Disease management expands from Medicaid to Medicare


CMS to set up several disease management pilots as part of the Medicare act



Disease management expands from Medicaid to Medicare

Disease management (DM) is moving into the mainstream. Medicaid agencies in Florida, Louisiana, and other states have been using DM for several years. Now Medicare is coming aboard the bandwagon. "The Centers for Medicare & Medicaid Services is finally considering itself a payer, the biggest we have," said Dan Garrett, senior director, medication adherence programs, at the American Pharmacists Association Foundation. "It is seeing other payers paying for care, not for sickness. CMS wants that difference."

In April, CMS announced a pilot project with up to 300,000 fee-for- service beneficiaries in 10 regions. The three-year trial will focus on diabetes, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). The agency's Voluntary Chronic Care Improvement Program is part of the 2003 Medicare Modernization Act, which is better known for creating the Medicare Part D prescription drug benefit. Groups providing care services will get a monthly fee per participating beneficiary. Payments are linked to quality of care, beneficiary and provider satisfaction, and financial savings to CMS compared with control groups.

CMS administrator Mark McClellan told a House Ways & Means subcommittee panel in May that if the pilot is successful, DM could be rolled out nationwide in late 2006. CMS is not saying how many disease management applications it received. A senior program official said an informational meeting it held recently was packed. More than 550 potential applicants attended in person and another 200 by telephone. "Our goal is to make as many awards as soon as possible," he told Drug Topics.

Disease management may be new to Medicare but not to Medicaid. CMS is encouraging more state Medicaid agencies to implement DM programs by offering federal matching funds. In a February letter to state Medicaid agencies, CMS suggested several models, including:

• States may contract with a disease management organization (DMO) to manage overall care. The capitated contract may not restrict access to other Medicaid services.

• States may also create a primary care case management (PCCM) program to enhance care for enrollees with chronic conditions.

• Individual providers, including R.Ph.s, can also contract with state agencies to provide management services.

Improved outcomes

According to Sandy Blake of outcomes research at the University of Louisiana at Monroe, Medicaid isn't just using DM on the more prevalent diseases such as asthma and diabetes. "It's managing CHF, COPD, and other diseases. Many studies show that these kinds of interventions improve outcomes," she said.

The financial impact is less clear. Earlier this year, the Florida legislature voted to end a Medicaid disease management contract with Pfizer Health Solutions (PHS) when the contract expires in 2005. Legislators said the program saved $7.9 million in its first year, far less than anticipated. Pfizer said legislators acted too soon with very little data. DM can change patient behavior and utilization patterns in a few months, explained PHS VP John Sory, but the financial impact lags by 18 to 24 months. "When we release results of the program's first two years, Florida will see that this has saved far more than we anticipated," he said. "We expect the decision to be reopened."

The financial reward is less of an issue for Blue Cross Blue Shield of Oklahoma. BCBSOK is expanding InformaCare, the same PHS chronic care management program that Florida walked away from. Calling its program "Health Promotion," BCBSOK saved $1.6 million in direct costs for diabetes care alone from inception in 2000 through 2002.

APhA is spreading the same message with a pharmacy slant. The APhA Foundation launched five 12-month pilot programs called "Patient Self-Management: Diabetes" in 2003.

The program aims to replicate pharmacy-based DM as practiced in Asheville, N.C. The self-insured city uses financial incentives to link R.Ph.s and city employees suffering from diabetes, asthma, hypertension, and hyperlipidemia. Pharmacists are paid to monitor and counsel patients on diet, exercise, stress reduction, medication usage, and physician referrals. The city offers free medications and supplies as long as patients see their pharmacist coach/cheerleader/case manager monthly. City risk manager John Miall said Asheville is getting a four-to-one return on its investment.

Wisconsin pharmacist Brian Jensen coordinates an APhA pilot covering 16,000 lives in Manitowoc County. The pharmacy-based DM program is developing a contract to cover state employees across the state. About 90% of state employees are in managed care groups.

Another DM advocate is Allen Nichol, R.Ph., who has been coaching patients for 12 years. As director of diabetes management, he oversees care for 230 diabetes patients in the Grandview Family Practice, a Columbus, Ohio, physician group. The average blood pressure for his patients is 126/78; more than 67% are below 135/85. The average hemoglobin A1c is 7.1; 64% are below 7, and 72% have cholesterol levels below 200. The annual management cost per patient is about $400.

"Overall, 64% of my patients have met all three goals," Nichol said. "The national average is 4%. CMS knows what it wants from disease management, it just doesn't know that pharmacists already know how to do it."

Fred Gebhart


Fred Gebhart. Disease management expands from Medicaid to Medicare.

Drug Topics

Sep. 13, 2004;148:26.

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