University of California, Office of the President

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1 CALIFORNIA PROGRAM POLICY RESEARCH O N ACCESS CENTER T O CARE Califor nia California Policy Program Resear on Access c h to Center Care University California University of California, Office of the President POLICY BRIEFING C O O R D INA T I N G M EDI - C A L C ARE FOR V U L N E R A B L E P O P U L ATI O N S : B LIND, D I S A B L E D, ELDERLY A N D PERSONS LIVIN G WITH HIV Wednesday, April 26, :00 p.m. to 4:00 p.m. California Secretary of State-Multi-Purpose Room th Street, Sacramento A G E N D A 1:00 p.m. INTRODUCTIONS BY CO-CONVENERS: CPAC AND UARP Gilbert Ojeda, Director, CPAC, UC Office of the President George Lemp, Dr. PH, Director, Universitywide AIDS Research Program, UC Office of the President PRESENTATION PANEL (20 minute presentations followed by 5 minute Q&A sessions) Moderator: Albert Lowey-Ball, MS, MA, Medi-Cal Advisor to CPAC 1:10 p.m. Access to Medicaid and its Impact on Insurance Coverage and Treatment of HIV+ Individuals" Arleen Leibowitz, PhD, Professor, Public Policy, School of Public Affairs, UC Los Angeles Neeraj Sood, PhD, Associate Professor and Economist RAND Corporation 1:35 p.m. The Impact of Medi-Cal Restructuring on Care of Beneficiaries with HIV/AIDS David Zingmond, MD, PhD, Associate Professor, Department of Medicine, UC Los Angeles 2:00 p.m. How Health Plans Coordinate Care to Vulnerable Medi-Cal Populations David Meadows, Vice President, State Health Programs, Health Net of California Janice Milligan, RN, Director of Strategy and Business Development, State Health Programs, Health Net of California 2:25 p.m. Medi-Cal Issues in Chronic Care Management Andrew Bindman, MD, Professor, School of Medicine, UC San Francisco 2:50 p.m. DISCUSSION PANEL (10 minutes each) Stan Rosenstein, Deputy Director, Medical Care Services, California Department of Health Services Bryon McDonald, Project Manager, World Institute of Disability, Berkeley Donald Lyman, MD, Chief, Division of Chronic Disease and Injury Prevention, California Department of Health Services

2 Access to Medicaid and its Impact on Insurance Coverage and Treatment of HIV+ Individuals Neeraj Sood (With Arleen Leibowitz & Arkadipta Ghosh) April 26, 2006

3 Medicaid is a Large and Growing Component of State Expenditure Second largest program in most states general fund budgets - accounts for 15-17% of state spending (Kaiser Commission, 2005) Also, the fastest growing state expenditure category - Grew at 13% in FY 2002 (Hoadley et al., 2004) - Moderated, but still growing at 7.5% in FY 2005 (Smith et al., 2005) 2

4 States have enacted several measures to reduce Medicaid costs Common cost containment policies: cutting or freezing provider payments, trimming benefits and premiums restricting eligibility In FY Provider payment rate changes were enforced in all states (except MA) and DC - 7 states reduced benefits (ID, LA, ME, NM, NC, OR, SC) - 8 introduced eligibility cuts (DE, ME, MS, MO, NM, OR, PA, TN) (Source: Kaiser Commission on Medicaid and the Uninsured, 2005) 3

5 Effect of Cost-containment on Insurance Coverage & Health Status Some evidence that charging premiums increases both disenrollment and the number of uninsured (Artiga & O Malley; 2005) Effects of more stringent income eligibility criteria on insurance coverage & treatment less clear -- for particularly vulnerable populations like the PLH 4

6 Research Questions How would changes in Medicaid eligibility affect insurance coverage of PLH? Replace with private insurance? Or become uninsured? What is the impact of changes in Medicaid eligibility on the use of antiretroviral therapy (HAART)? Are the disabled differentially affected? 5

7 Data HCSUS baseline data merged with database on states Medicaid eligibility rules Nationally representative sample of HIV+ persons in care in 1996 Detailed information on demographics, health, treatment and insurance coverage Also included state level data on unemployment and uninsurance rates 6

