Disease Management Initiative. Legislative Authorization. Program Objectives

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1 Disease Management Initiative Chronic diseases such as cardiovascular disease, asthma, hypertension, cancer, diabetes, depression, and HIV/AIDS are among the most prevalent, costly, and preventable of all health problems. Disease management provides a strategy for states to improve patient health outcomes and limit health care spending by identifying and monitoring high-risk populations; helping patient and provider populations better adhere to proven interventions; engaging patients in their own care management; and establishing more coordinated care interventions and follow up systems to prevent unnecessary, costly health complications. Recognizing the potential benefits of disease management, Florida was one of the first states to invest in disease management to benefit Medicaid beneficiaries. Program Objectives Provide and test different disease management models Encourage the organization and delivery of services resulting in: Better educated consumers The promotion of best practices Improved care Improved health outcomes Reduced inpatient hospitalizations Reduced ER visits Lower total costs The Agency s initial approach to the disease management initiative involved contracting with vendors or Disease Management Organizations (DMOs) to deliver a broad range of interventions with beneficiaries and providers. The flexibility afforded by the negotiation (ITN) process allowed the Agency to test various models for disease management. Seven different DMOs were awarded contracts for five disease states covered under the initial procurement process. The desire to test various innovative models resulted in substantial variation in the approaches employed by different DMOs. Care coordination, including self-management education and physician education, were prominent features of each model. Since the implementation of the disease management program in 1998, the Agency has gained a significant amount of experience in structuring disease management services and continues to be an innovator in this field. In addition to direct contracting for disease management services, several managed care entities provide disease management to individuals. Managed Care (MC) entities are broadly defined to include comprehensive HMOs and alternative MC programs such as the Provider Sponsored Network (PSN), ER Diversion Program and Minority Physician Network. Below is a survey of disease management activities undertaken by the Agency as well as a survey of disease management activities provided by managed care entities that provide services to Medicaid beneficiaries. Legislative Authorization Proviso language included in the FY General Appropriations Act (GAA) authorized the Agency for Health Care Administration (Agency) to implement disease management initiatives for asthma, diabetes, HIV/AIDS, and hemophilia; the FY GAA included a $4.2 million reduction in the Medicaid budget in anticipation of savings expected from the initiatives. Proviso language included in the FY General Appropriations Act authorized the Agency to implement new disease management initiatives for hypertension, cancer, heart disease, end-stage renal disease (ESRD) and sickle cell; the FY GAA included a $14.7 million reduction for new programs and $24.7 million reduction for continuation of programs previously authorized (asthma, diabetes, HIV/AIDS, hemophilia). Proviso language included in the FY General Appropriations Act included a $23 million budget reduction (for anticipated program efficiencies for managing the nine disease states already authorized) and a $46.1 million budget reduction (for expansion of disease management to include population-based disease management and diseases not already covered under the Disease Management Initiative). The $46.1 reduction was restored to the Medicaid budget in July 1, 2004

2 Section (14)(a), Florida Statutes, directs the Agency on methods and approaches to be used in managing diseases: Identify utilization and price patterns for cost effectiveness and medical appropriateness. Assess effectiveness of new or alternative methods of providing and monitoring services. Provide for integrated, systemic approaches for managing care of beneficiaries with a specific disease. Reduce overall costs and improve measurable outcomes. Section (38)(a)7, Florida Statutes, allows service and administrative investments (including disease management programs and other program benefits) which offset Medicaid expenditures to be deemed as supplemental rebates negotiated with pharmaceutical manufactures as part of the Agency s prescribed drug spending control program. Legislative Direction Fiscal Legislative Authorization Year Related to DM Implement programs for asthma, diabetes, HIV/AIDS, and hemophilia Continue programs for initial disease states Implement programs for CHF, ESRD, hypertension, cancer and sickle cell anemia Improve program efficiencies Expand initiative to include other diseases and population * Value added programs, including DM, allowed in lieu of supplemental rebates Implement Minority Physician Networks and Pediatric ER Diversion Project. Enhanced PCCM includes beneficiaries with chronic disease. *Part of $227 million prescribed drug budget reduction for FY Eligible Population As of June 2004 there were 2,034,658 Medicaid eligible beneficiaries. Of these, 594,887 were enrolled in a non-managed care environment (Fee for Service), with 65% of this population dually eligible for Medicare and Medicaid. Total Non-Managed Care Enrollment June 2004 Other 35% Dual Eligible 386,677 Other 208,210 Total 594,887 Total Managed Care Enrollment June 2004 MediPass 42% Dual Eligible 65% Other Managed Care 8% HMO 50% HMO 715,297 MediPass 602,355 Other Managed Care 122,119 Total 1,439,771 2 July 1, 2004

