Disease Management Advisor, March 2008


Health centers improve diabetes care, results

Patient-centered care critical to Medicaid programs

CMS: MHS ends this year

Industry responds to RAND report

Safety net for high-risk pregnancies

Health centers improve diabetes care, results

Community health centers can play a key role in reducing health disparities, but it takes more than simply opening a center in a medically underserved neighborhood. In order to bridge the racial and ethnic gap, strong leadership, a long-time commitment, adequate resources, and proper incentives are required, says Marshall Chin, MD, MPH, an associate professor of medicine at the University of Chicago and coauthor of the recent study Improving and Sustaining Diabetes Care in Community Health Centers with the Health Disparities Collaboratives.

Chin and seven other researchers wrote the study, which was published in the December 2007 Medical Care. They reviewed 34 Midwest and West Center cluster community health centers that participated in either the first or second Health Resources and Services Administration's Bureau of Primary Health Care (BPHC) Diabetes Collaborative initiative to improve diabetes care.

BPHC oversees the country's 5,000 community health centers that are improving care of the medically underserved through Health Disparities Collaboratives (HDC). Sixty-eight percent of the health centers in the HDC chose diabetes as their target disease, namely because of the difficulty of caring for patients with diabetes and its impact on ethnic and lower socioeconomic populations. "Diabetes is a paradigmatic disease for chronic care management," wrote the study's authors.

The study looked to answer two major questions about the HDC:

What impact does the HDC have on care and outcomes related to diabetes over a sustained period?

What is the effect of varying the intensity of the intervention? Do more intensive quality improvement (QI) efforts that incorporate organizational change, provider behavioral change, and patient empowerment improve care further?

Researchers discovered improved diabetes care and results over a five-year span (1998-2002).

Hemoglobin A1c and LDL levels decreased, whereas diabetes care standards improved, including A1c tests and lipid assessments, foot and eye exams or referrals, and aspirin use.

The study also showed the importance of perseverance. Although test-taking improved at the two-year mark of the study, it took the full four years to show improved test results. Chin says this is because it takes longer to see health improvements than simply improving care. The authors noted the "importance of enduring commitments to the QI intervention and long-term outcome studies."

The health centers used a Model for Improvement developed by Associates in Learning called the Plan-Do-Study-Act cycle. They also used the MacColl Chronic Care Model that was created by Group Health's MacColl Institute for Healthcare Innovations in Seattle. The Chronic Care Model has six target areas:

  • Patient self-management
  • Information systems
  • Decision support
  • Community outreach
  • Leadership organization
  • Effective delivery system

"Its ultimate goal is to improve the quality of care and outcomes by having activated, empowered patients working with a proactive team of doctors, nurses, and administrators," says Chin.

According to the authors, the study's "important implications" for health centers are: a powerful governmental organization can "facilitate sustained QI in a national network of generally highly motivated, idealistic [health centers] by training, lending assistance, and conveying that the QI collaborative approach should be done . . . The rapid QI approach and Chronic Care Model are paradigms that allow flexibility. [Health center staff is] used to working creatively in resource-constrained environments."

"There is a very positive message that when there is the will, the mission, and the leadership, and support in the overall program, you can make dramatic improvements in terms of quality and outcomes for diabetic patients even under very difficult circumstances," says Chin.

Chin says he figured the researchers would see care improvements but knew the centers faced challenges because of limited resources and patient population (poor, little education, and many without insurance). In fact, approximately one-third of the patients in the centers studied did not have health insurance, and about one-quarter were on Medicare.

Standard vs. high-intensity intervention

In addition to determining whether the HDC improves diabetes care in health centers, investigators reviewed whether more intensive interventions enhanced care further.

The standard-intensity arm included:

An HDC team that met regularly with the support of senior administrative leadership

Tracking by each center of a registry of diabetic patients to gauge care

The introduction of a Model for Improvement developed by Associates in Learning to the centers

Support from the BPHC, including quarterly progress reports from the QI teams and senior leadership, conference calls with other centers, and cluster coordinators

Yearly in-person meetings with other health centers

The high-intensity arm included the above and:

Four 1.5-day learning sessions

Training in patient-provider communication and behavioral change techniques

Patient empowerment videos and brochures

Monthly conference calls

The more intensive intervention showed a mixed bag. There were increases in the use of angiotensin converting enzyme inhibitors and aspirin, but less documentation of diabetes education and dietary and exercise counseling. "These findings suggest tradeoffs between intensifying medication use and participating in diabetes education and dietary/exercise counseling," wrote the study authors.

