1. ILLINOIS DISEASE MANAGEMENT MEDICAL HOME INITIATIVE State Coverage Initiatives Summer Workshop for State Officials ILLINOIS DISEASE MANAGEMENT MEDICAL HOME INITIATIVE State Coverage Initiatives Summer Workshop for State Officials San Francisco, California July 30 – August 1, 2008 Stephen E. Saunders, M.D., M.P.H Medicaid Medical Advisor

2. Illinois Background  2.3 Million beneficiaries in HFS programs  Primarily fee-for-service  Voluntary managed care in Cook and seven other rural counties (170,000 members)

3. Program Goals Goal –Improve health outcomes & reduce avoidable costs Program Design Concepts –Reduce inappropriate and unnecessary utilization, especially ED use –Reduce avoidable medical admissions through better community-based care –Establish a medical home to minimize fragmented care and improve continuity of care

4. Program Goals (2) –Improve coordination of care –Increase member compliance with treatment plan and improve self-management skills –Improve adherence to national, evidence- based clinical practice guidelines –Use data and IT tools to better monitor, report and improve clinical outcomes

5. Overview  Primary Care Case Management  PCCM Administrator responsible for provider recruitment, client enrollment, quality and EPSDT compliance.  Program designed to ensure Medical Home  1.7 million beneficiaries eligible  Disease Management population is a subset  220 beneficiaries eligible  Targets disabled adults and children with asthma

6. Program Status  PCCM Network development began in Fall 2006  Started member enrollment for Cook County in February 2007  Current status  Statewide enrollment complete  1.6 million members enrolled  5,300 medical homes (physicians and clinics) with over 5 million member capacity  DM program administrator started July, 2006.

7. Disease Management Eligibility  Disabled Adults: All eligible irrespective of disease or condition – 122,000  Persistent Asthma: Children and adults who have persistent asthma (utilizing the HEDIS definition) - 75,000  Frequent ER Users: Children and adults who are frequent emergency room users (defined as 6 or more visits a year) - 32,000  Participation in Your Healthcare Plus TM is voluntary, and statewide. Individuals can “opt out.”

8. Disease State of Eligible Members Disease state shown by primary diagnosis: –Over 26% of members have a primary diagnosis within the core five conditions (Asthma, Diabetes, COPD, CAD, CHF) –Over 22% of members have a primary diagnosis of a behavioral health condition –A significant portion of members suffer from multiple co-morbidities

9. DM Patient Activation Strategy DM Patient Activation Strategy  Community based teams of professional and lay educators – 170 local staff  Teams are comprised of individuals who are indigenous to these communities, culturally diverse  Staff is also placed in high volume sites (hospitals and clinics)  Other special projects to augment this effort

10. DM Program Model  Community Staff  Nurse  Lay community educators  Social workers  Behavioral health workers  Hospital based case managers  Clinic based staff  Special Projects  LTC initiatives  Pharmacy  Behavioral health

11. Services to HFS Clients Health Risk Assessment - to determine disease severity and knowledge of self-management and care practices Care Plan - to identify problems, goals and interventions specific to each client Ongoing Case Management - dependent on risk level with highest risk receiving monthly nurse case manager assistance Health Education - relative to medical conditions Level of Services – dependent on Risk stratification

12. PCP Support for Disease Management Members  Support providers care plan by facilitating patient compliance.  Nurses to provide education to patients with chronic conditions to help them better understand their disease, follow care plan and medication requirements.  Nurses to provide intensive care management to most complex patients.  Support provider in post ER and hospitalization follow- up.  Notify provider of any urgent medical problem or medication management/compliance issues.  Physicians receive support in identifying patients with unusual drug utilization patterns

13. PCCM Program Provider Reimbursement  PCPs are paid a PMPM month for every person whose care they are responsible to manage:  $2.00 per child  $3.00 per parent  $4.00 per disabled or elderly enrollee  The monthly care management fee is paid even if the enrollee does not get services that month.  PCPs will continue to receive their regular fee for service reimbursement for services from HFS.