3 For this same time period, 1,439,771 individuals enrolled in a Medicaid Managed Care entity. Of these individuals, 715,297 were enrolled in HMOs, 602,355 were enrolled in MediPass and 122,119 were enrolled in the Other Managed Care plans which include Provider Sponsored Network (PSN), Minority Physician Networks and the Pediatric Emergency Department Diversion Project. All of these delivery systems provide some type of disease management for enrollees. MediPass MediPass enrollees who reside in an area with a contracted disease management entity and meet the criteria for enrollment are eligible to receive services from the entity. As indicated above, during the FY and FY Legislative sessions, the Agency for Health Care Administration (Agency) was granted authorization to implement disease management for nine specified disease states. This authority was expanded in proviso language included in the FY General Appropriations Act to allow for expansion of disease management to include population-based disease management and diseases not already covered under the Disease Management Initiative. Table 1 provides a summary of beneficiaries enrolled in MediPass with one of eleven chronic conditions for FY and associated expenditures. The data is an ad hoc analysis from the Bureau of Health Systems Development and includes individuals identified as having a chronic condition during FY The figures do not represent enrollment in current DMO programs. For the MediPass population in Fiscal Year , 113,818 beneficiaries were identified as having chronic conditions. Nine of the conditions identified below are specified in Legislation. Chronic pain and Chronic Obstructive Pulmonary Disease (COPD) are conditions for which the State could implement a disease management program. The Agency implemented a COPD telemedicine pilot project, which ended in December of Figures 1 through 4 provide a breakdown of associated expenditures described in Table 1. Table 1 MediPass and Chronic Condition Summary of Beneficiaries, Case months and Total Claims Fiscal Year Number of Beneficiaries Member Months 1 Total Claims 2 PMPM 3 AIDS/ HIV 5,267 54,223 $101,650,410 $1,875 Hemophilia $13,788,644 $15,070 Sickle Cell 1,621 16,103 $19,671,209 $1,222 ESRD 2,520 26,304 $61,615,121 $2,342 CHF 5,497 57,636 $93,589,437 $1,624 Cancer 1,265 12,352 $18,636,741 $1,509 Diabetes 16, ,337 $163,631,761 $918 COPD 10, ,955 $129,132,743 $1,123 Hypertension 20, ,519 $136,268,183 $629 Asthma 20, ,870 $83,540,337 $406 Chronic Pain 28, ,394 $168,918,750 $611 No Chronic Condition 830,836 6,570,470 $1,242,158,241 $189 Total 944,654 7,730,078 $2,232,601,577 Source: Health Systems Development, Ad Hoc Analysis June See Figure 2 2 See Figure 1 3 See Figure 3 3 July 1, 2004

4 Figure 1 provides total spending for individuals with chronic conditions enrolled in MediPass which is $990,443,336, representing 44% of the spending for the entire MediPass population. Figure 1 DM Spend 44% of MediPass Claims No Chronic Condition 55.64% AIDS/ HIV 4.55% Hemophilia 0.62% Sickle Cell 0.88% CHF 4.19% ESRD 2.76% COPD 5.78% Cancer 0.83% Diabetes 7.33% Hypertension 6.10% Figure 3 provides the average per member per month (PMPM) costs ranging from $406 for individuals with asthma to $2,342 for individuals with ESRD. Figure 3 does not include the average PMPM for individuals with hemophilia, which is $15,070. $2,500 $2,000 $1,500 $1,000 Figure 3 Per Member Per Month Cost $918 $1,123 $1,222 $1,509 $1,624 $1,875 $2,342 Chronic Pain 7.57% Asthma 3.74% $500 $- $189 $406 $611 $629 Figure 2, provides the total case months for individuals identified with a chronic condition. As indicated in the chart, individuals with a chronic condition represent 15% of all case months for MediPass enrollees and account for almost half of all expenditures. MediPass Asthma Chronic Pain Hypertension Diabetes COPD Sickle Cell Cancer CHF AIDS/ HIV ESRD Figure 2 DM Months 15% MediPass Months Hemophilia 0.01% Sickle Cell 0.21% AIDS/ HIV 0.70% CHF ESRD 0.75% 0.34% Cancer 0.16% COPD 1.49% Diabetes 2.31% Hypertension 2.80% Asthma 2.66% Chronic Pain 3.58% No Chronic Condition 85.00% 4 July 1, 2004

