Florida Medicaid Disease Management:Challenges, Successes and
Lessons for the Future
Christobel E. Selecky, Chief Executive OfficerLifeMasters Supported SelfCare, Inc.
Third National Disease Management SummitBaltimore, MarylandMay 13, 2003
Third National Disease Management SummitBaltimore, MarylandMay 13, 2003
2© 2003 LifeMasters Supported SelfCare
ObjectiveReview issues related to implementing a Disease Management program for a State Medicaid Program.
Florida Medicaid: Challenges, Successes and Lessons for the
Future
3© 2003 LifeMasters Supported SelfCare
• Medicaid Challenges
• Successes – Solutions
• Lessons Learned
Presentation Outline
4© 2003 LifeMasters Supported SelfCare
• In 1998, LifeMasters was selected through rigorous RFP process to provide CHF disease management in North Florida
• Urban/rural population mix• Several thousand beneficiaries targeted for
program enrollment• Population-based program (all severity levels)• Included co-morbidity management – 1/3 of
CHF patients also had Diabetes• 100% Fee Risk – 6.5% net savings guarantee• Program started in September 2000
Program Overview
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Medicaid Programs Present Unique Challenges
• Beneficiaries
• Providers
• Contracting
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Our Founding Principles
• Clinical Decision Support for Physicians
• Supported SelfCare for their Patients
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Participant Self-MonitoringVital SignsSymptoms
Self-Monitoring
Data Capture & Analysis
Choice of easy to use methodsIVR, Web, Connected device
Customized for co-morbiditiesAlert Generation
MD-set thresholdsVerified and triaged by LifeMasters nurseProvides feedback to support coaching
Alert Generation & Data VerificationActionable information
Best Practice SupportEarly interventionImproved efficiency
MD Exception Reports
Physician Decision Support
8© 2003 LifeMasters Supported SelfCare
Routine self monitoring of vital signs and symptomsEasy to use data entryProvision of regular feedback
Self-MonitoringUse of data to constantly customize program
Coaching by LM nurseDynamic risk stratificationBehavioral change support
Coaching
Regular health education callsEducational materials
Video seriesLiving Well MagazineDisease specific literatureLifeMasters OnLine
Education
Assessment & TrainingIndividual assessment and orientationSelf care conceptsDisease-specific informationSelf-monitoring instruction and equipmentPlacement in individualized care program
Supported SelfCare
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• Communication• Telephones, language, cognitive
• Education Level• Reading proficiency
• Understanding of health issues
• Life Priorities• Basic needs such as housing & food are higher priorities than
healthcare
• Transience• Difficult to find and retain
• In and out of eligibility• Difficult to provide continuity of care
Medicaid-Specific Challenges: Beneficiaries
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• Access to care• Transportation
• Fewer Physicians to choose from
• Use of ED for primary care
• Dispersed and rural population
• Sicker population• High prevalence of obesity, smoking, co-morbidities
Medicaid-Specific Challenges: Beneficiaries
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Population Skewed More Toward High Risk Than Typically Experienced*
10 2 3 0 1
1154 12 70 12 0 4 13 8 5 15 2 7 16 4 2
2 4 63 7 3
4 8 6 5 2 6 5 5557 0
6 0 16 4 6
2 8 2
4 9 7
8 4 39 8 6 12 6 8
12 8 513 6 5
14 4 1
0
500
1000
1500
2000
2500
3000
3500
4000
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8
Low Risk Moderate Risk High Risk
Beneficiary Enrollment by Severity Level by Quarter
*nearly twice as many high/mods as average
12© 2003 LifeMasters Supported SelfCare
• Finding the Individual (Moved or Incorrect Address) • Hired “Local Locators” to find individuals• Provided information back to AHCA• Ongoing patient recruitment efforts at AHCA area offices
and health departments, hospital case mgrs and PCP’s• Individuals Without Phone Service
• Installed phones in Beneficiaries’ homes• Provided Direct Connect Mobile Phones
• High % of Individuals Who Missed Initial Training• Reminders • Coordinated transportation• In-Home training (57% - much higher than usual 10%)
Unique Population Needs can be Met by Adapting Outreach Efforts
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Unique Population Needs can be Met by Adapting Outreach Efforts
• Individuals In-and-Out of Coverage• Continued support for 90 days or until verification that they
weren’t eligible (with no reimbursement from AHCA) • Reminders to extend Medicaid coverage prior to expiration
of benefits
• Engaging the Individual • Allayed concerns over losing Medicaid benefits• Focused on building trust with disease manager• Negotiated with patient to determine minimum acceptable
level of participation • Positioned service as increasing access to healthcare
• Reading Challenges• Created 3rd/4th grade reading materials (versus 8th)• Developed videos – More beneficiaries (97%) have VCRs
than phones (90%)
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• Unique Needs• Provided higher frequency and level of support
• Depression and mental illness screening and referral
• Language barriers – materials in Spanish, Chinese, and
English; used Spanish speaking disease managers
• Dealt with mental and physical disabilities
• Needed to coordinate transportation
Unique Population Needs can be Met by Adapting Outreach Efforts
