There’s no single answer, and the decisions aren’t easy to make.

To control Medicaid costs, we could:

· Toughen eligibility standards allowing fewer people to enroll;
· Eliminate certain healthcare services;
· Shift more costs to hospitals; and/or
· Reduce reimbursement rates for providers who already face significant economic challenges to maintaining their practices.

These are options of last resort, but options nonetheless.

But we have another way to trim costs, and improve health and wellness at the same time: care management programs for the chronically ill. While this may sound like another entitlement program and a way to drain nearly empty state coffers, it’s neither.

Medicaid care management programs are proven and have generated one year savings for the states of Illinois and Pennsylvania of $34 million and $35.9 million, respectively.

Care Management, the Chronically Ill and Medicaid

The National Association of State Medicaid Directors says that Medicaid beneficiaries with one or more chronic conditions, such as asthma, diabetes or heart failure, account for 80% of Medicaid spending even though they make up only 40% of the non-institutionalized Medicaid population.

Helping these beneficiaries get a primary care provider and learn new ways to better self-manage chronic illnesses – everything from ensuring prescriptions are filled and medications taken as prescribed to learning what to do when a condition gets worse – is the foundation of care management.

Care management programs support providers through consistent engagement and partnership. This close integration gets results by reducing the unnecessary use of some healthcare services through a whole-person approach to managing chronic illnesses and co-morbid behavioral health conditions.

But this is just one piece of the puzzle.

It’s difficult if not impossible to concentrate on improving health, if you don’t have a way to get to a doctor’s appointment, a roof over your head or not enough food. If beneficiaries don’t have transportation to a doctor’s appointment, food or shelter, these programs can guide them to helpful services.

Care Management Programs Decrease Medicaid Costs

When Medicaid beneficiaries get help managing asthma, for example, and work with a primary care provider, the disease is better controlled and unnecessary visits to the emergency department (ED) – where costs are much greater and the care episodic – can be reduced significantly. The same can be said for other debilitating chronic diseases. Improved health and wellness is an added benefit. Better controlled diseases can lead to more activity, getting back to work and simply feeling better.

Even so, depending on whom you ask and which report you read, care management programs may not work as well as I’ve described.

Nevertheless, it’s been my experience that a focused program – one that targets high-cost, high-risk beneficiaries with a face-to-face intervention and ensures that each participant has his or her own primary care provider and makes allowances for transitions to different levels of care – does work.

For people with asthma it’s possible to decrease annual ED visits and in-patient admissions by 11% and 29%, respectively. For those with coronary artery disease, ED visits and in-patient admissions can be cut by 2% and 4%, respectively.
A few percentage points may not seem like a lot, but applied to groups with significant costs it’s easy to see how Illinois, Pennsylvania and other states have saved millions of dollars by reducing the use of expensive and unneeded services through better Medicaid beneficiary self-management.

I’m not suggesting that this is a panacea for the economic and healthcare challenges the nation faces today; however a comprehensive Medicaid care management program is part of the solution. Now more than ever states need to explore every option, especially those that ensure the most vulnerable among us continue to get the help that they need.

About the author: Jim Hardy is Senior Vice President and General Manager at McKesson Health Solutions in Broomfield, Colo., and is the former Deputy Secretary for Medical Assistance Programs at the Pennsylvania Department of Public Welfare.

Some Insights, Courtesy of McKesson's Disease Management Programs

The Disease Management Care Blog had a chance to chat with McKesson’s Senior Vice President and General Manager Jim Hardy. The DMCB welcomed the opportunity to talk disease management (DM) with Jim, who oversees his company’s care programs, many of which are serving State Medicaid programs. Prior to joining McKesson, Jim served as Deputy Secretary for Medical Assistance Programs in Pennsylvania’s Department of Public Welfare. He knows of what he speaks.

The DMCB asked Jim about the outlook for traditional old fashioned nurse based, ‘telephonic’ disease management. He replied that while the industry is morphing, their programs will always include a ‘telephonic base.’ Since States typically have tens of thousands of beneficiaries that are eligible for care management, there is no escaping the industrial level efficiency supported by a ‘remote’ telephonic outreach. McKesson is working to make its telephonic care programs better while simultaneously pairing them up with additional community-based, provider-‘embedded nurses’ who in turn become part of the local health care teams (or, if teaming is absent, catalyze its creation). In fact, Jim suspects more and more RFPs are headed in that direction.

DMCB comment: it’s one thing for advocates of the Patient Centered Medical Home to talk teaming, it’s another thing to have a nurse parachute in and make it happen.