Chin says intensive interventions did not affect care as much as expected because the standard health collaborative is already "pretty intensive."

"[The high-intensity arm] may help at the margin, but some of these ideas were already in the standard HDC . . . I think what this shows is you get a lot of bang out of the standard health disparities collaborative," says Chin.

Although the study focused on health centers, the authors noted that other healthcare entities can learn from the report.

"More generally, motivated, hardworking healthcare staff can improve care and diabetes outcomes when given autonomy and support to create change."

Six keys to bridge the disparity gap

Improving and Sustaining Diabetes Care in Community Health Centers with the Health Disparities Collaboratives showed how health centers affect care for the poor, but how do private insurers and DM companies reach that population?

Winston F. Wong, MD, MS, medical director of community benefit and director of disparities improvement and quality initiatives for Kaiser Permanente in Oakland, CA, provided these six keys to reduce health disparities for any healthcare organization:

  • Good data that highlight conditions affecting the specific population
  • Patient registries, at the very least disease registries
  • Bilingual, bicultural workers
  • Strong clinical leadership that sets the agenda for the clinicians
  • Partnerships with local and/or regional effort to improve care for vulnerable populations
  • Strong health educators and community health workers, including social workers and certified diabetic educators, that augment clinicians

Marshall Chin, MD, MPH, an associate professor of medicine at the University of Chicago and coauthor of the health center study, believes health plans, DM companies, and individual practices can learn from community health centers.

"I think the average practice can do an outstanding job also. I think for the health center, [caring for at-risk populations is] a larger priority. It's very much on the radar screen. The health centers serve a large number of ethnic minorities and poor patients. It's an integral part of the mission. Nationally, we're seeing equity issues becoming a larger part of the quality debate," he says.

Chin praises those who work at health centers for their open-mindedness and passion. Having a motivated staff that is not too large makes change possible. "One thing that centers have done very well is: how can you tailor to your own subpopulations? I think that the general message of tailoring to your specific population as opposed to just blindly using a one-size-fits-all approach is an important lesson of the collaborative," he says.

Flexibility is important

Having a chronic care model in place is a helpful foundation to bridge the health disparities gap, but Marshall Chin, MD, MPH, an associate professor of medicine at the University of Chicago, adds that the community health center must be flexible to implement programs that best help their patient population.

Winston F. Wong, MD, MS, medical director of community benefit and director of disparities improvement and quality initiatives for Kaiser Permanente in Oakland, CA, says health centers are able to quickly tweak care to best serve their populations because they are not bound by hierarchical and clinical roles and position descriptions that are common in other areas of healthcare. Making changes are not as easy for a large organization that must deal with thorny labor and HR issues.

"You have to be willing to wipe the board clean at least in a pilot site or a microsetting where there is enough willingness on all parties to look at what people do in the clinic and have definitions that enable flexibility to occur . . . You first have to see the clean board and understand the needs of patients come first rather than the preservation of job titles," says Wong, who was formerly the medical director at Asian Health Services in Oakland, CA, and a clinical officer for the Department of Health and Human Services' Region IX, which included overseeing health centers in Arizona, California, Nevada, Hawaii, and the Pacific Basin.

Part of the reason why health centers are able to adapt and know their community so well is because these centers' staff members are usually from the neighborhood and have risen through the ranks at the centers.

"The centers are such that for it to work you basically have to have buy-in from everyone. You need providers to be into it, the front-office staff, the senior leadership. You need an overall commitment and that kind of effort to do it," says Chin.

With PCP and nurse shortages expected in the near future, Wong says he is concerned about the prospects for health centers that serve the most vulnerable.

"There is a looming threat of not having enough nurses and not having enough community-oriented primary care physicians to care for the populations. Whenever those things happen, all good work that has been done in regard to caring for patients with special needs gets undermined," he says.

Patient-centered care critical to Medicaid programs

States battling spiraling Medicaid costs may have a friend in DM.

Two recent studies provide a glimpse into two Medicaid programs that not only improved care but contained costs. Containing costs is especially critical for Medicaid programs, which devote nearly 80% of funding toward chronic diseases. Both Medicaid programs, one in Virginia and the other in Washington state, controlled costs and improved care by involving physicians and engaging beneficiaries in a patient-centered system.

Researchers reviewed a DM program contracted with the Heritage Information System that was an extension of the Virginia Health Outcomes Partnership (VHOP). The researchers included Thomas T.H. Wan, PhD, along with Ning Jackie Zhang, Louis F. Rossiter, Matthew M. Murawski, and Urvashi B. Patel (Wan and Zhang are consultants for Heritage Information System). The result was a report, "Evaluation of Chronic Disease Management on Outcomes and Cost of Care for Medicaid Beneficiaries," that appeared in Health Policy. The study showed that the DM program improved patient drug compliance and quality of life while reducing ER, hospital, and physician office visits.

