Emerging Practices in Medicaid Primary Care Case Management Programs. Disease Management


Disease management strategies can be seen as both a form of quality improvement and a type of member services. The system is better served through appropriate utilization of services leading to lower overall costs; the chronically ill person is better served by having systematic health care that is state-of-the-art for his/her particular illness.

Three case-study states (Florida, North Carolina, and Oklahoma) have developed formalized disease management structures and approaches. Florida has chosen to contract with disease management organizations; sites in North Carolina's ACCESS II and III programs and Oklahoma's program have chosen to develop internal programs. Texas has implemented a special project on diabetes as a pre-curser to a formal disease management program. The Virginia Medicaid agency has a disease management program, but this is considered separate from its PCCM program; the two programs intersect if the PCCM member happens to require disease management assistance.

Florida has hired disease management organizations (DMOs) to serve patients with six chronic illnesses.

  • HIV/AIDS (one vendor covers all but two counties; second vendor covers remaining two counties)
  • Hemophilia (two providers)
  • End stage renal disease (ESRD) (one provider)
  • Congestive heart failure (one provider currently under contract; state is negotiating with second provider)
  • Diabetes (statewide)
  • Asthma (one provider)

Each contractor must guarantee the state 6.5 percent annual savings compared to adjusted baseline per member per month spending for PCCM members with these illnesses.

Approximately 100,000 Floridian PCCM members qualify for one of these DM programs. On a monthly basis, the Medicaid agency analyzes the claims of PCCM members to identify CPT codes that relate to the six illnesses listed above. The state created a claims analysis hierarchy with the first cut for HIV/AIDS, the second for hemophilia, and on down the list. Therefore, a person with both HIV/AIDS and asthma will be served by the HIV/AIDS DMO. The names of individuals with these CPT codes are sent to the appropriate DMOs, which are required to send letters within 30 days informing these individuals about the program. These individuals are automatically enrolled unless they choose to opt out. The DMOs are required to work with the individuals' PCPs. Many DMOs offer additional benefits to participants, such as glucometers for people with diabetes.

The Florida HIV/AIDS DMO distributed to physicians a CD-ROM with state-of-the-practice protocols and guidelines. It provides a comprehensive source of the most up-to-date information for the medical community and a baseline of information in support of the DM initiative. 26

All North Carolina's ACCESS II and III sites have implemented internal asthma disease management programs. One site is currently running diabetes disease management programs; all sites will have such programs within the next year. The sites chose asthma as the first DM initiative based on the following principles: 27

  • There are enough Medicaid members with the disease to obtain a return on investment.
  • Evidence exists that best practices lead to predictable and improved outcomes.
  • Appropriate evidenced-based practice guidelines are available.
  • Physicians will support the process.
  • Patient education and support can improve outcomes.
  • Best practices and outcomes are measurable, reliable, and relevant.
  • There is room for improvement — a gap exists between best practice and everyday practice.
  • The ability exists to measure baseline and thus to be able to measure improvement.

The core elements of the Asthma Disease Management Program were developed by the sites themselves with the help of state staff. The four core elements are listed below and further detailed in Appendix B.

  • Build capacity for routine assessment of asthma.
  • Reduce unintended variation of care and establish consistency of care.
  • Build capacity to educate patients, families, and school personnel about asthma.
  • Regularly report outcomes and process measures to all providers and staff.

With these core elements in place, the participating sites implemented a number of asthma management initiatives.

  • A health risk assessment process;
  • An asthma action/management plan;
  • A process to ensure that a copy of the asthma action plan goes to the patient and family, PCP, and local school/day care;
  • An arrangement with durable medical equipment providers to stock and provide peak flow meters and spacers to Medicaid beneficiaries while they are in the PCP's office;
  • Patient education materials on asthma management;
  • Home and environment assessments on the at-risk asthma population;
  • Provider and provider staff education sessions;
  • Asthma management forms for the PCP and medical records that coordinate care and ease the burden of paperwork; and
  • Shared office processes and best practices.

The group also developed quarterly performance measures for the Asthma Disease Management Program. These take into account both outcomes (e.g., emergency room use rate for asthma) and process (e.g., proportion of asthma patients with an asthma management plan). Outcome information is gathered from claims data. Process information is obtained through chart reviews.

In Oklahoma, participating physicians assess their practices related to diagnosis and treatment. They are expected to follow the National Asthma Education and Prevention (NAEP) guidelines recommended by the National Heart, Lung, and Blood Institute. The state offers on-site assistance, patient education, and monitoring materials. Physicians benefit from participation because they are able to apply what they learn, along with the program materials (encounter forms, self-assessment and action plans, patient education brochures) to their entire asthma patient population. Oklahoma is also considering a collaborative on depression and a diabetes disease management program.

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