Innovations and Opportunities to Manage Chronic Disease

June 15, 2007

Rishabh Mehrotra

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Prevalence of Pre-disease Risk• High correlation between income, education and pre-disease risk• Social barriers to good health are ubiquitous, yet vary dramatically

by location and community down to a personal level Prevalence of Chronic Disease• Chronic disease and co-morbidities drive 80% of medical cost• 61% of adults and 31% of children have at least one chronic

disease / disability• Diabetes, asthma, heart disease and high blood pressure near

epidemic levels

The Medicaid Population: Prevalence of Risk

Preventing or mitigating chronic disease while fostering personal wellness is one of the few ways that states can create more value for Medicaid recipients while reducing spending for taxpayers.

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Key Challenges

• How do we measure and manage clinical risk?• What are the key risk drivers for chronic disease within a

community? – Medication compliance?– Compliance with evidence-based medical guidelines?– Physician involvement / support?– Ability to administer self-care?– Social barriers to self-care?

• How can we transform a procedure based, transactional and impersonal care delivery system?

• How do we coordinate health and social services to optimize personal well-being?

• How do we link together health programs that are typically procured, staffed, delivered and evaluated in silos?

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Traditional DM Models Ineffective

• Obsolete models for assessing health and financial risk• Misused return-on-investment calculations• Unsupported promises for rapid results• Limited coordination with local providers and social services• Impersonal outreach not appropriate to the unique characteristics of

a particular community• Inability to manage co-morbid conditions and social barriers that

prevent individuals from optimizing personal health– Physical access to physicians, clinics, and pharmacies– Child care– Cultural bias– Literacy– Housing – Ability to purchase, store and prepare nutritious food

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Transforming Medicaid

• Myth: We need a new program

• Reality: To better manage chronic conditions, we need to fundamentally rethink how we structure, staff and deliver Medicaid services from the ground up

• Key steps to drive better health outcomes at lower costs: – Understand the health and financial risks of the covered population– Identify key risk drivers– Prioritize interventions based on financial impact – Align policy and program design– Address unique population needs– Achieve member-centric, integrated program delivery – Produce comprehensive metrics

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Benchmark:

Starting Point: Comprehensive Health Metrics

Clinical Risk Score Card

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Value to Managing Chronic Disease?

• Provides an effective framework for total population health status – Continuous risk profiling for elevation of risk– Provides early program eligibility identification

• Provides in depth analysis and understanding of population risk profiles– Includes critical drivers of risk, enabling more targeted

interventions

• Assists in defining the right set of programs for a population by disease state

• Triggers individual interventions, linking action to outcome

• Illustrates correlation between clinical health and ROI

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The Importance of Integrated Delivery

• Medicaid demands a person-centric delivery model to address underlying drivers of poor health– Laser focus on clinical risk– Coordinates all services supporting individual well being,

including personal, medical, behavioral, social service, economic and community resources

– Provides appropriate financial incentives and tools (e.g. health opportunity accounts) to empower individual recipients

– Focus changes from coverage of acute and institutional services to optimization of personal wellness

– Rewards personal responsibility without denying access to care

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Four Principles of Transformation

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Align Structure and Incentives

• Align the flow of funds to create system-wide bias toward better health at lower costs

• Incentivize states, providers and recipients to achieve right program design and outcomes– Reward healthy decisions and

encourage individual responsibility

– Incentive evidence-based care through provider pay-for- performance programs

– Improve performance through CMS waivers, pilot programs and public-private partnerships

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Promote Social Advancement

• Foster independence, self- respect and personal responsibility – 67 percent of Medicaid

recipients expressed interest in health opportunity accounts, according to a Gallup poll

• Address underlying poverty and social conditions that contribute to or amplify poor health– Transportation issues– Living conditions– Substance / alcohol abuse

• Encourage “graduation” from Medicaid system

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Manage Health and Financial Risks

• Measure ongoing health and treatment outcomes of entire population – Medicaid Health Index– Personal Health Index

• Manage, measure and adjust programs based on data – Identify and expand

interventions with greatest payoff

– Hold providers accountable for evidence-based treatment

– Hold vendors and managed care companies accountable for quality of service

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Provide Integrated Delivery

• Utilize technology and ancillary services to create effective, person-centric services – 360-degree portrait of

recipient health status• Better coordinate healthcare

delivery and social services– Real-time information

exchange among all relevant Medicaid touch points

• Eliminate silos in Medicaid and healthcare system – Collaboration among vendors,

including MMIS providers, managed care providers, health systems, third-party services

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Managing Chronic Disease in Medicaid

Old: Disease Management

• Fragmented population, fragmented metrics

• Impersonal • Co-morbidities not addressed• Social barriers to personal

health not addressed – Disconnected from mental

health, public health and social aid outreach

• Limited outreach• Limited incentives• Providers not engaged

New: Health Advocacy

• Person-centric, advocate-based• Comprehensive metrics • Highly localized, personalized • Coordinates all services that

support individual well-being• Addresses healthcare continuum

– Precise targeting of individuals with chronic disease

• Clear, frequent communication • Utilizes incentives to drive

program goals• Engages and empowers

providers

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Policy Takeaways

• Good policy starts with comprehensive, transparent health metrics• Management of chronic disease in Medicaid requires a person

centric approach:– Unites diverse social services into a delivery model focused on

individual well-being– Must be convenient and relevant for individual recipients– Empowers and engages providers within an overall care team

• Current and proposed statutes should be measured against four core principles:– Align structure and incentives– Promote social advancement– Manage health and financial risks– Provide integrated delivery

• Multi-year, evolutionary approach– Foundation: metrics, claims infrastructure, technology platforms– Development of medical homes, care coordination and personal

outreach

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Some Practical Considerations

• Procurement– Does the current procurement process reinforce existing fragmented

programs and silos?– Are your RFPs consistent with a person-centric model?– Can your internal systems and third party vendors support cross-

functional applications?• Technology

– Does your technology strategy support evolution towards a person- centric model?

• Personal empowerment programs– Do you have the right financial tools in place (health opportunity

accounts) to empower individuals?• Comprehensive measurement of clinical risk

– Can you accurately identify prevalence and key risk drivers within populations? To what extent are metrics integrated into operations?

• Structure– Does the current structure support an integrated delivery model?

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Making Medicaid Work

• Co-authored book with the Center for Health Transformation

• Explores framework for creating a person-centric Medicaid system

• Includes interviews with Medicaid thought leaders– State health secretaries and

directors– CMS administrator– US Dept of HHS Secretary

Leavitt• Register for complimentary

copy at www.shps.com

Appendix A:

Medicaid Care Management Implementation Checklist

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Implementation Checklist

Source: Making Medicaid Work (2007)

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Implementation Checklist

Source: Making Medicaid Work (2007)