Prepared Witness Testimony

The House Committee on Energy and Commerce

Evaluating Coordination of Care in Medicaid: Improving Quality and Clinical Outcomes.

Subcommittee on Health
October 15, 2003
10:00 AM
2123 Rayburn House Office Building 

Ms. Melanie M. Bella
Assistant Secretary
Office of Medicaid Policy & Planning
402 W. Washington Street
Room W382, MS-07
Indianapolis, IN, 46204-2739

Chairman Bilirakis, Ranking Member Brown, distinguished Subcommittee members, thank you for this opportunity to share with you an initiative designed to improve quality and clinical outcomes for Medicaid recipients in Indiana.My name is Melanie Bella, and I am the Assistant Secretary of the Indiana Family and Social Services Administration, and the Director of the Office of Medicaid Policy and Planning (OMPP).In partnership with the Indiana State Department of Health and the State Health Commissioner, Greg Wilson, M.D., we have developed and implemented a comprehensive initiative, the Indiana Chronic Disease Management Program (ICDMP), designed to change the way health care is delivered across the state of Indiana. 

The goal of the ICDMP is to build a comprehensive, locally based infrastructure that:1.) is sustainable; 2.) strengthens the existing public health infrastructure; and 3.) helps improve the quality of health care for all populations, not just Medicaid recipients.  We hope that the ICDMP infrastructure will be an asset not only for patients but also for healthcare providers.We also hope the ICDMP can serve as a model for other states that may be interested in building integrated, locally based infrastructures for their Medicaid program and state as a whole.Strengthening public health systems and care delivery networks designed to decrease the prevalence of chronic illness and increase the use of primary care ensures that states are maximizing the public investment in achieving quality health outcomes. 

Medicaid Challenge

The Medicaid program in Indiana covers approximately 765,000 recipients at a cost of $4.3 billion today.Like most states, enrollment and demand for Medicaid services continues to increase.By the end of State Fiscal Year 2005, Indiana expects to spend $4.8 billion to cover over 825,000 recipients.Even with continued cost containment efforts, the rates of growth in Medicaid expenditures will continue to be unsustainable for states unless they develop new strategies for managing Medicaid costs.The new strategies must address the primary drivers of Medicaid expenditures:utilization and poor quality.It is critical that Medicaid programs focus on controlling utilization and improving health care quality for recipients with chronic illness.By making strategic system investments, states can develop the infrastructure necessary to improve care delivery and quality outcomes, which will help chronically ill patients lead more productive lives, slow the rate of growth in the short term and, ultimately, reduce costs in the long term. 

Background

In 2000, approximately 125 million people in the United States had some type of chronic illness and by 2020 it is estimated to grow to 157 million. By 2010, 17% of our GDP will be spent on health care, and 78% of these costs will result from chronic diseases, including almost 80% of total Medicaid expenditures, and this is increasing as our population ages. Numerous surveys and audits have documented gaps between well-established guidelines for the clinical aspects of care and how practitioners are actually delivering care.Providers feel resource constrained and too rushed to meet the clinical, educational, and psychological needs of chronically ill patients and their caregivers.Patients often experience care that is uncoordinated, impersonal and unsupportive, which may leave them feeling incapable of meeting the day-to-day needs of managing their chronic condition.  

In Indiana, national, state, and local partners are working together to implement a model of care for people with chronic conditions.Indiana's five major objectives for its chronic disease management program are as follows:

·       Provide consistently high quality care to Medicaid recipients that improves health status, enhances quality of life and teaches self-management skills.

·       Provide support to primary care providers and integrate primary care with case management.

·       Utilize and strengthen the public health infrastructure.

·       Reduce the overall cost of providing health care to Medicaid patients suffering from chronic diseases.

·       Achieve long term results by changing the way primary care is delivered across the state, not just for Medicaid.  

The key themes underlying the objectives are: patient self management, involvement of primary care providers, utilization of public health infrastructure and cost effectiveness.Most importantly, Indiana's program eventually aims to change the way care is delivered statewide - regardless of payer source and regardless of illness.  