8 Methods: Medicaid Eligibility, Insurance & HAART Use Estimate how insurance coverage (None, Private, Medicaid, Medicare) and HAART use relate statistically to: State Medicaid eligibility, measured by Medically- Needy Threshold Individual health and demographics State unemployment and uninsurance rates Census region 7

9 Restricting Eligibility Increases Uninsurance & has No Effect on Private Coverage Medically Needy Threshold None Private Medicaid 0 8 0

10 Restricting Eligibility Reduces HAART Use Medically Needy Threshold HAART 9

11 What About the Disabled? Almost half the respondents in HCSUS are currently not working due to disability Frequency Percent Disabled 1, Non-disabled 1, Total 2,

12 Hypothesis Restricting Medicaid eligibility will affect the disabled more because they lack private insurance options Employer based coverage Individual insurance policies 11

13 Restricting Eligibility Increases Uninsurance with a larger impact on the Disabled Medically Needy Threshold 20 0 No Insurance (All) No Insurance (Disabled) Medicaid (All) Medicaid (Disabled)

14 Restricting Eligibility Reduces HAART Use with a larger impact on the Disabled Medically Needy Threshold All Disabled 13

15 Results are Supported by Previous Findings Bhattacharya, Goldman, & Sood (2003): Both public and private insurance facilitates treatment and prevents premature death among the PLH 66% decline in one-year mortality with public insurance 79% decline in one-year mortality with private insurance.. Extending public insurance coverage to HIV+ patients in the early stage of the disease. might prevent a significant number of premature HIV related deaths. 14

16 Conclusion Lower Medicaid Eligibility thresholds are likely to raise uninsurance rates and reduce HAART use Lower eligibility thresholds reduce Medicaid coverage but have negligible effect on private coverage No crowd out effects for HIV+ population even though such effects might exist for other Medicaid populations Lower eligibility thresholds are likely to have a larger effect on uninsurance rates and HAART use among the disabled and unemployed 15

17 Impact of Medi-Cal managed care enrollment on persons with AIDS: implications for Medi-Cal restructuring David Zingmond MD, PhD, Thomas Rice PhD, and William Cunningham MD, MPH UCLA Schools of Medicine and Public Health

18 Background Medi-Cal is a major provider for Californians living with HIV/AIDS. Between 1/4 and 1/3 of Californians with AIDS are enrolled in Medi-Cal. Monthly census is > 24,000 enrollees living with HIV or AIDS Medi-Cal pays for more than half of all AIDS hospitalizations in CA each year.

19 Background In Medi-Cal, fee-for-service (FFS) is the traditional model, but voluntary and mandatory enrollment in managed care (MCP) programs has been implemented. ~15% of enrollees with AIDS are in MCPs Half have mandatory MCP enrollment.

20 Medi-Cal Managed Care Implementation Two-Plan Model - 2 not-for-profit Managed Care Plans voluntary enrollment GMC - 6 or more Managed Care Plans voluntary enrollment COHS - 1 county-operated Managed Care Plan mandatory enrollment Other limited provider plan participation Fee-For-Service - Rural counties

21 Background Mandatory MCP enrollment for all aged, blind, and disabled enrollees has been proposed to save money and improve the efficiency of care in Medi-Cal. The impact of mandatory MCP enrollment on the care and outcomes of Medi-Cal enrollees with AIDS is not well known.

22 Study Objectives 1. Determine characteristics of Medi-Cal FFS/ Managed Care Plan (MCP) enrollees. 2. Examine the impact of FFS/MCP enrollment on clinical outcomes. 3. Identify the impact of FFS/MCP enrollment on plan switching and disenrollment. 4. Compare current MCP capitation rates to estimated costs of care. 5. Examine PCP vs. specialist visits and ARV use as indicators of MD readiness for MCP participation.

