COMMUNITY PRACTICE

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.

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