The other report, compiled by Milliman Consultants and Actuaries in Seattle, reviewed McKesson Health Solutions' Medicaid program in the state of Washington and showed a $13.3 million savings and 3:1 ROI in the program's final year (August 2005 to June 2006).


Researchers from the University of Central Florida, The College of William and Mary, Purdue University, and Milliman reviewed the Virginia DM program that focused on five chronic diseases and comorbidities (diabetes, hypertension/CHF, depression, gastro-esophageal reflux disease/peptic ulcer disease, and asthma/chronic obstructive pulmonary disease) from 1999 to 2001.

The DM program required providers, including 5,995 physicians and 1,410 pharmacists, to offer monitoring, assessments, and interventions for patient self-management. VHOP hosted an introductory videoconference before the first intervention and sent quarterly educational mailings to providers. The mailings included up-to-date practice guidelines, claims data-based feedback sheets, and clinical measurements for each disease. The program asked the providers to consult with patients about their lifestyles, treatments, and drug uses, according to the study authors.

To find program savings, researchers compared hospitalizations, ER visits, and physician office visits for the 35,628 people in the experimental groups (broken into two subgroups: physician/pharmacist-intervention and physician-intervention) and compared them with the 29,504 beneficiaries in the control group.

"Results show that patients in the experimental groups with single diseases generally reduced their medical utilizations more than those in the control group did, but at a different rate for each disease," wrote the researchers.

Although medical utilizations decreased after interventions, the researchers noted that statistical significance wasn't found for depression and/or diabetes patients. This could have been because depression and diabetes patients "rarely have acute symptoms and are less likely to require emergency room visits," wrote the study authors.

Another finding in the study is that groups with physician/pharmacist interventions reduced ER visits and hospitalizations more than the physician-intervention group-although this was not statistically significant for the majority of the target diseases. The three statistically significant differences between the groups were ER visits for hypertension/CHF and gastro-esophageal reflux disease/peptic ulcer disease patients, and office visits for comorbidity patients.

"Disease management programs that include the education of physicians and pharmacists represent coordinated care that reduces medical utilizations and adverse drug events and improves patients' quality of life while saving costs, although these impacts of the program were not evidenced throughout all disease groups," wrote the study authors.

"I think the message to take away is there is something we can do to improve the coordination," says Wan, a professor of public affairs, health service admission, and medicine, and associate dean for research at the University of Central Florida's College of Health and Public Affairs.

According to the authors, the average payments per hospitalization per patient over the assessment period for the experimental and control groups were $1,548 and $1,896 respectively. The authors estimated that if every person in the study had been in the experimental group, the Medicaid program would have saved at least an average of $2.99 million over the two-year assessment period. The program also achieved a 1.7:1 ROI, according to the researchers.

Having a system in which the physician, pharmacist, and DM company work together, which was the case in the Virginia program, can improve care and reduce costs-particularly in the Medicaid population. The healthcare system should further explore that model, says Wan. "I think the entire delivery system is in the wrong direction," he says about the current system. "The focus should be on the patient. Patient-centric care management should be implemented."


Milliman Consultants and Actuaries performed the computations for Washington's Medicaid DM program that ended in June 2006. The program managed four diseases: asthma, diabetes, CHF, and chronic obstructive pulmonary disease.

The DM program included a 24/7 nurse advice line that beneficiaries used for recommendations about acute medical issues and informed decision-support.

Ricardo Guggenheim, MD, MBA, vice president of product management and program outcomes management at McKesson in Broomfield, CO, says the Washington Medicaid program was an earlier-generation DM program. Since creating the Washington program, Guggenheim says McKesson has expanded its programs and focuses more on the total needs of patients rather than the particular chronic disease. McKesson now has Medicaid programs in Illinois, Pennsylvania, Texas, Oregon, New Hampshire, Montana, California, and Florida.

Guggenheim says McKesson learned from the Washington program. "Working with the state on this program, we learned a lot, which helped shape our approach to programs going forward," he says.

The clinical outcomes showed improvements in all four disease states, including patients using prescribed medications and receiving the proper testing.

Guggenheim says a key to McKesson's Medicaid program was identifying gaps in care by reviewing medical claims.