23 Methods

24 Data Sources 1 Linked patient level data - Medi-Cal Eligibility files - Medi-Cal FFS claims - California AIDS Registry - California (OSHPD) hospital discharge records - California Death Statistical Master File Mean capitation rates for TPM MCPs

25 Data Sources 2 Linked provider level data - Medi-Cal provider file - Medi-Cal FFS claims - American Academy of HIV Medicine - membership - ABIM I.D. board certification

26 Cohort Enrollment and Outcome analyses Medi-Cal enrollment Jan 2000 to Dec 2003 Living in TPM and GMC counties AIDS verified by the AIDS Registry > 20 years old Cost and physician readiness analyses Medi-Cal Enrollment (MD) or 2003 (cost) Not enrolled in Medicare Living in TPM and GMC counties AIDS verified by the AIDS Registry > 20 years old

27 Dependent Measures Clinical outcomes time to death, time to hospitalization Enrollment time to disenrollment, time to plan change Cost estimated non-arv costs (vs. cap. Rates) MD Readiness PCP visit, specialist visit, use of ARV

28 Independent Measures Demographics - age, race, sex, residence location, time enrolled in Medi-Cal, dual Medicare enrollment Disease measures - exposure route, time with AIDS, Severity Classification of AIDS Hospitalizations (SCAH) Other severity measures - hospitalization in past two years

29 Analytic Methods Bivariate comparisons of independent and dependent variables by MCP/FFS enrollment Chi square and t-tests Time to event analyses Unadjusted comparisons (KM curves) Cox multivariate regressions Cost analyses GEE with gamma model and log-link function MD Readiness Multivariate logistic regressions

30 Results

31 1. Determine characteristics of Medi- Cal FFS/ Managed Care Plan (MCP) enrollees. 2. Examine the impact of FFS/MCP enrollment on clinical outcomes. 3. Identify the impact of FFS/MCP enrollment on plan switching and disenrollment. 4. Compare current MCP capitation rates to estimated costs of care. 5. Examine PCP vs. specialist visits and ARV use as indicators of MD readiness for MCP participation.

32 Demographics Variable N Male (%) Age (mean; years) Race (%) White Black FFS MCP 11,004 1, ** Latino Asian 2 3 Other/Unknown 1 1 Time enrolled (median; mths) ** *

33 Case-Mix Severity Variable FFS MCP HIV Exposure Risk Factors (%) ** MSM-IVDU MSM IVDU Blood Product 0 0 Heterosexual exposure 8 16 Other/Unknown 7 8 Time with AIDS (mean; years) 5 5 Severity of AIDS (SCAH; %) ** Hospitalization in the past 2 yrs (%) **

34 1. Determine characteristics of Medi-Cal FFS/ Managed Care Plan (MCP) enrollees. 2. Examine the impact of FFS/MCP enrollment on clinical outcomes. 3. Identify the impact of FFS/MCP enrollment on plan switching and disenrollment. 4. Compare current MCP capitation rates to estimated costs of care. 5. Examine PCP vs. specialist visits and ARV use as indicators of MD readiness for MCP participation.

35 Mortality P = 0.020

36 Hospitalization P < 0.001

37 Disenrollment from Medi-Cal P = 0.034

38 Medi-Cal Plan Change P < 0.001

39 Multivariate Results: Clinical Outcomes and Enrollment HR 95% CI Clinical Outcomes Mortality Hospitalization Enrollment Disenrollment Plan Change Multivariate Cox regression analyses controlling for age, race, sex, risk factor exposure, time AIDS, SCAH, Charlson Index, hospitalization in past two years, time enrolled in Medi-Cal, with clustering for county of residence.

40 1. Determine characteristics of Medi-Cal FFS/ Managed Care Plan (MCP) enrollees. 2. Examine the impact of FFS/MCP enrollment on clinical outcomes. 3. Identify the impact of FFS/MCP enrollment on plan switching and disenrollment. 4. Compare current MCP capitation rates to estimated costs of care. 5. Examine PCP vs. specialist visits and ARV use as indicators of MD readiness for MCP participation.

