Presentation to the Vermont Commission on Health Care Reform

1. Presentation to the Vermont Commission on Health Care Reform Kenneth E. Thorpe, Ph.D. Robert W. Woodruff Professor and Chair Department of Health Policy and Management Rollins School of Public Health Emory University kthorpe@sph.emory.edu December 2005

2. Agenda • Challenges facing a “fast-track” implementation of the state’s chronic care initiative • How do other states / state Medicaid programs design disease management programs? • Lessons and implications for the Commission discussion December 2005

3. Chronic Care Blueprint • Population identification processes • Evidence-based practice guidelines • Collaborative practice models to include physician and support-service providers • Patient self-management education (may include primary prevention, behavior modification programs, and compliance/surveillance) • Process and outcomes measurement, evaluation and management • Routine reporting / feedback loop December 2005

4. Key Challenges Facing the Rapid Implementation of the Chronic Care Blueprint • Time remaining to complete the patient registry – key infrastructure to identify chronically ill patients • Integrating providers and patients into the model – “buy-in” • Changing provider payments – payment reforms needed • Finalizing measurable set of standard clinical performance measures, outcomes measures, patient satisfaction measures • Role of OVHA / State employees: Build vs. contract with external vendor (latter much faster) December 2005

5. Challenges Facing the Chronic Care Blueprint • Identification of patients eligible for disease management service (i.e. know who your patients are!) • Need Patient registry to identify all eligible members and stratify for risk/level of intervention. Also allows for comprehensive tool for managing clinical needs • Cannot move ahead without automated registry, or external vendor identifying potential candidates Challenges: Requires data from several providers, labs, pharmacy clearinghouses, hospitals, physician practices, health plans. • Full completion could be two years away • Key first step is the accelerate the completion of the registry December 2005

6. Challenges • Finalize clinical protocols that will be adopted across all patients. • Successful program will need • Outcome, utilization, and process measurements December 2005

7. Process and Outcomes Measures (still under construction) • Member and Provider Satisfaction Surveys • Health status outcome - examples • Improved overall health status of members at least 10% • Decrease in hospital admissions at least 10% • Decrease in total inpatient days at least 10% • Decrease in Emergency Department visits by at least 10% • Increased education (knowledge) of providers and members by 10% December 2005

8. Illustrative Clinical Outcome Metrics for Diabetes – Variables to be Measured December 2005

9. Illustrative Clinical Outcome Metrics for Diabetes – Variables to be Measured December 2005

10. Create Comprehensive Care Plans that Include: • Management of disease states and co-morbid conditions • Severity of care • Improvement of risk factors related to disease (i.e. obesity) • Management of appropriate usage of all medications • Preventative care and wellness promotion • Evaluation of home environment for levels of common environmental triggers December 2005

11. 4. Create Comprehensive Care Plans that Include: (continued) • Action plans for diseases that are required per clinical guidelines (i.e. asthma) • Prevention of acute episodes including hospitalizations and emergency-room visits • Member self-management strategies • Communication feedback among all providers • Member and provider adherence to clinical guidelines • Member’s compliance with care plan • Are compliant and cooperative with the recommended care plan December 2005

12. Payment Reform • Plans paid a PMPM amount for managing health care of enrollees • Cannot fully develop all aspects of chronic care model absent changes in how providers are paid. • Not currently planned • Physician Buy-in • Must seamlessly integrate all parts of the CCI • Role of OVHA / State Employees in the CCI • Could include OVHA and the state employees through an RFP process with an external vendor • Not currently anticipated December 2005

13. How Do Other States Provide Disease Management for Medicaid / State Employees? • Generally through an RFP process • RFP requires vendor to describe (examples) • Approach for identifying eligible members • Approach for conducting baseline assessments of health risk, and non-adherence risk. • Identify educational / wellness / clinical management protocols by risk state (i.e. mild asthmatics v. severe asthmatics) • Approach for enrolling patients opt-in / opt-out December 2005

14. How Do Other States Provide Disease Management for Medicaid / State Employees? • Identify how vendor would integrate with: • Medicaid provider community • FQHCs • Rural and public health clinics • Process for coordinating interventions and care • Measure /evaluate outcomes December 2005

15. RFPs Require • Evidence based guidelines • Case managers (face to face, telephone) • Care Plans that include: • Management of disease states and co-morbid conditions • Severity level of care • Improvement of risk factors related to disease • Management of appropriate usage of all medications • Preventative care and wellness promotion December 2005

16. RFPs Require (continued) • Evaluation of home environment for levels of common environmental triggers • Action plans for diseases that are required per clinical guidelines (i.e. asthma) • Prevention of acute episodes including hospitalizations and emergency-room visits • Member self-management strategies • Communication feedback among all providers • Member and provider adherence to clinical guidelines • Member’s compliance with care plan • Are compliant and cooperative with the recommended care plan December 2005

17. Key Part Many RFPs: • Guaranteed Net Savings • Expect generally 4% savings for aged/blind/disabled populations • Higher savings (10%) for other populations • Pay a PMPM fee to vendor that is at risk (see example) December 2005

18. SAMPLE CALCULATION OF SAVINGS FOR “BEND THE TREND” PROGRAM (Georgia Medicaid RFP) All numbers provided are for demonstration purposes only. December 2005

19. SAMPLE CALCULATION OF SAVINGS FOR “BEND THE TREND” PROGRAM (Georgia Medicaid RFP) All numbers provided are for demonstration purposes only. December 2005

20. December 2005

21. Key Issue: Role of OVHA in Chronic Care Blueprint • Build vs. RFP (lease) Issue • Could develop RFP contract with external vendor and jump start the process • Could require performance guarantees on savings December 2005