Impact of the MMA on Existing Disease Management Programs and

Managed Care Initiatives for the Aged and Disabled

Center for State Health PolicyCenter for State Health Policy

Rutgers, The State University of New JerseyRutgers, The State University of New Jersey

Roberta KelleyRoberta Kelley

Chief, Bureau of Health Systems DevelopmentChief, Bureau of Health Systems Development

Florida Agency for Health Care AdministrationFlorida Agency for Health Care Administration

MMA and Florida MedicaidFlorida: Over Age 65 Population

15.2 Million Residents15.2 Million Residents

17.6 percent over age 65 versus 12.4 percent 17.6 percent over age 65 versus 12.4 percent nationallynationally

2.9 Million Medicare Beneficiaries2.9 Million Medicare Beneficiaries

MMA and Florida MedicaidMedicaid Enrollment (Estimated FY2003-04)

2.1 Million Eligibles2.1 Million Eligibles Approximately 480,000 are dual eligiblesApproximately 480,000 are dual eligibles

$13 Billion in Expenditures$13 Billion in Expenditures Dual eligible account for 40% of total Dual eligible account for 40% of total

expendituresexpenditures Dual eligible drug costs account for 55.5% of Dual eligible drug costs account for 55.5% of

total drug spendtotal drug spend Exempt from Managed CareExempt from Managed Care

MMA and Florida MedicaidDisease Management Initial Statutory Direction

• Medicaid Reform Task Force• Legislative Authorization (HIV, Asthma, Diabetes, Hemophilia)

• Legislative Authorization (ESRD, Heart Failure)• Asthma Agreement• ITNs for HIV, Diabetes and Hemophilia• ITNs for ESRD and Heart Failure

• Diabetes Contract• HIV/AIDS (except S. FL) and Hemophilia Contracts• Legislative Authority to Expand to Other Diseases as Necessary• COPD Pilot Contract

• ESRD and Heart Failure Contracts• Legislative Authorization for ‘Value-Added’ Programs

• Pfizer Agreement (Asthma, Diabetes, Hypertension, Heart Failure)• Bristol-Myers Squibb Agreement (Diabetes, Depression)• Autoimmune Center Contract• HIV/AIDS (S. FL) Contract

July 1997

July 1998

July 1999

July 2000

July 2001

MMA and Florida MedicaidDM Initiative History

DatesDates Disease State(s)Disease State(s) DMO(s)DMO(s)

8/98–2/008/98–2/00 AsthmaAsthma -Integrated Therapeutics Group-Integrated Therapeutics Group

5/99-6/025/99-6/02 DiabetesDiabetes -Coordinated Care Solutions-Coordinated Care Solutions

6/99-6/046/99-6/04 HIV/AIDSHIV/AIDS -AIDS Health Care Foundation-AIDS Health Care Foundation(With Public Health Trust of Miami-Dade/N. Broward Hospital District in (With Public Health Trust of Miami-Dade/N. Broward Hospital District in S.FL)S.FL)

6/99-7/016/99-7/01

9/00-1/039/00-1/03

HemophiliaHemophilia -Accordant (S. FL)-Accordant (S. FL)-Caremark (N. FL)-Caremark (N. FL)

9/01-8/039/01-8/03 ESRD/CKDESRD/CKD -RMS Disease Management-RMS Disease Management

9/01-8/059/01-8/05 CHFCHF -Lifemasters Supported SelfCare-Lifemasters Supported SelfCare

8/00-12/018/00-12/01 COPDCOPD -CyberCare Technologies-CyberCare Technologies

1/02-6/041/02-6/04 Autoimmune DisordersAutoimmune Disorders -University of Florida-University of Florida

7/01-9/057/01-9/05 Diabetes, Asthma, CHF, HTNDiabetes, Asthma, CHF, HTN -Pfizer/Pfizer Health Solutions-Pfizer/Pfizer Health Solutions

5/02-6/035/02-6/03 Diabetes, DepressionDiabetes, Depression -Bristol Myers Squibb-Bristol Myers Squibb

Spring 04Spring 04 Evaluation of InitiativeEvaluation of Initiative -Contract with CorSolutions-Contract with CorSolutions