41 Average Monthly FFS Costs non-er ambulatory visit $24 ER visit $4 Hospital $134 Total Mental Health $61 Other Medications $641 Other Tests / Treatments $277 Anti-Retroviral Treatment Costs $784 Sub-total: non-arv Costs $1,142 Total $1,926 Patients enrolled only in FFS Medi-Cal only in TPM/GMC counties in N = 6,376

42 Estimated non-arv Costs vs. TPM Capitation Rates Estimated non- ARV Costs Average TPM Capitation Rates $974 $1,308 N = 499; TPM MCP Enrollees in the 11 TPM Counties in 2003 Dual Medicare enrollees excluded.

43 1. Determine characteristics of Medi-Cal FFS/ Managed Care Plan (MCP) enrollees. 2. Examine the impact of FFS/MCP enrollment on clinical outcomes. 3. Identify the impact of FFS/MCP enrollment on plan switching and disenrollment. 4. Compare current MCP capitation rates to estimated costs of care. 5. Examine PCP vs. specialist visits and ARV use as indicators of MD readiness for MCP participation.

44 Physician Availability Spec non- Spec Total # Doctors 101 3,534 3,635 # enrollees / MD Ave # visits / MD N = 6,316 Medi-Cal only FFS enrollees with AIDS in TPM/GMC counties Providers / ambulatory care visits in in TPM/GMC counties Specialty Doctors HIV Society membership or I.D. specialist Visits to doctors in

45 Outpatient Visits for Patients Variable % mean # visits / Pt with visit median # visits / Pt with visit Any outpatient visit Any primary care visit MD was an HIV-MD Any ER visit Any hospitalization 45 - Death in '02 or ' N=6,316; Visit characteristics from for FFS Medi-Cal only enrollees with AIDS living in TPM/GMC counties

46 Multivariate Predictors of PMD Visit OR 95% CI Latino ** years * years ** Risky sexual exposure * SCAH = ** Months in Medi-Cal ** P Multivariate logistic regression, FFS Medi-Cal only enrollees with AIDS living in TPM/GMC counties in , N = 6,316 1 vs. non-latino Whites; 2 vs years old; 3 vs. MSM; 4 vs. SCAH = 0

47 Impact of Having an HIV Provider Use of ARV HAART Use (%) Any ARV Usage (%) Provider Type (%) ** ** HIV Provider Other Provider No Provider ARV Any Antiretroviral Therapy; HAART Highly Active Antiretroviral Therapy HAART or ARV in the last month of enrollment for persons with AIDS in

48 Impact of Having an HIV Provider Use of ARV Any HAART Any ARV OR 95% CI P OR 95% CI P Provider Type (%) HIV Provider Other Provider No Provider ARV Any Antiretroviral Therapy; HAART Highly Active Antiretroviral Therapy HAART or ARV in the last month of enrollment for persons with AIDS in Multivariate logistic regression accounting for age, gender, race, exposure, SCAH, hospitalization, time w/aids, time in MCD, distance to the closest high volume provider.

49 Discussion Clinical Outcomes Although MCP patients appear healthier, riskadjusted outcomes do not differ between MCP and FFS enrollees. - Prior work in the study of MCPs suggests patient selection is an important factor in unadjusted differences in outcomes and utilization. - Patients who voluntarily enroll in managed care are likely to be healthier, thus requiring lesser amounts of care.

50 Discussion - Enrollment MCP enrollees are more likely to change to FFS enrollment than those in FFS to MCP. - Switching from MCP to traditional FFS Medi-Cal may be a marker for patient dissatisfaction or access issues. - Together, these raise important questions regarding the appropriateness of current managed care implementations for chronically ill populations.

51 Discussion Capitation Rates Lower predicted costs of care among MCP enrollees suggest overly generous payments for care. - This indicates potentially inefficient use of resources. - It undercuts the argument of cost-savings among MCP enrollees. - May represent information asymmetry between MCPs and Medi-Cal. - MCPs may be offering additional care.

52 Discussion MD Readiness A large number of providers are seeing HIV-infected patients at this time. However, relatively few providers are seeing the large majority of cases. The highest volume providers tend to be institutional providers, but some individuals do see a large number of cases. There are high volume providers in all counties.

