RD278 - Virginia Medicaid "Healthy Returns" Disease Management and Chronic Care Management Programs - November 1, 2009


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, chronic illnesses account for more than 75 percent of total U.S. health care spending.

In contrast to Medicaid managed care in Virginia, the Medicaid and FAMIS fee-for-service populations have not historically had consistent access to disease management (DM) services. However, in 2004, Health Management Corporation (HMC), a wholly owned subsidiary of Anthem, approached the Department of Medical Assistance Services (DMAS) and proposed a pilot 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. HMC was awarded the contract and the expanded DM program was implemented on January 13, 2006. "Healthy Returns" focuses on preventive care, promotion of self-management, and appropriate use of medical services in the fee-for-service system. "Healthy Returns" provides DM services to Medicaid and FAMIS fee-for-service recipients with asthma, chronic obstructive pulmonary disease (COPD), heart failure (HF), coronary artery disease (CAD), and diabetes.

The "Healthy Returns" program continues to be fully operational, in accordance with Item 306 Z of the 2009 Appropriations Act (Attachment A). Item 306 Z requires that DMAS provide annual reports to the General Assembly on the status of the DM program. 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:

• Utilization data in addition to claims-based health outcomes and self-reported data;

• An additional year’s worth of data which enables DMAS to assess how well the DM program is meeting its goals and objectives; and,

• A description of DMAS’ care coordination efforts for Virginia’s Elderly or Disabled with Consumer Direction (EDCD) long-term care waiver participants.

On September 8, 2009, Governor Kaine announced his cost savings actions to reduce spending in Fiscal Year 2010. As part of his plan, the contract for the "Healthy Returns" disease management program, which is up for renewal in November 2009, will not be renewed (Attachment B). Consequently, the program will no longer be available effective October 31, 2009. Therefore, this report summarizes data from the last complete year that the DM program will operate.