We are initially targeting recipients with diabetes and congestive heart failure (CHF) and are quickly expanding to include asthma, stroke, hypertension and HIV/AIDS.Other chronic diseases will be added as appropriate and necessary.The clinical priorities of each condition are based on currently available scientific evidence.The principles used to improve care for the chronic conditions include:  

·       Implementation of the Chronic Care Model in the primary care settings.

·       Creation of a care management network to provide support to primary care practices.  

This will begin through a series of "Collaborative" learning sessions, which will serve as the foundation for spreading the Chronic Care Model statewide.The Breakthrough Series Collaboratives were developed by the Institute for Healthcare Improvement (IHI) in the mid 90's to facilitate health system change.Participants in the Collaborative will learn and implement an organizational approach to caring for people with chronic disease that utilizes and supports a comprehensive, sustainable locally based care network.The Collaborative model will be implemented statewide in a phased approach over a twelve-month period by sharing the best available scientific knowledge on the care for people with these conditions, and by learning and applying methods for change in the delivery of primary care.

State Options for Managing Chronic Disease

In the 2001 legislative session, the Indiana General Assembly mandated that the Office of Medicaid Policy and Planning (OMPP) contract with a commercial vendor to provide disease management to recipients with diabetes, congestive heart failure, asthma, HIV/AIDs and to provide case management for recipients with the top 10% of costs.OMPP issued a request for proposal (RFP), received bids from four vendors, selected one and began negotiations.Eleven months later, OMPP canceled the procurement.In the 2002 legislative session, the General Assembly removed the requirement that OMPP contract with a commercial vendor.  

We learned that there are options other than the commercial vendor approach, and it is important for other states to know that alternative options exist.Many people assume there are just two choices:"make" or "buy"."Make" usually implies starting from scratch and states are legitimately concerned about the time, resources and potential duplication of effort of that approach.The "buy" option is attractive because states can hold a vendor accountable and augment scarce state resources.The question is what is the state left with when the contract ends.Luckily, there is a third option: "assemble".The assemble approach is basically a hybrid of the make or buy models that allows states to assemble the best pieces together into a locally based infrastructure that supports and enhances the existing state public health infrastructure.Indiana chose the assemble approach, but it is important to note the pros and cons of each option.     

There are two major options in the "Buy Model":outsourcing completely to a commercial vendor or utilizing commercial chronic illness software.Based on our analysis, we identified some of the major pros and cons of each to be as follows.  

Buy:Commercial Vendor Approach 

Pros                                                                           Cons

  Buy:Chronic Illness Software  

Pros                                                                           Cons

  Assemble:Chronic Care Model  

Pros                                                                           Cons

 Indiana's Choice:Chronic Disease Management Program (ICDMP)

During the period of negotiations with the commercial vendor, Indiana was chosen to participate in a Policy Academy on Chronic Disease Management and Prevention sponsored by the National Governors Association.A team of state policymakers, legislators and community stakeholders attended a planning session and developed a strategic action plan.As part of that process, we became introduced to experts in the field of chronic disease management and began to question if what we had asked for in the RFP and were in the process of negotiating was in the long-term best interests of the State.As we learned more and the negotiations narrowed to debates over guaranteed cost savings as opposed to interventions, protocols and quality improvement, we concluded that the commercial vendor approach we had originally envisioned was no longer the model we wanted to pursue.We enlisted the support of Dr. Ed Wagner, Director of the MacColl Institute for Healthcare Innovation, Center for Health Studies, Group Health Cooperative, and his team in developing a program grounded in the principles of the Chronic Care Model.The Chronic Care Model was developed through Improving Chronic Illness Care (ICIC), a national program supported by the Robert Wood Johnson Foundation.The Chronic Care Model focuses on improving care delivery and promoting system change through the use of evidence based care practices, strong patient self-management and extensive involvement of primary care providers and practices.The Chronic Care Model reinforces all the elements necessary for creating a sustainable, comprehensive, locally based infrastructure: 

