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Medicaid programs find opportunities for improvement in complex patient populations

Aged, blind, and disabled (ABD) Medicaid beneficiaries are among the most complicated and expensive patients to manage. Although they account for less than one-third of all Medicaid enrollees, they are responsible for nearly three-quarters of the agency’s healthcare spending.

However, this population also presents multiple opportunities for cost savings, according to Melanie Bella, senior vice president of the Center for Health Care Strategies (CHCS) in Hamilton, NJ. Speaking during a teleconference cosponsored by CHCS and the Government Innovators Network at Harvard University’s John F. Kennedy School of Government in Cambridge, MA, Bella stressed that realizing sustained financial benefits from this population requires strategic vision rather than simply slicing reimbursements and services.

“These [strategies] are not getting at the root cause of spending, which really has to do with utilization, whether it is misuse, overuse, or underuse of services,” she said. However, what can work, according to Bella, are quality improvement interventions that are targeted toward the true drivers of healthcare spending in this population. And as subsequent speakers at the conference illustrated, this is where effective case finding, DM, and comprehensive solutions can make a significant dent in both clinical and financial returns.

P4P program drives improved outcomes

The teleconference “Medicaid Best Buys: Managed Care Models for Aged, Blind, and Disabled Beneficiaries” was held on May 29 and was the fourth in a series of CHCS-sponsored presentations focused on disseminating strategies that the organization believes can offer the most powerful returns—from both clinical and financial standpoints.

David Kelley, MD, MPA, chief medical officer for Pennsylvania’s Department of Public Welfare, outlined several strategies that his state has implemented as part of Access Plus, a fee-for-service program operating in 42 rural counties and covering about 290,000 lives. “In this model, we are trying to establish for both kids and adults a medical home,” said Kelley, describing the program as an enhanced primary care/case management model. However, because the population includes a high percentage of recipients with chronic diseases and other complex healthcare needs, a primary focus of the model is to provide support, in terms of specialty care and care coordination, to PCPs who are the centerpiece of the medical home concept.

Consequently, the state has put in place a complex case management unit, including 24 full-time RNs, to help manage and coordinate care for those patients with highly complex needs. In addition, the state is working closely with McKesson Health Solutions, a Broomfield, CO–based DM vendor that is providing services to patients with diabetes, coronary artery disease, CHF, asthma, chronic obstructive pulmonary disease, and the array of comorbidities that typically go along with these diseases.

“McKesson mainly uses a telephonic model [originating] from both Colorado and Pennsylvania, but there are also community-based nurses involved as well as community- based, nonclinical care coordinators in the field to help coordinate services,” said Kelley. “The other thing that is very important in working with McKesson is the coordination between their DM nurses and our special needs unit nurses, because many times, they are handing off cases to one another.”

To get providers engaged in the DM process, McKesson also oversees a pay-for-performance (P4P) program that applies chiefly to PCPs who provide a medical home for Access Plus patients. “We are paying providers to assist with DM enrollment and for identifying appropriate candidates for DM,” said Kelley. In addition, providers can receive P4P funds for encouraging patients to participate in DM, for participating in care plan development, and for completing certain disease-specific evidence- based care practices.

“We pay for the additional effort that we know goes on in the care of very complex patients,” said Kelley. And 12-month data suggest that the approach is delivering improved clinical outcomes on a number of measures.

In addition, Kelley noted that half of all DM participants dropped from level three, the highest severity level of illness, to level one or two. And he pointed out that conservative calculations suggest that one-year cost-savings from the DM program are in the $27 million range. “We feel confident in that number. We feel [it represents] true cost savings attributable to the DM population,” said Kelley, adding that the ROI was about 1.3.

IT system links critical data sources

Noting that the typical ABD high-utilizer has no PCP or medical home and frequently uses the ER for primary care, it is easy to see how expenses pile up for these complex patients, particularly when you consider that there is often very little information linking these various points of utilization and no integration of pharmacy, laboratory, or behavioral health data, explains Coleen Kivlahan, MD, MSPH, senior vice president of medical affairs for Schaller Anderson, Inc., an Arizona-based healthcare company that manages more than 100,000 ABD recipients in several states. This is precisely why Schaller Anderson decided to invest heavily in IT with the aim of finding out who these patients are and where opportunities exist for improved care coordination, added Kivlahan.