14. PCP Requirements  Maintain hospital admitting and/or delivery privileges or have arrangements for admission  Make medically necessary referrals to HFS enrolled providers, including specialists, as needed  Provide direct access to enrollees through an answering service/paging mechanism or other approved arrangement for coverage 24 hours a day, 7 days a week. Automatic referral to an emergency room does not qualify  Maintain office hours of at least 24 hours/week (solo practices) or 32 hours/week (group practices)  Follow recognized preventive care guidelines  Manage chronic disease  Appointment scheduling guidelines.

15. PCP SUPPORT PCP access to secure web portal which contains PCP support materials Patient roster Mailed monthly but also available electronically Provides information on needed preventive services Well child visits Pap smears Mammograms Electronic version sortable

16. Provider Portal

17. Provider Roster

18. PCP Support  Provider profiles  20 HEDIS and HEDIS-like metrics  System and provider specific performance  Listing of members with chronic diseases and their level of metric compliance.  Historical claims  2 years Medicaid claims  Pharmacy  Immunizations (7 years of data)  Office visits  Hospitalization  Diagnosis  Procedures

19. Provider Profile

21. Claims History  Prescription Summary  Prescription Date  Prescription Quantity  Prescription Description  Immunization Summary  Immunization Date  Immunization Code  Immunization Description  Claim Summary  Service Date  Claim Date  Provider Name  Diagnosis Code  Procedure Code  Claim Type

22. Claims History

23. PCP Support  Pay for Performance  Bonus payment for meeting National 50 th HEDIS percentile.  Measures  Immunizations  Developmental Screening  Asthma Management  Diabetes Management (HbAIC)  Mammograms  EPSDT (Well Child )

24. PCP Support - (continued)  Provider Services Representatives  11 Provider Services Reps in field  Provider Services Help desk – 1-877-912-1999  Outreach and Education to support Providers and their staff  Site Visits  Training Sessions  Billing  EPSDT Support  Quality Assurance  Monthly Webinars  Specialty Resource Database  Provider Newsletter and web site

25. Provider Continuing Education  Education program provided by AAP and AFP under subcontract.  Continuing Medical Education programs on evidence-based evaluation and management of common chronic conditions.  Chronic Care Model  Asthma  Depression  Diabetes  COPD  Substance Abuse  Topics also include preventive health  Immunizations  Developmental Assessment  Medical Home  In-Office training for physician and staff in addition to traditional CME.

26. Measures of DM Program Success  Patient and provider satisfaction (survey)  Reductions in avoidable hospitalization, ED visits  Calculated cost avoidance relative to preprogram cost trends  Improvements in state defined clinical indicators  Heart Failure: Percent of pts on ACE/ARB medication  Diabetes: Retinal exam, HgbA1c testing rates  CAD: Cholesterol testing rates, Statins, ACE/ARB  Asthma: Use of controller medications  COPD: Use of spirometry for dx, corticosteroids post exacerbation

27. PCCM Quality Measures  Childhood immunizations  Lead testing  Developmental screening  Appropriate medications asthma, diabetes care (HbA1c)  Well baby/well child visits  Cervical cancer screening  Breast cancer screening

28. PCCM Quality Measures (Continued)  Adolescent well care  Prenatal care frequency/timeliness  Post partum care  Depression treatment  Adult access to preventive care  ER visits/1000  Ambulatory care sensitive hospital visits

29. Lessons Learned Difficult to find high risk members – especially Chicago Mental Health is a significant problem both as a primary diagnosis and as co-morbidity Behavioral health component requires specialized focus and outreach Importance of interagency coordination, especially behavioral health Importance of physician buy in and need for provider input

30. Lessons Learned (2) Delayed launch of PCCM program made launching DM program more difficult Need ability to analyze claims data rapidly LTC community very different and more difficult to engage Interventions, program components staggered during program launch – some components take longer than anticipated Avoid promising significant savings in year one

31. RESULTS: Year 1 $34 million net savings Reduction in hospitalization costs (9%) Provider and patient satisfaction 94% members satisfied or very satisfied 65% providers report program useful and 70% would recommend their patients participate Modest improvement in clinical metrics Disease specific hospital admission rate decreases CAD - 20% CHF - 19% Asthma - 19%