Medicaid DM program addresses gaps in care

Vulnerable population responds favorably

A Medicaid disease management program represents a huge potential to improve the health of the publicly insured while decreasing overall health care costs, Sandeep Wadhwa, MD, asserts.

"With publicly funded populations, there is usually a greater gap between the standards of care and practices," he adds.

"There are real opportunities to help these people, whose conditions are typically more severe than those in the commercially insured populations," says Wadhwa, vice president of medical management services at McKesson Corp. based in San Francisco.

Several years ago, McKesson made the commitment to use its expertise in disease management for commercial populations and to offer disease management services for Medicaid recipients whose care is not covered by managed care plans.

The company studied Medicaid regulations and adapted its disease management programs to more of a community-based disease management program rather than a health plan model, he says.

"We recognized that there was an unserved need among Medicaid patients and that many companies are reluctant to serve them because of the complex population and regulatory barriers," Wadhwa points out.

"We made a decision a few years ago to make an investment to overcome the barriers and learn to serve that population," he says.

The Medicaid population has a higher prevalence of chronic conditions than commercial populations and represents a tremendous opportunity for savings while improving the health of chronically ill people, he says.

Beginning a program

"There is so much more need with this population. The fact that their health is impairing their quality of life and functional ability, combined with the absence of resources, makes them a good target for disease management," he says.

Washington, Oregon, and Florida were among the first states that signed up for McKesson’s Medicaid disease management programs.

The Centers for Medicare & Medicaid Services (CMS) has begun urging states to adopt programs to help those with chronic illnesses.

"What we are seeing now out of CMS is recognition that these states' early experiences can be translated into benefits for a vulnerable population," Wadhwa says.

Before beginning a program, McKesson gets data from the state Medicaid departments and uses proprietary algorithms and predictive models to identify the patients and determine who is at highest risk.

The McKesson staff also work with hospitals, physicians, and other sources to identify patients who do not have claims data. About 90% of the patients are identified through claims.

The company sends introductory letters to patients’ primary care physicians and notification letters to patients. Depending on the contract with the states, the patients may choose to opt into the program or be automatically enrolled with the choice of opting out.

Identified patients

After the letters are sent, a disease management nurse contacts the patient by telephone or arranges a visit if the patient is in the highest risk group.

All patients identified for the program receive regular educational mailings.

When a beneficiary is identified for the program, McKesson performs an initial assessment that puts the patient into a risk level and generates a plan of care.

Beneficiaries may get more than the specified visit and calls, depending on their understanding of their condition or other needs.

High-risk patients generally receive a call or a visit once a month. About 5% of the population chooses to opt out of the programs, a figure much lower than in many commercial populations.

"They may be transient and have a lot of other pulls for their limited time and resources. We’ve found they really appreciate the service and that we have much higher rates of participation than in our commercial populations," he says.

Geographic analysis

When the company contracts with a state for its Medicaid population, it does a geographic density analysis to decide where the field teams and call center should be located.

For instance, in Mississippi, the nurses are concentrated in the population centers of Jackson, the Delta region, and on the Gulf Coast, with a floating nurse responsible for patients in a big rural area.