The process begins with predictive modeling software that Schaller Anderson uses in concert with pharmacy data, and a series of risk tools to identify which patients are at highest risk. “We are looking at 12-month claims costs across the board, including labs, durable medical equipment, procedures, and pharmacy. And then, finally, we look at care gaps or evidence-based care concerns or considerations for these patients,” said Kivlahan, noting that all of this information is then consolidated on a single IT system. 

The analysis ultimately ranks all members in a searchable database so that health planners can focus in on high-risk patients, particular patient populations, or groups of patients with specific characteristics. Further, Schaller Anderson has implemented a tool that alerts care managers every time a member is in the hospital. “The combination of predictive modeling and this [prediction tool] in the hospital gives us a great sense for what is happening to all of our members in real time,” said Kivlahan.

Generated from all of this information are care plans that target interventions and clinical tasks toward those patients most in need of these services. Kivlahan noted that the care plans are made available electronically to both providers and patients. In addition, at two sites, Schaller Anderson has begun to make available to providers and patients summaries of the predictive modeling analyses so that they can incorporate care plan changes, and have them disseminated to all of the appropriate stakeholders, with approval from patients.

Kivlahan did not have any outcomes to share about the approach, but she noted that Schaller Anderson hopes to eventually further enrich its data resources with self-reported information about functional status and quality-of-life indicators. “We would also love to see expansions in social and behavioral health indicators collected on all of these members, and we have begun to do that now in several states,” she added.

Support for PCPs is the priority

With just 230 employees, Portland, OR–based CareOregon is a tiny health plan with limited resources. Consequently, rather than providing financial incentives for providers, the plan has taken a different tack in engaging providers to manage the complex ABD population in its CareSupport program. “For us, it has been really important to create partnerships and relationships with our PCP base to create medical homes and to really convince them that they can deal with this complex population,” explained David Labby, MD, PhD, medical director of CareOregon.

To do that, Labby explained that the plan focuses much of its energy and resources on supporting PCPs by providing them with care coordination assistance and by taking steps to activate patients. “A lot of our patients aren’t treatment ready; they don’t know how to do a doctor visit, and they don’t know how to do self-management,” said Labby. “So a lot of the coaching and engagement that we do is actually to get them to take advantage of what would be a medical home.”

To support providers, the health plan has brought in pharmacists, social workers, and what they call healthcare guides—nonclinicians who implement patient reminder calls and other administrative tasks that do not require clinical skills—in order to create multidisciplinary teams capable of managing complex patients.

“We have teams with all of these components assigned to clinics so they know the nurse to call or the social worker to call,” said Labby. “We want to be sort of an extension of the PCP office.”

The plan has implemented rounds whereby the multidisciplinary teams regularly discuss cases and conduct assessments. Initially, these rounds were “clunky” and inefficient, but by standardizing procedures, Labby noted, the plan has streamlined the process to the point at which the teams can now review several patients very quickly.

In fact, the plan has attempted to standardize as many processes as possible, including the assessment that patients go through when they are identified for being included in the CareSupport program. “It takes about 40 minutes, but we go through all the domains [outlined in the chronic care model] to understand what their drivers of risk are because we are looking for modifiable risk,” he says.

Through this process, what the plan has learned is that some of the major drivers of risk are related to problems with decision-making and memory. Consequently, Labby said, a major focus of the health plan has been to guide people toward effective decision-making and to give them strategies that can help them remember important self-care tasks.

By helping patients to overcome such barriers, Labby noted, the plan is freeing up providers to focus on medical care. And he pointed out that early data suggest that the approach is resulting in significant cost reductions. “It is our feeling that the closer we get to integrating with the provider office and the more we support what they are doing, the more effective we will be,” he said. “We are now trying to figure out ways in which we can move the case management process actually into the provider office [as well].”