The DMCB next asked what explains the disconnect between skeptical public policy and the persistence of State DM programs? Are buyers smarter? Using different metrics? Jim thought that because the States have been doing this for a long time, their measurement methodologies have become more established and that there is often a high degree of mutual accountability. Jim felt Medicaid purchasers are smarter, savvier, more experienced and know how to navigate DM’s clinical and financial outcomes. What’s more, States also are very willing to share insights with each other via learning collaboratives, various formal meetings and other informal communication channels.

DMCB comment: It remains to be seen whether the architects of national health care reform will tap into this knowledge base.

The DMCB also asked about impact of ARRA and the Medicaid supplemental funding on States’ DM programs. Jim replied that since States are having significant budget crises, it’s unlikely that more money will be pumped into new chronic illness, wellness and prevention programs. Rather, the funding will be used to plug budget holes in existing programs. Any money left over may spur investment in programs aimed at controlling the trend in high cost subpopulations. An example may be waiver groups.

The DMCB thinks this is interesting. If the Administration’s economic forecasts turn out to be too rosy, future interest DM programs may be spurred by the pressing need to address uncontrolled costs rather than notions of quality or value.

Finally, the DMCB has about the role ‘risk-based' DM contracting. Jim pointed out that every deal currently has fees that are at risk for both financial and clinical outcomes. This is not going away, but it has stabilized with few contracts having upside gain sharing but most having a floor. In McKesson’s instance, there is enough at risk in most programs that ‘they have our attention.’

DMCB Comment: The DMCB can attest to the motivation and discipline that comes with risk contracting. It wonders when the same approach will be applied to pay-for-performance, the electronic health record and the patient centered medical home.

++++++++++++

Are you and you company interested in talking to the DMCB? If the topic has to do with population-based care programs, the DMCB is always happy to chat. It and its readers will be better off for it.

The DMCB admits any interview will probably have to be done the old fashioned way. While the DMCB notes with some lust that other blogs are into 'pod casting,' the DMCB has yet to crack that technology barrier. The DMCB spouse suggests it use the blog's Google ad income to pay for any necessary computer upgrades. As that conversation continues, the DMCB will keep readers apprised.

Disease Management and the Medical Home Podcast

The Disease Management Care Blog is in a podcast? That DMCB first is thanks to the DMAA posting the audio from a November 25 keynote panel held at the Hollywood Florida Forum 08 Meeting. The topic was a DMCB favorite: the patient centered medical home and disease management. Hundreds listened in on the presentation and this is your chance to share in the knowledge.

The link to the audio is here. In it, you'll hear the real stars of the show, Lisa Latts MD of WellPoint, Paul Wallace MD of Kaiser Permanente and Ricardo Guggenheim MD of McKesson. These experts know of which they speak. So, if you must eat your lunch at your desk, the DMCB suggests listening to this will make your left-over turkey, lettuce n' mayo sandwich that much tastier.

A summary prepared by the DMAA eNews is below in case you don't have the time to listen right now.

'The panelists generally expressed optimism about the medical home model, but cautioned that questions remain about the fundamental design, payment mechanisms and patient engagement strategies. Dr. Wallace suggested that the patient-centered medical home might be better positioned as one component of a more complex "medical neighborhood" with a diversity of providers and a care delivery infrastructure supported, in part, by population health improvement. He also argued for greater patient involvement in health care decision making as the best path to a successful medical home. "Patient-centeredness is something we can do," he said of physicians. But "'personalized' is something that we can only do together with the patient. I think we have to trust the patient to help us find that spot." Dr. Guggenheim noted the need to include hospitals in the "medical neighborhood" concept. Success, he stated, will depend on the ability of the population health improvement industry to provide actionable, real-time data; IT tools to facilitate the care management process; and consumer-focused service.

Dr. Latts noted the challenge of providing additional payment to primary care physicians for medical home services with a limited pot of money that also must fund specialty care. She emphasized that, to succeed, the medical home must be simple to administer for primary care practices, with a coordinated approach to working with multiple vendors, including those providing population health improvement services. Dr. Guggenheim also spoke about the challenge of finding an acceptable payment model for the medical home, calling it "the biggest hurdle" to change. "I think the biggest problem that you have with changes in payment structure is that everyone wants them but nobody's that eager to sign up for them," he said.

Dr. Wallace said that payment reform is achievable, but must include "some accountability in the process for what patients care about." Patients, he said, "care about cost, they care about service and they also care about health. And I think that that's really the dilemma about how we align that incentive. I think that's where managed care and we came up short in the '90s." He also said the medical home must encourage the primary care provider to serve as a gateway to appropriate specialty care rather than as a gatekeeper to limit access to specialists.