• Evidence based guidelines
• Tools to support and assist providers
• Strong patient self management and involvement in health care decisions
• Investment in public health infrastructure
• Creation of sustainable infrastructure in a locally based manner that benefits state as a whole and leaves the state better off than when it started
• Long term focus on improving quality vs. short term focus on "guaranteed" savings

The Chronic Care Model changes the approach of medical care from reactive, acute care for illness to a preventive, coordinated care model for health that will decrease complications and eventually reduce costs.As mentioned earlier, we will be spreading the Chronic Care Model through a series of Collaborative learning sessions developed by the Institute for Healthcare Improvement (IHI).IHI has been a valuable partner in teaching us how to test change concepts and develop and implement quality improvement initiatives in the medical care environment.    

Assembling the Infrastructure

Using the assemble approach, the first step is to identify the best components and partners available to build and strengthen the existing public health infrastructure and that will facilitate the interaction between primary care and chronic disease case management statewide.  

The ICDMP has the following major components and partners:

• Program Management.Medicaid and the Department of Health are jointly responsible for the program including policy development, contracting and monitoring performance.

• Primary Care. The focal point of patient care is the primary care physician.Key elements of the ICDMP are designed to provide information and resources to support the physician.The Medicaid provider community is our partner in this component, and we are working with them to ensure our reimbursement is aligned with the outcomes we hope to achieve. 

• Care Management.Care management is comprised of:

• A Call Center that monitors patient status and follow-up based on the established protocols.We partnered with the existing Medicaid call center vendor to provide these services to take advantage of the relationships, credibility and knowledge they already have with our recipients and providers.The call center services are available for all ICDMP patients.

• A Nurse Care Manager network whose nurses provide more intense follow up and support to a smaller group of high-risk patients.We partnered with the Indiana Minority Health Coalition and the Indiana Primary Health Care Association to hire nurses and deploy them statewide, according to physician practice and geographic area.These organizations are natural partners in that they have established relationships and credibility across the state and are fairly evenly split between urban and rural areas, which prevent overlap or duplication.

• Patient Data Registry.An electronic data registry is available to physicians and can be used for all patients.For Medicaid patients, it will be populated with claims data and case management data.We partnered with Mountain Pacific Quality Health Foundation, the Medicare Quality Improvement Organization for Montana, in the development of the Chronic Disease Management System (CDMS).CDMS contains the ICDMP care protocols and clinical guidelines, patient education materials, Medicaid claims data, reminder and recall functions and other clinical data entered by the call center, providers or nurse care managers. 

• Measurement & Evaluation.Measures of program performance are being established using both claims history data and individual health outcomes indicators for both an intervention and control group.We partnered with the Regenstrief Institute, of the Indiana University School of Medicine, to perform a statewide evaluation as well as a randomized controlled clinical study within Marion County (Central Indiana region).We are committed to a rigorous evaluation of this program that will measure total costs (not just savings from reduced hospitalizations) and identify which components are effective as well as those that are not achieving the intended outcome and need to be changed. For an evaluation to be meaningful, it must be clearly structured to measure total program effectiveness.As such, when evaluating chronic disease management programs, it is critical to examine all costs for all patients during the intervention.Looking only at selected costs or only at the most expensive groups of patients can be deceiving.

In closing, I'd like to thank the Members of the Subcommittee for the opportunity to discuss this important issue with you.The Indiana Chronic Disease Management Program was assembled with the help of many experts in this field to solve a public health problem that reaches far beyond the Medicaid program alone.We would be more than happy to share any of our materials (clinical protocols, consensus guidelines, patient education materials, call center scripts, patient identification criteria, etc) with any state that is interested in assembling their own chronic disease management program.Thank you again for your time, and I would be happy to answer any questions you may have.

For additional information or to download materials used in the Indiana Chronic Disease Management Program, please visit the website at http://www.indianacdmprogram.com/ 

For additional information about the Chronic Care Model, please visit the Improving Chronic Illness Care website at http://www.improvingchroniccare.org/

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