1、November 14-15, 2005 Montpelier, VT,Chronic Care Management: Options for Vermont,Kenneth E. Thorpe, Ph.D. Robert W. Woodruff Professor and Chair Department of Health Policy and Management Rollins School of Public Health Emory University kthorpesph.emory.edu,November 14-15, 2005 Montpelier, VT,Key Fa
2、cts,Cost of treating chronically ill patients accounts for 75% of health spending in Vermont (over $3 Billion per year) Rise in chronic illnesses and obesity key factors in driving growth in spending Chronically ill patients receive about 50% of the clinically recommended care The IOM and others hav
3、e highlighted the need to dramatically restructure how we deliver services Patient focused/central “integrated” multi-disciplinary approach Proactive not reactive model,November 14-15, 2005 Montpelier, VT,Chronic Care Model (CCM):,Does It Work? Yes. Interventions that contain 1 or more elements of t
4、he chronic care model improve clinical outcomes and processes and to lesser extent quality of life according to RAND findings.Implementation Challenges Facing The State: Can Vermont Build the CCM? Change how Medicaid pays for carekey challenge for existing Blueprint.,November 14-15, 2005 Montpelier,
5、 VT,Disease States Commonly Targeted by DM Industry,CHF, Cardiovascular disease Asthma Chronic Obstructive Pulmonary Disease (COPD) Diabetes Cancer Maternal/Neonatal Rare Diseases ESRD,November 14-15, 2005 Montpelier, VT,Components of DM Products,November 14-15, 2005 Montpelier, VT,Full Integration:
6、 Population Based and Chronic Care Case Based Model,Lifestyle interventions,Low risk,At risk,Disease Management,Disease,Symptoms,Early Signs,Preventive Services,Case Management,Screening,Primary and Secondary Prevention,Acute treatment,Disease Management,HEALTH IMPROVEMENT,DISEASE MANAGEMENT,HEALTH
7、MANAGEMENT,POPULATION-BASED,CASE-BASED,November 14-15, 2005 Montpelier, VT,Disease Management Targets for Vermont,Medicaid, could be effective approach for managing global commitment State employees Dual eligible (Medicaid/Medicare) Commercial market,November 14-15, 2005 Montpelier, VT,Managed Care
8、Organizations (MCOs) Play Key Role In Medicaid DM Nationally,Some MCOs manage directly, others outsource and pay vendors on performance (e.g. % reduction in hemoglobin A/C levels among diabetics, % reduction in hospital days among asthmatics) Disease states typically targeted in Medicaid depression
9、- anxiety disorders psychosis - diabetes hypertension - asthma CHF, CVD,November 14-15, 2005 Montpelier, VT,Other states are implementing disease management programs to provide beneficiaries with higher quality care at a lower cost,Florida runs in AIDS, Congestive Heart Failure (CHF), End Stage Rena
10、l Disease (ESRD), diabetes, hemophilia and asthma. Five of these programs reported successful results Washington state runs programs in ESRD, diabetes, asthma and CHF and has also published favorable results. Montana started recently with five common chronic diseases and a highly popular nurse call
11、in line to help beneficiaries coordinate care. Indiana is building its own program rather than outsourcing to disease management vendors. Wyoming, Texas, New Hampshire, Georgia, Tennessee, and South Carolina are in various stages of RFPs with disease management vendors and will likely begin operatio
12、ns soon.,November 14-15, 2005 Montpelier, VT,Selected Examples of DM in Medicaid FFS,November 14-15, 2005 Montpelier, VT,DM Contracting Examples,Washington - full risk 80% payment at risk based on projected savings 20% payment at risk based on performance/quality Has been effective in Washington Fin
13、ancial and clinical goals need to be clear Need methodology for program evaluation,November 14-15, 2005 Montpelier, VT,Based on other states experience and vendor guarantees, significant savings can be achieved, e.g.,Disabled and Blind 4%Aged Community & Custodial Care Acute Care Medical 25% Drugs 1
14、0% Aged in Skilled Nursing 20% TANF Neonates 6% ESRD 8% Contracts typically include performance guarantees. States typically pay base administrative fees to DSM vendors. At the end of the reporting period (Usually a Fiscal year), savings are measured. If the net savings “guarantee” is not met, the v
15、endor will reimburse the state up to 100% of their administrative fees. SOURCE: COMPUTER SCIENCES CORPORATION,November 14-15, 2005 Montpelier, VT,Vermont can expect challenges to implementing these programs,Need continuous enrollment (at least 12 monthly enrollment by Medicaid / SCHIP) populations N
16、eed to define business model: Per member, per month adjusted for risk (i.e. Medicare Advantage Methods). Contracts with physician groups based in cost savings / quality / clinical measures,November 14-15, 2005 Montpelier, VT,Inside the “Black Box”: Key Implementation Issues,How to identify candidate
17、s Registry Claims data Physician referralHow to enroll beneficiaries “opt-in” (low enrollment 30%) “engagement or opt-out model” (are enrolled unless they decline up to 95% participation),November 14-15, 2005 Montpelier, VT,Inside the “Black Box”: Key Implementation Issues,How to pay for DM Perhaps
18、the Key Issue Full insurance risk (PMPM risk adjusted payment using Medicare Advantage Model) P4P Performance Risk Define evidence based guidelines,November 14-15, 2005 Montpelier, VT,Inside the “Black Box”: Key Implementation Issues,P4P (continued) Bonus pool distribution at practical network level based on HEDIS measures (50% weight) Patient satisfaction (30% weight) IT investment (20% weight),