MMA and Florida MedicaidDM Initiative Currently

Florida: A Healthy StateFlorida: A Healthy State Asthma, Diabetes, Hypertension statewide; CHF Areas 8-11Asthma, Diabetes, Hypertension statewide; CHF Areas 8-11

Positive Healthcare Positive Healthcare AIDS Healthcare Foundation, HIV/AIDS statewideAIDS Healthcare Foundation, HIV/AIDS statewide

Diabetik Smart Promotora Diabetes Program Diabetik Smart Promotora Diabetes Program Health Choice Network, Dade and Broward countiesHealth Choice Network, Dade and Broward counties

LifeMasters Supported Self Care, Inc. LifeMasters Supported Self Care, Inc. CHF Areas 1-7CHF Areas 1-7

University of Florida University of Florida Center for Orphan Autoimmune DisordersCenter for Orphan Autoimmune Disorders

MMA and Florida MedicaidMedicaid DM Enrollment Process

Claims Based Disease State Algorithms:Claims Based Disease State Algorithms: ICD-9 codesICD-9 codes NDC codesNDC codes UtilizationUtilization

Beneficiaries assigned to DM program Beneficiaries assigned to DM program based on Disease State Hierarchy based on Disease State Hierarchy

Duals excluded from DM except for PACDuals excluded from DM except for PAC

MMA and Florida MedicaidDM and Long Term Care

HIV/AIDs DM works with Home HIV/AIDs DM works with Home Community Based Waiver ProgramCommunity Based Waiver Program

Approximately 3,200 of 5,880 enrollees are Approximately 3,200 of 5,880 enrollees are dual eligibledual eligible

Responsible for utilization review and Responsible for utilization review and assessmentsassessments

Reduction in Home Health and Skilled Reduction in Home Health and Skilled NursingNursing

MMA and Florida MedicaidPart D Drug Coverage and Impact on FL DM

Availability of Claims Data (medical and Availability of Claims Data (medical and pharmacy) to identify beneficiaries pharmacy) to identify beneficiaries

Coordination of Benefits Coordination of Benefits Medicare only providersMedicare only providers

Lack of UR/UM measures for populationLack of UR/UM measures for population Education of Drug CoverageEducation of Drug Coverage

MMA and Florida MedicaidEnrollment in Part D

States have not been given authority to ensure States have not been given authority to ensure that duals are enrolled. that duals are enrolled.

Duals are Duals are expectedexpected to secure Part D coverage. to secure Part D coverage. … … but enrollment is voluntary; non selection but enrollment is voluntary; non selection

= assignment; and = assignment; and although automatically enrolled, they may opt although automatically enrolled, they may opt

outout

MMA and Florida MedicaidChronic Care Improvement Program

Coverage of CHF and Diabetes Coverage of CHF and Diabetes Participation is VoluntaryParticipation is Voluntary Florida is a possible siteFlorida is a possible site Strong Evaluation Component Strong Evaluation Component Scalability of ProgramScalability of Program

MMA and Florida MedicaidMedicare Advantage

Encouraged to provide DMEncouraged to provide DM

Creation of Specialty Health PlansCreation of Specialty Health Plans May increase DM and enhance coordination of May increase DM and enhance coordination of

Medicare covered services Medicare covered services Medicaid services are unmanagedMedicaid services are unmanaged

MMA and Florida MedicaidConclusion

Short TermShort Term Enrollment and Coverage of Prescription DrugsEnrollment and Coverage of Prescription Drugs Fragmentation as CCIP becomes operationalFragmentation as CCIP becomes operational

Long TermLong Term Scalability of DM ProgramsScalability of DM Programs Decision to better manage duals and integration Decision to better manage duals and integration

with long term carewith long term care

Roberta KelleyRoberta Kelley

Chief, Bureau of Health Systems DevelopmentChief, Bureau of Health Systems Development

Florida Agency for Health Care Administration Florida Agency for Health Care Administration

kelleyro@fdhc.state.fl.uskelleyro@fdhc.state.fl.us

Ph. 850-487-2355Ph. 850-487-2355

Medicaid: Medicaid:

http://www.fdhc.state.fl.us/Medicaid/index.shtmlhttp://www.fdhc.state.fl.us/Medicaid/index.shtml