Disease Management and Medicaid Waiver Services for HIV/AIDS Patients. Medicaid Disease Management


A 2003 study of three Medicaid DM programs (for all chronic conditions, not HIV-specific DM) indicated that the states’ varied program designs produced short-term net savings and improved outcomes in their patient populations (Gillespie & Rossiter, 2003). Because of the variability in the programs reviewed and the range of chronic conditions addressed by the programs, it is difficult to generalize about the overall effectiveness of DM. However, these three states’ programs provide examples of how Medicaid can address the needs of low-income and elderly patients using DM. In February 2004, CMS urged states to adopt programs to help Medicaid patients with chronic illnesses better manage their diseases. In a letter to state Medicaid officials, CMS announced it would match state costs of running DM programs aimed at improving health outcomes while lowering the medical costs associated with these diseases. CMS suggested three models that states might use that would be eligible for federal matching funds:

  1. States can contract with a disease management organization (DMO) that manages the overall care of the beneficiary but does not restrict access to other Medicaid services. A state can pay the DMO a capped amount per beneficiary with the organization being responsible for any expenses over the set amount;
  2. States can establish a primary care case management program (PCCM), whereby the state works with PCCM providers to enhance the care it delivers to enrollees with chronic conditions; or
  3. Individual providers (physicians, pharmacists, or dietitians) can contract with states to provide DM services.

State legislatures have shown interest in DM primarily as a cost containment tool, and according to the National Conference of State Legislatures, 26 states have passed laws specifically addressing DM. In addition to using disease management in Medicaid, some state health departments encourage their public health clinics and public hospital systems to incorporate DM approaches in their care delivery. Currently, there is only a limited amount of information available about Medicaid DM program outcomes and even less data available specifically concerning Medicaid HIV disease management. Clinical quality management is a common operational component of state Medicaid programs, but budget constraints frequently limit the amount of resources dedicated to producing rigorous, independent evaluation reports. As the interest in DM expands, more information should be made available about the models that have been used and what their impacts were.

New Hampshire, Oregon, Texas, and Washington are states that provide Medicaid disease management for common chronic illnesses such as asthma and diabetes, but not for HIV disease. The chronic diseases commonly targeted in Medicaid disease management are the same high-cost conditions most frequently targeted in commercial disease management programs: congestive heart failure, diabetes, asthma, chronic renal failure, lung diseases, and hypertension. In general, Medicaid disease management programs do not target mental illness or patients dually eligible for Medicaid and Medicare even though these individuals represent a large proportion of Medicaid enrollees with chronic conditions (Williams, 2004). The reason may be an assumption about the degree to which these high-cost populations can realistically be managed by DM interventions, due to their need for a wide range of services; or the behavior changes needed for self-management may be more difficult among these populations.

McKesson Corporation is a vendor that has operated Medicaid DM programs for a variety of chronic illnesses in several states. Another separate branch of McKesson’s business is a licensed wholesale distributor of oncology and specialty pharmaceuticals. McKesson’s National Committee for Quality Assurance (NCQA)-accredited DM programs are for diabetes, asthma, and heart failure. McKesson has implemented DM for Medicare managed care populations in addition to DM for Medicaid, and has publicly reported results from only select programs. For example, New Hampshire’s program for more than 4,400 Medicaid clients with asthma, diabetes, heart failure, coronary artery disease, chronic obstructive pulmonary disease, end stage renal disease and chronic kidney disease generated $4.8 million net savings to the state over two years. McKesson also reported that the New Hampshire Medicaid DM program led to a 12 percent reduction in emergency department costs in the program’s second year. Too few states have conducted independent evaluations of their Medicaid disease management programs, but perhaps as their experience with DM grows, they may publish findings about their program outcomes.

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