53 Discussion MD Readiness Identifiable HIV specialists are different. They tend to have many more encounters than non-specialists. HIV providers appear to deliver better care (as measured by patient ARV usage).

54 Discussion Identifiable use of ambulatory care by patients appears to low. < 40% of MCD FFS patients had a PMD visit. Only 11% of persons with a PMD had an HIV specialist as a PMD. Latinos & persons with high risk sexual exposure are less likely to get PMD, but overall rates are just too low.

55 Limitations Retrospective observational study. Results and conclusions may not be generalizable to other regions, MCP arrangements, or other ill populations. MD readiness results limited to persons with AIDS in MCD-only in TPM/GMC counties. MCR enrollees appear to have underreporting of physician encounters. MCP enrollees do not have reliable claims. Analyses likely undercount HIV specialists.

56 Conclusions There are no compelling benefits for the currently proposed mandatory enrollment of the Medi-Cal AIDS population into MCPs. 1. MCP pts are healthier than FFS pts. 2. MCP & FFS pts have similar outcomes. 3. MCP enrollees are more likely to leave MCPs they may have lower satisfaction. 4. Current TPM reimbursements appear overly generous vs. estimated FFS costs.

57 Conclusions Access to providers already appears limited. - Care for pts is concentrated in a small number of providers. - Pts do not appear to have adequate numbers of office visits to PMDs. - MCPs will have to focus on identifying and retaining specialty providers.

58 Stage of Disease Overall County Type County AIDS Unknown COHS Monterey Napa Orange San Mateo Santa Barbara Santa Cruz Solano Subtotal 1,038 1,017 2,055 GMC Sacramento ,109 San Diego 1,336 1,125 2,461 Subtotal 1,831 1,739 3,570 TPM Alameda ,677 Contra Costa Fresno Kern Los Angeles 4,762 6,534 11,296 Riverside ,086 San Bernardino ,107 San Francisco 2,212 1,698 3,910 San Joaquin Santa Clara Stanislaus Tulare Subtotal 10,072 12,263 22,335 Rural 1,006 1,416 2,422 Total 13,947 16,435 30,382

59 AIDS Patients by County FFS No MCR MCR MCP Total Alameda Contra Costa Fresno Kern Los Angeles 2,606 2,108 1,094 5,808 Riverside Sacramento San Bernardino San Diego ,507 San Francisco 1,190 1, ,502 San Joaquin Santa Clara Stanislaus Tulare Total 6,316 6,238 1,612 14,166 Enrollees with Verified AIDS in TPM / GMC Counties, 2002

60 Cost Estimates by County County Name Obs Est. Monthly Costs ($) SE ($) Ave Monthly Cap. Rate ($) Alameda ,396 ** Contra Costa ,225 ** Fresno ,298 ** Kern 20 1,453 2,687 1,263 Los Angeles 264 1, ,307 ** Riverside ,226 ** San Bernardino ,283 ** San Francisco 34 1, ,400 ** San Joaquin ,226 * Santa Clara ,458 ** Stanislaus 3 1, ,180 Tulare ,305 ** Overall ,308 ** AIDS Health Care Foundation 345 1,

61 Number of Doctors by County non- HIV HIV Total Alameda Contra Costa Fresno Kern Los Angeles 1, ,889 Riverside Sacramento San Bernardino San Diego San Francisco San Joaquin Santa Clara Stanislaus Tulare Total 3, ,635 Providers who saw patients for ambulatory care in HIV Doctors Society membership, board certification, or ID reported services by Medi-Cal claims.

62 Number of Patients to Doctors non- HIV HIV Total Alameda Contra Costa Fresno Kern Los Angeles Riverside Sacramento San Bernardino San Diego San Francisco San Joaquin Santa Clara Stanislaus Tulare Total Ratio of FFS AIDS Pts to Providers who saw patients for ambulatory care in HIV Doctors Society membership, board certification, or ID reported services by Medi-Cal claims.

