RD287 - Virginia Medicaid "Healthy Returns" Disease Management and Chronic Care Management Programs - November 1, 2008


Executive Summary:
According to the Centers for Disease Control and Prevention (CDC), chronic diseases are the leading causes of death and disability in the United States. They account for seven out of ten deaths. Furthermore, the medical costs associated with people with chronic diseases account for more than 75 percent of the $1.4 trillion spent on health care in the United States.(*1)

In contrast to Medicaid managed care in Virginia, the Medicaid and FAMIS fee-for-service populations have not had consistent access to disease management (DM) services. However, in 2004, Health Management Corporation (HMC), a wholly owned subsidiary of Anthem, approached DMAS and proposed a pilot disease management (DM) program at no cost to the Commonwealth. The pilot was successful, and in 2005, Virginia issued a Request for Proposals (RFP) to expand its DM initiatives.(*2) HMC was awarded the contract and the expanded DM program was implemented on January 13, 2006. Healthy ReturnsSM focuses on preventive care, promotion of self-management, and appropriate use of medical services in the fee-for-service system. Healthy ReturnsSM provides DM services to Medicaid and FAMIS fee-for-service recipients with asthma, chronic obstructive pulmonary disease (COPD)(*3), congestive heart failure (CHF), coronary artery disease (CAD), and diabetes.

The Healthy ReturnsSM program continues to be fully operational, in accordance with Item 306 Z.1 of the 2008 Appropriations Act (Attachment A). Item 306.Z.2 of the 2008 Appropriations Act requires that DMAS provide annual reports to the General Assembly on the status of the DM and CCM programs (Attachment A). DMAS has submitted annual reports to the General Assembly since the inception of the DM program. However, this year’s report differs from previous reports because:

• It includes claims-based DM health outcomes data in addition to self-reported data.

• The report includes an additional year’s worth of data which enables DMAS to assess how well the DM program is meeting its goals and objectives. Last year, data was not available since the program was still new and baseline data was under development.

• This is the first year DMAS has reported on the CCM program.
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(*1) 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.
(*2) In accordance with the provisions of Item 326 #11c of the 2005 Appropriations Act.
(*3) In accordance with the provisions of Item 302 FFF of the 2006 Appropriations Act, DMAS added chronic obstructive pulmonary disease to the Healthy ReturnsSM disease management program on May 1, 2007.