5 Figure 4 provides a break down of aggregate expenditures on behalf of individuals with chronic conditions as identified in Table 1. As indicated in Figure 4, pharmacy expenditures account for 38% of total dollars spent. Figure 4 Expenditures FY Table 2 provides the average number of times that an individual with one of the specified chronic condition went to an outpatient emergency center. Table 2 Emergency Room Visits per Beneficiary FY All other services 20% Prescribed Medicine/ Pharmacy Claims 38% Inpatient Claims 24% Outpatient Claims/ ER 7% Physician Services/ Medical Claims 11% TANF SSI HIV/AIDS Hemophilia Sickle Cell ESRD CHF Cancer Diabetes COPD Hypertension Asthma Chronic Pain July 1, 2004

6 Florida currently provides disease management to approximately 94,578 individuals with the following conditions: diabetes, asthma, CHF, hypertension and HIV/AIDS. Below is a summary of all contracts since the inception of the disease management initiative. The contracts executed to implement the Florida Medicaid Disease Management programs are described below. Medicaid Disease Management Programs Disease Disease Management Contractor Diabetes Coordinated Care Solutions HIV/AIDS AIDS Healthcare Foundation AHF, Public Health Trust, and the North Broward Hospital District Geographic Contract Period Coverage Start End Contract Terms Statewide May 1999 August Advanced Administrative Fees at Risk Statewide (except Dade and Broward) Dade and Broward 2002 Hemophilia Accordant Areas ESRD RMS Disease Management Caremark Areas Statewide 2000 July 1999 June Advanced Administrative Fees at Risk June 2004 Advanced Administrative Fees at Risk 6.5% Savings Guarantee Current Number of Enrolled Beneficiaries Contract terminated June ,000 Enrolled at Height 4,014 2,373 June 2002 Fixed Administrative Fees Services ended June 2001 Contract terminated June 2002 January Advanced Administrative Fees at Risk August 2003 Advanced Administrative Fees at Risk 6.5% Savings Guarantee 70 Enrolled at Height Contract terminated January Enrolled at Height Services ended November 2002; Contract terminated August ,800 Enrolled at Height CHF LifeMasters Supported Self-care Areas Advanced Administrative Fees at Risk 6.5% Savings Guarantee 3,663 1 Contract end date extended via contract amendment October Fixed Administrative Fees 6 July 1, 2004

7 Medicaid Disease Management Programs Disease Disease Management Contractor Geographic Contract Period Coverage Start End Contract Terms COPD Cybercare, Inc. Areas 5-6 July 2000 December 2001 Autoimmune Disorders University of Florida Center for Orphan Autoimmune Disorders Statewide January 2002 Telemedicine Pilot Administrative Fees not at risk No Savings Guarantee June Administrative Fees not at risk No Savings Guarantee Current Number of Enrolled Beneficiaries Contract Terminated December Enrolled at Height 324 Asthma, Congestive Heart Failure, Diabetes, Hypertension Diabetes Promotora Program and Behavioral Health Program Value Added Agreement with Pfizer Inc. Contracts with 10 Hospital Systems Statewide and One Call Center for Service Provision in Florida: a Healthy State Program Value Added Agreement with Bristol-Myers Squibb Contract with Health Choice Network for Service Provision in DiabetikSMART Program 1 Contract end date extended via contract amendment Statewide for Asthma, Diabetes, Hypertension Areas 8-11 CHF Term 1: Dade, Broward, Pasco, Manatee, Lee Hendry, Collier, Glades, Monroe Palm Beach and Charlotte Term 2: Dade, Broward Term 1: June 2001 Term 2: 2003 Term 1: March 2002 Term 2: October June 2003 June 2005 Savings and Investment Guarantee of $33 Million the First Term. Savings and Investment Guarantee of $45 Million the Second Term Savings and Investment Guarantee of $ 21 Million the First Term Savings and Investment Guarantee of $9.1 Million the Second Term 113,015 reached (first term) 14,950 actively care managed (first term) Approximately 150,000 reached (second term to date) Over 19,000 care managed (second term to date) 1,741 Diabetics eligible (first term) 494 Diabetics actively participated (first term) 95 actively participated in the Behavioral Health program 3,400 reached via Diabetic Sundays (Faith Based Outreach events) 7 July 1, 2004

8 Disease Management HMO Disease Management Disease management services are also provided to Florida Medicaid beneficiaries through the disease management programs implemented by the HMOs and programs implemented though contracts for enhanced primary care case management. As of June 2003, the Agency contracted with eleven HMOs to provide services to over 700,000 Medicaid beneficiaries. Below is a map of the areas covered by HMOs, and the number of enrolled beneficiaries within a county. Medicaid Disease Management Programs Currently Provided MediPass Disease HMO* Management AIDS/ HIV 2 X Hemophilia Sickle Cell ESRD CHF 8 X Cancer Diabetes 10 X COPD 1 Hypertension 1 X Asthma 9 X Chronic Pain * Number of Medicaid HMOs providing services 8 July 1, 2004