63 Average Pt Visits to Doctor HIV MD non-hiv MD N Mean N Mean Alameda Contra Costa Fresno Kern Los Angeles , Riverside Sacramento San Bernardino San Diego San Francisco San Joaquin Santa Clara Stanislaus Tulare Overall , Providers who saw HIV/AIDS patients for ambulatory care in HIV Doctors Society membership, board certification, or ID reported services by Medi-Cal claims. Average # MCD-only visits to doctors in

64 Case Volume: # of Pts Seen Quintile # MDs Pts / Range MD Min Max , Overall 3, Results stratified by equal # s of total patients seen per quintile

65 Case Volume: # of Visits Quintile # MDs Visits Range / MD Min Max 1 9 1, , , Overall 3, ,824 Results stratified by equal # s of total pt visits per quintile

66 Who Are the High Volume Providers? 24 / 48 providers by # of visits are individuals The top five providers by # of visits were all group / institutional providers

67 Patient Characteristics Associated with a PMD Visit N=6,316 Had a PMD Visit Yes No N 2,378 3,938 Male (%) Race (%) White Black Latino Asian 3 3 Other 1 1 Age (%) < 20 years years years years years years 3 3 ** **

68 Patient Characteristics Associated with a PMD Visit N=6,316 Had a PMD Visit Yes No N 2,378 3,938 Risk Exposure (%) MSM-IVDU MSM IVDU Transfusion 0 0 Risky sexual exposure Other or Unknown 9 10 SCAH (%) ** Charlson (%) ** No hospitalization to to to > 6 1 1

69 Patient Characteristics Associated with a PMD Visit Had a PMD Visit Yes No N 2,378 3,938 Hospitalization, past 2 yrs (%) * Years with AIDS (mean) ** Months in Medi-Cal (mean) ** Miles to HVP (mean) Miles to HVP (90% ptile) PMD is an HIV MD (%) 11 - N=6,316

70 Multivariate Predictors of PMD Visit OR 95% CI P Race (%) White Black Latino Asian Other Age (%) years years years years years

71 Multivariate Predictors of PMD Visit OR 95% CI P Risk Exposure (%) MSM-IVDU MSM IVDU Transfusion Risky sexual exposure Other or Unknown SCAH (%) Months in Medi-Cal (mean) Not significant: male, past hospitalization, yrs w/aids, & distance

72 Coordinating Care to Vulnerable Medi-Cal Populations Dave Meadows Vice President, State Health Programs Health Net of California Jennifer Nuovo, MD Regional Medical Director, State Health Programs Health Net of California April 26, 2006

73 Overview Health Net is one of the largest health plans in California Health Net has: More than 2.5 million members in California Nearly 700,000 Medi-Cal, Healthy Families, AIM, and Healthy Kids members Nationally, more than 5.3 million members in 14 states including Medicaid in Connecticut and New Jersey More than 48,000 doctors 750 physician group locations 4,600 pharmacies

74 Recent Program Additions Medicare: Special Needs Plan in Los Angeles, Kern and Orange counties Healthy Kids: Children s Health Initiatives -- health plans for kids not eligible for Medi-Cal or Healthy Families Kern, Tulare, Fresno, Sacramento, Colusa, Yuba and El Dorado counties

75 Medi-Cal MCH Experience Majority of Medi-Cal Managed Care members are children and their mothers Improved outcomes are a result of an integrated health care delivery system designed to meet the needs of vulnerable populations Rather than recreate the wheel, Health Net sought out and contracted traditional and safety net providers Developed coordination of care agreements with over 20 maternal and child health programs

76 Medi-Cal MCH Experience (cont.) Adopted Comprehensive Perinatal Services Program (CPSP) provider standards Adopted Child Health and Disability Prevention (CHDP) Program provider standards and procedures Implemented the Children with Special Health Care Needs (CSHCN) best practices for screening and coordinating care, including coordination with California Children s Services (CCS), schools, Early Start and Regional Centers

77 SPD Enrollment Growth Cumulative SPD Enrollment Growth Rate Compared to Overall Enrollment 9.0% 8.5% 8.0% 7.5% 7.0% 6.5% 6.0% 5.5% 5.0% 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% -0.5% -1.0% -1.5% -2.0% -2.5% Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 HN SPD Cumulative Growth Rate HN Overall Cumulative Growth Rate Total Managed Care Cumulative Growth Rate

