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Iowa program targets the 5% most costly Medicaid clients
Iowa Medicaid's disease management program, implemented in July 2010, has a focus that's a "little bit unique," according to Leslie Schechtman, DO, medical director of Iowa Medicaid Enterprise, Member Services. "We used a stratification methodology."
The program targets the 5% of members believed to be the highest cost and highest risk, says Dr. Schechtman. These individuals, she says, get additional care coordination to improve the quality of care and member outcomes.
Stephen Saunders, MD, MPH, chief medical officer of APS Healthcare, a subcontractor for Iowa Medicaid, explains that while many programs target high-cost members, Iowa's program also considers which members are most likely to change behaviors, such as frequent ED use. "We look at which members have behaviors we think we can impact," he says.
For instance, a Medicaid beneficiary may not be going to a primary care physician as often as he or she should be, explains Dr. Saunders. "This change would improve care coordination," he says.
Obstacles to care removed
Participating members receive one-on-one education over the phone from a health coach, says Dr. Schechtman. "We do primarily telephonic outreach," she says. "We don't have nurses do home visits, but they could arrange for a social worker to come into the home."
Social workers can then coordinate with other family members, says Dr. Schechtman, in the event their assistance is needed to help with the proper care of the member.
"We try to remove any barriers or obstacles to them getting the care they need," Dr. Schechtman says. "It could be a medication management issue, or any other type of issue that could come into play that could impact their care."
Coaches ensure that transportation resources are in place, says Dr. Schechtman, and that appointments with physicians are scheduled and followed. They also address any educational gaps in the patient's understanding of his or her disease, and ensure medications are taken properly to avoid disease relapse, she adds.
"A health coach would query the member on an initial assessment to determine social needs and disease-specific issues," says Dr. Schechtman. "Then, a care plan is determined to assist the member in following the physician's recommended plan."
Care managers coordinate with hospitals throughout the state, Dr. Schechtman says, so that members are contacted very quickly after being discharged from the hospital. "We make sure they have a good plan in place, and that they are following up with medication adherence," she says. "This reduces readmission costs."
Nationally, about 15% of hospitalized Medicaid members are readmitted within 30 days, notes Dr. Saunders. "To really impact these costs is a major target of our program," he says.
If a patient is seeing multiple physicians, the health coach helps the patient to establish one primary care physician to better coordinate his or her disease, says Dr. Schechtman. "Patients need one doctor they can count on to coordinate their care," she explains.
This could reduce admissions and readmissions, says Dr. Schechtman, because the patient's primary care physician assists with coordination of specialty care and community resources. "This avoids duplication of efforts and gaps in care," she says.
Seven health coaches make about 6,000 calls each month, Dr. Schechtman says, with a full assessment of the member's needs done on the first call. The health coach then sets up a time for a follow-up call, to review the things that were discussed.
"Our goal is to change behaviors. Our health coaches develop a good rapport with our members," says Dr. Schechtman. "A relationship develops, and that relationship keeps the continuity going."
Dr. Schechtman says she found it somewhat surprising that so many of the participants used the ER as their primary care provider, and that many lacked a single primary care provider. "Those are two big areas that I like to focus on," she says.
The health coach is notified about members with "impactible" issues based on their medical claims, she says. For instance, a member may have had an ED visit in the last month, or have congestive heart failure and isn't taking an angiotensin-converting enzyme inhibitor, she says.
"A classic Medicaid example is someone with asthma who doesn't understand the disease very well and is not taking their medications regularly," says Dr. Saunders. "The health coach can work with them to understand that they need to take their long-acting medication every day, not just when they start to wheeze. By then, it's too late."
Dr. Saunders adds that costs have been escalating for individuals with chronic diseases. "This is the reason why it's more effective to target a much smaller group," he says. "Many Medicaid beneficiaries are healthy and don't necessarily cost too much. The beauty of this is that at the same time, these folks get better care for their chronic disease."
Iowa Medicaid's lock-in program is an offshoot program for a population of 300, focusing on inappropriate ED utilization and medication misuse, says Dr. Schechtman. A patient may be getting narcotic medications from a lot of different providers, she explains.
"There may be drug-seeking behaviors," she says. "We lock them in to one provider, one ER, one hospital and one pharmacy. Through that, we hope to enforce a change in behavior."
ROI in first year
By targeting adults with chronic disease, says Dr. Saunders, it is possible to see a return on investment in the first year. "These are folks who are costing you money right now," he says. "You get a fairly quick return, because their uncoordinated care can be so expensive. A single hospitalization can cost thousands of dollars."
One obstacle is that the health coaches sometimes have trouble reaching members, notes Dr. Schechtman. "Iowa Medicaid's population is pretty transient," she says. "Keeping on top of locating them is oftentimes a challenge. We try to contact the provider's offices or pharmacies and health maintenance workers for updated contact information."
While the program itself is voluntary, and members do have the option to opt out if they choose, the majority of individuals who have been contacted have agreed to participate, Dr. Schechtman says.
"We do our best to coordinate our resources with all of the other resources in the state, including WIC and our partners who run the mental health and behavioral health components," she adds.
Significant cost savings are expected from the program, reports Dr. Schechtman, mainly due to fewer hospitalizations and emergency department visits.
"The savings will more than pay for the cost of the program," she says. "Increased care coordination will help with the expected 80,000 to 100,000 newly eligible Medicaid population in 2014, many of whom are currently uninsured with a chronic disease."
Contact Dr. Saunders at (800) 305-3720 and Dr. Schechtman at (515) 974-3201 or firstname.lastname@example.org.