Virginia s Healthy Returns Alternative Benefit Design

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1 Virginia s Healthy Returns Alternative Benefit Design Presentation to the: National Governors Association s Center for Best Practices: State Defined Benefit Package Workshop Patrick W. Finnerty, Director Department of Medical Assistance Services March 27, 2008 Philadelphia, Pennsylvania

2 Presentation Overview Virginia s Healthy Returns Disease Management Program Approval Process as an Alternative Benefit Under the DRA, 2005 Program Details, Results and Next Steps 2

3 Disease Management in Virginia Virginia Healthy Returns SM disease management (DM) program has been operated through a contract with Health Management Corporation (HMC) since 2006 Healthy Returns SM focuses on preventative care, promotion of self-management, and appropriate use of medical services in the fee-for-service system 100% of the program is administered via mail or telephonic interventions; no face-to-face contact Focused on improving quality of patient care 3

4 Disease Management in Virginia Healthy Returns SM provides DM services to Medicaid/SCHIP fee-for-service recipients with the following conditions: Asthma (all individuals) Chronic Obstructive Pulmonary Disease (individuals 18 years old and over ) Congestive Heart Failure (individuals 18 years old and over ) Coronary Artery Disease (individuals 18 years old and over ) Diabetes (all individuals) 4

5 Presentation Overview Virginia s Healthy Returns Disease Management Program Approval Process as an Alternative Benefit Under the DRA, 2005 Program Details, Results and Next Steps 5

6 Virginia Faced Several Initial Challenges Obtaining CMS Approval of Healthy Returns Determining whether the program operated as an administrative program or a medical service. (Medical) Determining whether actuarial certification was necessary for a per-member per-month (PMPM) fee that was competitively procured. (Yes) Deciding whether or not to change the program enrollment from a voluntary opt-in process to an automatic opt-out enrollment process. (Opt-in) This application was not approved due to several disagreements, most notably, the requirement for actuarial certification for all Prepaid Ambulatory Health Plans (PAHPs). Virginia rescinded its waiver application. 6

7 DRA State Plan Amendment Submitted a Deficit Reduction Act (DRA) alternative benefit state plan amendment (SPA) Included in the Standards Established and Methods Used to Assure High Quality Care section. This section consists of utilization review standards and criteria for some Medicaid services. Changed the program to voluntary enrollment (as required under the DRA). Removed the provision placing contractor fees at risk. 7

8 DRA State Plan Amendment Created an alternative benefits package that includes disease management plus all Medicaid State Plan services. DM program still operates as a PAHP, so actuarial certification was ultimately required. Benefit of DRA SPA over a 1915(b) waiver: No renewal required No cost-effectiveness requirement 8

9 Presentation Overview Virginia s Healthy Returns Disease Management Program Approval Process as an Alternative Benefit Under the DRA, 2005 Program Details, Results and Next Steps 9

10 Healthy Returns Eligibility Criteria All fee-for-service Medicaid and SCHIP enrollees EXCEPT: Individuals enrolled in Medicaid/SCHIP managed care organizations (MCOs); Individuals enrolled in both Medicaid and Medicare (dual eligibles); Individuals who live in institutional settings; and Individuals who have third party insurance Virginia is the first state to offer DM services to participants receiving long-term care services though one of seven home and community-based waivers. 10

11 Main Program Components Care Management Nurse Line Evidence-Based Guidelines 11

12 Care Management Provide care management of program participants consistent with evidence-based guidelines to include: Baseline health status assessment Routine monitoring Education on health needs and self-management Monitoring participant compliance with selfmanagement protocols Facilitate contact with providers and community agencies 12

13 Nurse Line Available to participants 24 hours per day, 7 days per week through a centralized toll-free number ( ). Provides clinical support to answer medical questions for DM program participants and assist participants with referrals. The Nurse Line is: Staffed by appropriately licensed medical professionals, Provides prompt and courteous service, and is HIPAA compliant Ensures services for non-english speaking enrollees are provided. 13

14 Evidence-Based Guidelines Utilizes national evidence-based guidelines for the specialized conditions Includes the use of HEDIS measures Disseminates treatment protocols to participants and providers Provides support to providers 14

15 Two Levels of DM Services Standard Program: Includes an initial letter, a welcome kit including detailed information on his/her condition, and quarterly educational newsletters. Standard enrollees may also contact the 24-Hour Call Line. High Intensity Program: Individuals receive scheduled phone calls from a HMC nurse, in addition to services that are provided in the standard program. Individuals placed into service level based on predictive modeling factors including, but not limited to, recent emergency room utilization and progression of condition 15

16 Program Participants (January 2008) Condition High Intensity Enrollees Standard Intensity Enrollees Asthma 2,447 6,418 Chronic Obstructive Pulmonary Disease Congestive Heart Failure Coronary Artery Disease Diabetes 1,124 2,151 TOTAL 4,290 10,276 16

17 Preliminary Outcomes Increase in the number of members receiving flu vaccines. 68% of members with diabetes perform blood glucose monitoring, up from 58%; 42% report A1C values of 7 or less, up from 32%, and 80% report LDL values of 130 or less. 88% of members with CAD reported controlled blood pressure and 69% reported LDL values of 130 or less. Prescriptions for beta blockers among members with congestive heart failure increased to 62%, up from 58%. Improvements in mental and physical functioning and a decrease in the average number of days of lost activity. 17

18 Next Steps Continue monitoring self-reported and claims-based data. Monitor participant and provider satisfaction. Measure utilization of services, including: Number of hospital admissions and readmissions Number of emergency room and ambulatory care visits Pharmacy use Utilization/physician office visits Contract with a third-party vendor to conduct an independent evaluation of the DM program. 18

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