15© 2003 LifeMasters Supported SelfCare
Florida Medicaid Enrollment Q1 to Q8
37293493
32403027
27822483
1171
482
0500
1000150020002500300035004000
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8
Customization Resulted in High Success in Finding and Enrolling Beneficiaries
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Beneficiaries Actively Participated in the Program by Entering their Vital Signs
Percent Monitoring - High & Moderate SeverityQ1 to Q8
0.00%
20.00%
40.00%
60.00%
80.00%
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8N=809 N=857 N=892 N=885N=134 N=574 N=896 N=909
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As Expected, Web Use was Not High but Alternative Methods are Always Available
0%10%20%30%40%50%60%70%80%90%
100%
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8
TelephoneWebIVR
Method of Data Entry by Beneficiary by Quarter
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High Success in Changing Beneficiary Behavior
• 63.8% of smokers reported compliance with decreasing or abstaining from smoking
• 98% of recipients reported compliance with prescription drug therapy
• 92.5% of recipients reported compliance with dietary restrictions related to CHF
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• Lack of experience with DM programs• Fewer physicians accept Medicaid
• Lower reimbursement rates
• Challenging population
• Little coordination of care• Lack of traditional relationship with PCP
• ER often used as overflow mechanism
• Few rural physicians• Beneficiaries with unmet health needs
• Lower adherence to best practices• No incentives or oversight
Medicaid-specific Challenges:Providers
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Provider Objections Can Be Overcome by Adapting Outreach Efforts
• Improving DM experience and acceptance
• Detailed high volume physicians and clinics
• AHCA letters to providers encouraging their participation
• Sponsored Grand Rounds at Medicaid-dense hospitals
• Supporting best practice adherence
• Initiated incentive study to determine effectiveness of incentives
to drive best practices, ACE Inhibitor usage, etc.
• Enhancing coordination of care
• Reports to physicians on quarterly basis and when patient
experiences validated out of bounds clinical event (exception
reporting)
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Valuable Information was Given to Providers about their Patients
Exception Report Reasons - Year 2
12.1%4.60%7.10%13.5%
16.4%
18.20%
28.20%
0%10%20%30%40%50%60%70%80%90%
100%
1
Weight Gain
BP or Pulse
Chest Discomfort
Shortness of Breath
Swelling
MedicationDiscrepencyOther
22© 2003 LifeMasters Supported SelfCare
Providers Participated Actively in the Program by Responding to the Reports
Provider Response Time to Exception Reports by Quarter
8 7 %8 1%
7 2 %
6 1%
7 3 %
8 5 %7 6 % 7 6 %
9 5 % 9 6 %9 0 %
8 4 %9 3 % 9 5 % 9 2 % 9 0 %
0
20
40
60
80
100
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8
< or = to 3 Days < or = to 7 Days
23© 2003 LifeMasters Supported SelfCare
3,000 PatientsBaseline year = 7/1/98 to 6/30/99 (adjusted for Medicaid Budget increases and North Florida expense)Measurement year = 9/1/00 to 8/31/01
First year Results on a Total CHF Population – Florida Medicaid*
$0
$5,000,000
$10,000,000
$15,000,000
$20,000,000
$25,000,000
$30,000,000
Baseline Year One
*Preliminary results pending final AHCA approval
Program Cost
Claims Cost
Claims Cost
9%
24© 2003 LifeMasters Supported SelfCare
• Baseline & measurement methodology• Establishing financial and quality metrics that
accurately measure program performance• Adjusting for changes in population demographics,
disease prevalence & severity, inflation• Identifying excluded services & members• Dealing with eligibility issues
• Data exchange• AHCA driven identification process• No data in advance to perform stratification• Retroactivity and eligibility issues in quarterly data
refreshes• Incomplete beneficiary and provider data
Medicaid-Specific Challenges: Contracting and Implementation
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• Timing• Very early DM program with little precedent -
negotiation took a year• CMS (HCFA) waiver approval took 18 months
• Politics• Aggressive Savings Guarantees & Fee Risk
(Legislature had proactively reduced AHCA budget anticipating DM savings)
• OPPAGA Audit right when LM program was beginning
Medicaid-Specific Challenges: Contracting and Implementation
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• Identify and codify program design, expected outcomes, baseline, and data exchange up front
• Employ a proactive vs. reactive approach with Beneficiaries and Providers
• Monitoring is essential as early warning of clinical exacerbation for severe CHF patients
• Manage the entire person including life issues• Co-morbidities must be managed and population
programs work best (no more “disease of the month”)• Enrollment must be fast & creative to achieve optimal
outcomes• Combined telephonic/local approach works best• Identify & solve communication issues early – use
methods best suited to population/individual
Lessons Learned
27© 2003 LifeMasters Supported SelfCare
Florida Medicaid Disease Management:Challenges, Successes and Lessons for the FutureChristobel E. Selecky, Chief Executive OfficerLifeMasters Supported SelfCare, Inc.
Third National Disease Management SummitBaltimore, MarylandMay 13, 2003
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