78 Medi-Cal Managed Care Expansion January 2005, Governor proposes to expand the Medi-Cal Managed Care program to include seniors and persons with disabilities (SPDs) Health Net has retained consultants from the Centers for Disabilities at Western University to conduct an internal readiness assessment to facilitate the physical and communication pathways needed for the SPD population to access services, including: development of enhanced delivery system development of policies and procedures that outline Health Net s enhanced program to facilitate effective health care services for SPD membership

79 Access Access means Ability to get timely needed services Availability of services Awareness that services exist and how to obtain them Access elements Physical and equipment Communication and attitude Competent services and programs June Isaacson Kales, MSW, LCSW

80 SPD Expansion Health Net s objectives: Create corporate culture that can meet the needs of persons with disabilities Increase understanding of health care access issues for people with disabilities Increase understanding of how providers can better serve people with disabilities Expand our health care network to include specialty providers and programs June Isaacson Kales, MSW, LCSW

81 SPD Expansion Health Net s training and site certification activities: Participated in OPA disability survey Enhanced primary care facility site review launched in Los Angeles County Developed alternative format health plan materials Enhanced line staff disability training

82 Medi-Cal Managed Care Health Care Coordination Challenges to current system: Existing State adult case management programs aren t well integrated in health plans Focus has been on preventive care for well populations State s Quality Improvement Programs focus on well populations and/or children Narrow scope of disease state management programs

83 Meeting the Challenges Opportunities: Create a community-model case management program in conjunction with existing agencies Develop primary case management coordination model Expand disease state management programs with an emphasis on dual diagnoses

84 Core Program Components Develop adult initial comprehensive health assessment system Enhance member service outreach to include scheduling appointments and arranging transportation Develop primary care case management provider credentialing system Link to appropriate primary care case management provider based on condition and access

85 Care Management Plan Development Case conference Anticipate health needs Rate acuity Assign delivery network Quarterly case management plan evaluation Contract Formal collaboration/coordination with community-based organizations

86 Integrated Health Plan Case Management Week 1: Initial health screens coordinated by the health plan Member Relations Department, PCP visit scheduled Week 2: Primary care assessment complete Week 3: In-house medical management team case management plan completed and acuity assigned Field Case Managers Health Net employees with provider site case management privileges Onsite with plan electronic management access Responsible for case management plan revision and acuity update

87 Health Plan Case Management Resource Sharing: develop agreements with provider system to augment availability and capacity via grants Examples: equipment, personnel, MD contracts, skilled nursing, wrap-arounds Case management system Examples: case management, plan integration, medical management staff Carve-out program resource integration

88 Health Plan Case Management Choreworker Primary Care Nursing Care DME Member Home Health Meals on Wheels Home Modification Community Based Programs Coordination of Care Program Provider System Prescriptions Physical Therapy Medical Alert System Laboratory Personal Care

89 Chronic Care Management in Medi-Cal Andrew B. Bindman, MD University of California San Francisco April 26, 2006 Work in part supported by the California HealthCare Foundation and California Program on Access to Care

90 Medi-Cal Managed Care Managed care requires beneficiaries to have a regular primary care provider A regular source of care may improve access to care and coordination of services Opportunities for population-based care management to improve quality

91 California Health Interview Survey: Medi-Cal Beneficiaries Reported Access to Care Delivery Model Access/Utilization Measures n Fee-forservice Managed Care p- value Percentage Has usual source of care <0.001 Physician visit prior 12 mos Cervical cancer screening Breast cancer screening Colon cancer screening

92 Annual Hospitalization Rate for Ambulatory Care Sensitive Conditions in Medi-Cal FFS and Managed Care Hospitalization Rate per 1000 Person Years Voluntary Managed Care 58 Mandatory Managed Care 66 Fee-For- Service Source: Office of Statewide Health Planning and Development/Department of Health Services

93 Medi-Cal Managed Care Most of the experience is with TANF population SPD population has substantially greater chronic care needs than TANF population

