RD296 - Virginia Medicaid Healthy Returns Disease Management Program


Executive Summary:
According to Johns Hopkins University, people with chronic conditions account for 88 percent of all prescriptions filled, 72 percent of all physician visits, and 76 percent of all inpatient stays. The incidence of co-morbidities is escalating, causing treatment plans to become increasingly complex. Patients find it difficult to accurately follow through on a physician’s directions, which often results in missed or inappropriate dosages of medications, failure to heed to warning signs, and overlooked appointments. This can lead to extensive emergency room use particularly in the case of uncontrolled asthma, and exacerbate expensive conditions, such as kidney failure and amputations, in the case of uncontrolled diabetes.

Health insurers and companies are developing disease management (DM) programs in an effort to alleviate individuals and society of the physical, psychological, social, and economic pressures associated with chronic conditions and diseases. DM programs attempt to both improve the quality of patient care and slow the growth of healthcare costs. DM programs were once considered experimental in the early 1990s, but their success in helping to improve quality of care has led to unprecedented growth in this industry. Many health insurance plans and most Medicaid programs now offer some form of DM services. DM programs are operated by managed care plans, provider groups, state agencies, and specialized DM companies.

Disease management targets chronic illness/conditions (e.g. asthma, diabetes, congestive heart failure, coronary artery disease, HIV/AIDS, etc.) by:
• Empowering the patient (with professional resources) to manage the condition, rather than forcing the healthcare system to treat acute episodes;
• Improving a patient’s quality of care through promotion of evidence-based treatment; and

Beyond health status improvements, DM has the potential to contain the costs of healthcare by focusing on prevention and therefore, avoidance of acute care services.

DM programs offer a range of activities to address the shortcomings of the current healthcare system. Well-designed DM programs typically include the following activities: the targeting of high-risk patient populations; the promotion of evidence-based treatment plans with primary care physicians; patient self-management and education programs; patient monitoring and provider feedback; and, a rigorous system of evaluation.

Programs can be patient-centric, provider-centric, or a hybrid of both designs. Patient-centric programs typically utilize a nurse care manager to conduct assessments, monitor treatment, and support patients, often from a remote location (usually telephonically). The main goals of patient-centric programs are to educate patients about their condition and promote self-care. In the patient-centric design, provider participation is ideal, but not essential. Conversely, for provider-centric programs provider participation is essential to the program’s success. In a provider-centric program, the primary care provider (e.g. physician, nurse practitioner, physician assistant) conducts an assessment and develops a treatment plan in accordance with national evidence-based standards. Provider-centric programs operate a team approach to healthcare, where the primary care provider acts as the coordinator of the participant’s healthcare. An additional incentive or compensation structure (often referred to as “pay-for-performance”) is often essential for the success of a provider-centric program. Recently, DM programs began to offer blended or hybrid program designs that focus efforts on both the patient and the provider. Healthcare delivery is more effective and efficient if patients take an active role in their care and providers are supported with necessary resources and expertise to better assist patients in managing illness. Virginia’s DM programs operate as patient-centric programs that focus on empowering the patient to take an active role in their heath care.

I. Overview of Disease Management in Virginia Medicaid

Disease Management in Virginia’s Medicaid Managed Care Program

Virginia’s Medicaid program offers two general models of care delivery: managed care for a specific subset of recipients (primarily children and non-institutionalized adults) and fee-for-service for everyone else. For several years now, Virginia has offered asthma, diabetes and other DM services to participants enrolled in Virginia’s Medicaid Managed Care Organizations (MCOs). The plans are required to submit HEDIS data results (*1) and are benchmarked against each other and other national plans. In 2005, 431,529 Medicaid recipients received services through five Medicaid MCOs. DMAS worked with the MCOs to ensure that each MCO will offer DM for asthma, congestive heart failure, coronary artery disease, and diabetes by 2007.
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(*1) HEDIS measures are standardized performance measures designed to reliably compare the performance of managed health care plans.