For instance, the American Diabetes Association recommends diabetic patients have A1c tests twice per year. If a diabetic patient had not received an A1c test, McKesson informed the physician and patient. Knowledge gaps about chronic care are common not only within Medicaid populations. "You would be surprised by the percentage of people across all demographic groups and education levels that really don't know much about the chronic disease they have. It's a universal issue," says Guggenheim.

However, caring for Medicaid populations complicates those issues further. There are often significant barriers to care that may include:

Challenges to remaining in contact with beneficiaries. Medicaid beneficiaries are often a more mobile population and may regularly change their addresses

Transportation issues that make it difficult to keep doctor appointments or working conditions that make it challenging to miss work to go to the doctor

Difficulty in finding physicians who accept Medicaid, which provides lower reimbursements than Medicare or commercial insurers

Prevalence of severe mental illness (Guggenheim estimates that 25%-30% of Medicaid costs are because of mental illness)

"You want to engage with these members, but it is far more difficult to engage with Medicaid members than with commercial members because they are more mobile and difficult to find," he says.

A key aspect of that engagement is getting physicians involved with the DM program, which is consistent in both successful Medicaid programs featured in this article.

Guggenheim says DM companies must allay physician fears and make it clear that they are there to help the physician with the goal to get the Medicaid beneficiary into the doctor's office for care.

Guggenheim says the roles of vendors and doctors are changing, with providers taking the lead in the delivery of care for patients.

"It won't be long before providers are the primary care managers of their patients. Programs like ours will support this new role of providers and will play a critical role supporting the needs of patients so they can effectively interact with providers around their medical needs," says Guggenheim.

CMS: MHS ends this year

No word on future of Phase II

Proving cost savings is a goal of any program administered by the CMS, but Medicare Health Support (MHS)-the large pilot program that was initially seen by DM providers as a panacea and a large boon to their successful business-was different. Now, two and a half years after the start of the MHS pilots by eight DM providers, the industry finds itself defending the ability of the DM model of care management to produce results in an older and much sicker Medicare population.

CMS called the five companies remaining in the MHS pilot in late January to tell them that their pilot programs would end exactly three years to the date that they each began. At the same time, the federal agency published a fact sheet on its Web site (www.cms.hhs.gov) about the MHS changes. These changes also included an end to the 5% savings threshold that was lifted December 28. The shocking news for DM companies was the fact that there was no date announced for an industry-expected move into an expanded MHS pilot (Phase II). There will be no transition for chronic care services for Medicare beneficiaries who are currently enrolled in the pilots.

The DM industry is pushing back hard on the latest CMS announcement. "Ending Phase I of MHS without ensuring continuity of these services as regulators consider movement toward Phase II will strand many chronically ill fee-for-service beneficiaries who most need coordinated care," says Tracey Moorhead, president and CEO of DMAA: The Care Continuum Alliance in Washington, DC. "DMAA urges federal regulators to move on an accelerated track toward Phase II and ensure continued provision and expansion of needed chronic care services for our nation's elderly," she says. Moorhead also challenges CMS on questions raised by DM providers about the MHS pilot that the agency has never addressed.

"We also request an expeditious, thorough review of documented shortcomings of the pilot's design and execution, including participant selection and randomization," she says. "Last year's interim report found insufficient evidence for any firm conclusion about the pilot's performance and noted significant disparities between the control and intervention groups and other critical flaws."

DM industry expert Vince Kuraitis, JD, MBA, principal at Better Health Technologies, LLC, in Boise, ID, says the long-term concern is that, "Medicare will conclude that 'carve out disease management' doesn't work and that we shouldn't try any more demos with them."

Kuraitis says CMS' decision is undoubtedly a disappointment to DM providers, but the news is unlikely to translate into reluctance by DM providers to play in the Medicare market. "It's too huge to ignore," he says.

Drop of 5% cost savings requirement

MHS was created by the Medicare Modernization Act of 2003 as a way to test chronic care improvement programs for people living with multiple chronic illnesses. The legislation required that it be budget neutral, but when CMS drew up the program itself, the agency added a requirement that providers meet a net 5% savings threshold and agree to 100% fee risk for performance that falls short of that goal. That threshold proved to be a major headache for DM providers.

The pilot will still require budget neutrality as it continues in 2008, but the news that the onerous 5% threshold has been lifted was met with nothing but praise from DM industry leaders. It had been sought for some time as a critical step to saving the program. "We are extremely pleased to see the performance threshold brought in line with the authorizing statute," says Christopher Coloian, chair of the Government Affairs Committee of DMAA: The Care Continuum Alliance. Coloian is also a vice president of CIGNA, a company that participated in MHS from September 2005 until January 14. "The change will help place the focus back on improved clinical measures and beneficiary satisfaction," Coloian says.