94 Percentage of Medi-Cal Beneficiaries < 65 Years in Managed Care: All Beneficiaries TANF SPD

95 SPD Beneficiaries Annual Admission Rates in Fee- For-Service (FFS), Mandatory Managed Care (MMC), and Voluntary Managed Care (VMC) for Diabetes Rate per 1000 Person Years FFS 5 MMC 4 VMC Diabetes

96 Effect of Managed Care on the SPD Hospitalization Rates for Ambulatory Care Sensitive Conditions Over Time Year Observed ACS rates with managed care increase Expected ACS rates without managed care increase

97 How Can Medi-Cal Improve Chronic Care Quality? Organizational structure that rewards chronic care quality Physician decision support Patient self-management support Delivery system re-design Linkages with community resources

98 Rewarding Chronic Care Quality Assignment of default patients to higher quality plans is an innovative first step Pay for performance can be tied more specifically to quality of chronic care Need to remove dis-incentive for caring for high cost patients through risk adjustment

99 How Can Medi-Cal Improve Chronic Care Quality? Organizational structure that rewards chronic care quality Physician decision support Patient self-management support Delivery system re-design Linkages with community resources

100 Medi-Cal Care Management Practices for Asthma/Diabetes Medical Directors Report 2/3 provide guideline training 1/2 have registries, patient reminders, and self management support 1/3 use physician reminders Care management practices associated with penetration of Medi-Cal managed care Rittenhouse, Medical Care, 2006

101 Integrating Chronic Care Management Practices Quality improvement is more likely to occur in settings in which multiple care management tools (>4) are coordinated and focused on a clinical problem This is more often done in integrated delivery systems, group practices, and clinics but is seen in some IPA networks as well

102 How Can Medi-Cal Improve Chronic Care Quality? Organizational structure that rewards chronic care quality Physician decision support Patient self-management support Delivery system re-design Linkages with community resources

103

104 Tailor Chronic Care to Medi-Cal Population Characteristics Medi-Cal population has a greater representation of minorities than California population as a whole Medi-Cal population at increased risk for limited health literacy Average reading level = 5th grade Spanish speakers, African Americans, elderly, women more likely to have limited health literacy Limited health literacy impacts knowledge of chronic conditions and ability to do self-care

105 Automated Telephone Disease Management (ATDM) Nurse Diabetes Care Manager ATDM: Weekly Monitoring and Health Education Primary Care Physician Patient Interactive touch tone response technology Weekly surveillance & health education In patients preferred language (English, Spanish or Cantonese) Generates weekly reports of out of range responses Live phone follow-up through a bilingual nurse

106 Computerized Visual Medication Schedule

107 How Can Medi-Cal Improve Chronic Care Quality? Organizational structure that rewards chronic care quality Physician decision support Patient self-management support Delivery system re-design Linkages with community resources

108 Delivery System Re-Design

109 Group Medical Visits Monthly Group Medical Visits -Primary Care Provider -Health Educator -Pharmacist English- Speaking Groups Spanish- Speaking Groups Cantonese- Speaking Groups 6-10 patients in monthly group meetings In patients preferred language (English, Spanish, or Cantonese) Facilitated by a bilingual health educator and a primary care provider A pharmacist present at end of each group visit Encourage patients to become active in self-care through participatory learning and peer education

110 How Can Medi-Cal Improve Chronic Care Quality? Organizational structure that rewards chronic care quality Physician decision support Patient self-management support Delivery system re-design Linkages with community resources

111 Computer kiosk Patient answers questions about physical environment, exercise preferences, and transportation needs. Database Program searches for high-quality, easily-accessible resources for physical activity. Exercise Prescription Do you like to swim? yes Prints out a physical activity prescription, which includes suggestions for community resources to use and directions for how to access those resources. no I don t know

112 Medi-Cal s Opportunities to Improve Chronic Care Quality Provide explicit guidance on standard of care Invest in the development and dissemination of successful care management practices and patient self management approaches Encourage practice re-design and engagement of community resources Evaluate provider performance - process and outcomes Learn from variation Link payment to performance