Dr. Wallace sounded a positive note for population health, saying that the industry's expertise in reaching out to patients will underscore its value in a care delivery model centered on patients' needs. "I think that's why I'm hopeful for this industry, because this industry has survived only because it has figured out how to connect with patients," he said. "The challenge here is how do we take that connection with patients and align it with the rest of the delivery system?"'

Coda: Next year's meeting Forum '09 Sept 20-23 in San Diego. Mark your calendar.

McKesson Teaches the Disease Management Care Blog About a New Word: Promotores

Over half of the States’ Medicaid programs have myriad disease management programs aimed at the usual illnesses like asthma, diabetes, high risk pregnancy, ASCVD, chronic heart failure, depression and others. Wanting to find out more, the Disease Management Care Blog contacted McKesson’s disease management folks via e-mail and was promptly answered. They have disease management programs in California, Montana, Florida, Illinois, Pennsylvania, New Hampshire, Texas and Oregon.

If you check the National Conference of State Legislatures’ descriptions of the programs as well as the AHRQ ‘how to’ web-site, you’ll note that there is no standard Medicaid template. Once you’ve seen one disease management program, you’ve seen one disease management program. Even with a single disease management company such as McKesson, there is variation. They are fostering assignment of patients to a primary care ‘medical home’ and deploying community based care health workers in Illinois, while in Pennsylvania and Texas, they are deploying a version of pay for performance linked to their programs' recruitment and outcomes.

And speaking of Texas, how about them promotores. Haven't heard of them until you read the DMCB? Well now you know that instead of relying on pricey, remote nurse-based coaching support, it may be appropriate to turn to an alternate care model that depends on lay-health workers who are recruited from the community, are trained and then teach basic self-management skills in the local neighborhood. McKesson, to their credit, picked up on this model also, which was probably an ingredient in securing an extension of their contract. Different States, different Medicaid programs, different approaches.

The DMCB got to meet a real live promotora not too long ago in north Philadelphia and came away seriously impressed. To paraphrase Archimedes, with enough health care workers like her, we can move some serious HbA1c.

Pay for Performance (P4P) & Disease Management

In keeping with the season, the Disease Management Blog wanted to bracket this week with a famous bit of verse from the 4^th Chapter of Matthew:

The tempter came to him and said, "If you are the Son of God, tell these stones to become bread." Jesus answered, "It is written: 'Man does not live on bread alone, but on every word that comes from the mouth of God.”

At the time, most of the world was preoccupied getting enough to live on, not dying prematurely and securing as much power as possible. In dealing with these Three Great Temptations, this itinerant carpenter succinctly pointed out that mankind deserved better and that our greatest potential in every aspect of our day-to-day existence was built on something far greater.

Our effort to shape the delivery of health care is no different. I think the “bread alone” issue is what annoys many stakeholders about “pay for performance.” Patients wonder why physicians should be paid to “do the right thing,” while physicians distrust the use of pieces of silver to shape their profession. Both parties know "bread alone" falls short. As testimony to this, not too long ago I watched a respected colleague practically tear up a check at a Departmental meeting in disdainful disgust.

That’s why I was very interested in this telling videotape of Bob Margolis MD, the CEO of HealthCare Partners, discussing how P4P works in California. It’s about 40 minutes long and well worth watching. Kick back, get your lunch and enjoy.

It was not what you might expect. I thought Dr. Margolis was going to suggest that paying docs to do the right thing was bread enough. I was pleasantly surprised. Among his many excellent points is that paying docs to do the right this is all well and good, but more importantly:

• This is also a function of not paying for the wrong thing.

• The exercise in creating P4P generates measurement, which – independent of the bread - is a critical ingredient in the improvement of health care delivery.

• P4P draws stakeholders to the table and gets everyone to talk about quality.

• Because physician groups are large and many of the docs are salaried, they haven’t necessarily seen any increase in pay for their performance. Rather, the pay is used to invest in systems of care that promote performance. Important distinction.

The key lesson is that P4P may deliver more dollars to the doctors (since I'm a doc, the the disease management blog supports the idea), but when it's done right, it can be a catalyst that brings out other more important positive forces. I'm not necessarily saying this is a key to heaven, but there is something to be said for appealing to dimensions of health care that have nothing to do with self-interest.

As an aside, I’ll point out that the lessons are important for the disease management industry, which should also strive to live by more than bread alone. I’ll leave the broader dimensions of this to another blog, but at a more discreet level, check out McKesson’s AccessPlus P4P (more like Pay for Participation) for Medicaid in Pennsylvania (special attention to page 8). Just like the potential of a combined Medical Home-Disease Management approach, there may be merit to a combined P4P-Disease Management approach. McKesson deserves a lot of credit.

Or how about a P4P plus Medical Home plus Disease Management approach? Anyone know of any examples?