Coloian tells Disease Management Advisor that the "constant threat" of the 5% requirement made it difficult for providers to focus on the broader goals of clinical performance and quality improvements among beneficiaries.

Other pilot sites agreed. "The pilot now has a better chance to be judged as successful," says Robb Cohen, chief government affairs officer for XLHealth in Baltimore, one of the five companies administering an MHS pilot site. Cohen says the issue of cost savings has somewhat overshadowed several other key factors that have influenced the success of the MHS pilot so far: study design (including the comparability of the control group), identification of enrollees, and collaboration with physicians.

Stock shock

The news that CMS was ending Phase I of MHS was a shock to the industry and to shareholders of publicly traded companies like DM giant Healthways. On January 29, Healthways stock closed at $66.37 per share. After the MHS announcement, the closing price was $55.85 (a 15.85% loss) one day later.

"The MHS program was intended to lower Medicare claims costs, and it has only a nominal impact," says Doug Simpson of Merrill Lynch. The financial picture may be even bleaker than the one-day drop in stock price. CMS says in a fact sheet available on its Web site that even with the threshold for savings pegged at budget neutrality, the five companies, including Healthways, that remain in MHS will need to produce Medicare claims costs between $300 and $800 per participant per month for the remaining months of the pilot program.

This represents a 20%-40% reduction in claims costs from the current levels that are being billed, according to CMS. The government says that program fees paid as of January represent an increase of 5%-11% in Medicare costs for the participating beneficiaries. If the companies do not meet budget neutrality at the end of Phase I, they will have to return at least partial payments to CMS.

"This looks very much like it could be the end of the MHS pilots for Healthways," says Joshua Raskin, an analyst for Lehman Brothers. "Failure to move into the next phase would deal a blow to Healthways, which has already spent about $23.5 million to support these MHS programs," he says. CMS officials are cautious about the future of MHS.

Kuraitis and others are finding it difficult to understand CMS' thinking on MHS. "CMS needs to be more transparent about its plan," he says.

"We are allowing Phase I of the Medicare Health Support pilot to run its course," a CMS official tells DMA. (Editor's note: CMS policy does not permit public attribution of comments by its staff members.) "The next step is to continue the ongoing evaluations to determine if the goals of the pilot were met. If we find evidence of success, CMS may move to a Phase II as allowed for in the enabling legislation," says this official.

The official says that because the agency has yet to find evidence of success, it is doubtful that the program will expand to Phase II anytime before the second required report to Congress, which is due in February 2009. The legislation required three independent reports on the pilot. The first was based only on the first six months of interventions in the pilot program and was given to Congress in 2006. The third report is due in February 2011. Phase II can be initiated at any time by CMS if it finds evidence that the program met its three statutory requirements: improve clinical quality outcomes, improve beneficiary satisfaction, and achieve budget neutral financial savings.

Lessons learned

Although costs savings are a major factor in the success or failure of MHS, the industry says the pilot raised other concerns about the application of DM in older patients with more than one chronic condition. Coloian says the MHS pilot has demonstrated the need for DM interventions earlier in the disease process.

"We have to stop the production of illness and disease, if you will, before it takes its toll on the patient and on the healthcare system," he says. "In the commercial space, we are focusing on the lower end of both preventing the onset of chronic conditions and in managing these conditions on a lower end," he says. "We think it is only a matter of time before we move to this reality in the fee-for-service market."

The original MHS design was to enroll beneficiaries with multiple comorbid conditions who were responsible for the highest percentage of Medicare costs. "We may have erred by targeting the high end rather than looking for more achievable savings in beneficiaries with less chronic disease," Coloian says.

"The time period for when the beneficiaries were first identified to when the program launched may have resulted in participants being even further progressed in their illnesses," says XLHealth's Cohen.

The original eligibility criteria for MHS also did not disqualify beneficiaries with cognitive impairment and social and psychological issues that might have made it harder to fully implement DM efforts, Coloian says.

Coloian says the MHS pilot also does not make data available on a timely basis. Evidence of this, he says, is that although the sites have been administering the program for more than two years, data are yet to be available for anything beyond the first six months. The hope in a program meant to test certain ideas would be that problems would be identified early and adjustments made. But these changes can't happen without data, he says. Cohen says that any successful DM program takes time to have an impact, and, like Coloian, he points to the lack of good data identified so far in the MHS pilots by CMS. "We believe that our program has shown quality improvement and high satisfaction among beneficiaries," says Cohen. Likewise, he says the XLHealth program has improved the coordination




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