Melanie Bella Center for Health Care Strategies

1. Integrated Care Delivery Models:Managing Comorbidities and Improving Care in MedicaidJune 6, 2008 Melanie Bella Center for Health Care Strategies

2. Per Capita Medicaid Spending Total Per Capita Costs Percent of Medicaid Population Source: Sommers A. and Cohen M. Medicaid’s High Cost Enrollees: How Much Do They Drive Program Spending? Kaiser Commission on Medicaid and the Uninsured, March 2006.

3. Impact of Chronic Illness on Medicaid • High Cost • Top 3.6% of beneficiaries accounted for nearly half of total Medicaid spending • High Need • Nearly two-thirds (61%) of Medicaid beneficiaries have one or more chronic or disabling condition • Almost half (46%) of Medicaid beneficiaries with one chronic or disabling condition have another • “Really” High Need: Dual Eligibles • 7 million dual eligibles drive 42% of Medicaid spending and 24% of Medicare spending • 87% of dual eligibles have 1 or more chronic conditions

4. Cluster Data Analysis: Faces II 4 Purpose • Describe clusters of comorbidities among Medicaid recipients and the utilization and expenditure patterns associated with the clusters • Provide a description that will be useful to purchasers, plans, and providers in figuring out how to improve the care for patients with multiple chronic conditions Project • Analysis of 2001 and 2002 national, person-level Medicaid utilization and cost data • Conducted by Rick Kronick, et al at UCSD

5. Medicaid-Only Disabled, by Number of CDPS Categories

6. Top 5% Disabled, by Number of CDPS Categories

7. Key Findings • Among high-cost beneficiaries: • Virtually all have multiple chronic conditions. Within the most expensive 1% of beneficiaries in acute care spending, almost 83% had three or more chronic conditions, and over 60% had five or more chronic conditions. • Almost all have many different types of problems. Average number of diagnostic groups among high-cost patients is above 5; many of these patients have cardiovascular disease, psychiatric illnesses, pulmonary problems, and many other conditions.

8. Key Findings • For Medicaid-only persons with disability, each additional chronic condition is associated, on average, with an increase in costs of approximately $700/month, or approximately $8,400 per year (“super-additivity”). • Some pairs of diagnoses demonstrate strong correlations. For example, 68% of Medicaid-only disabled beneficiaries diagnosed with diabetes also have cardiovascular disease. • Identifying the most prevalent diagnostic pairs/sets of diseases (“dyads” or “triads”) holds promise for prioritizing care and developing care pathways.

9. Top Five Diagnostic Dyads among the Most Expensive 5% of Patients 9

10. Managing Comorbidities: The Medicaid Value Program (MVP) • MVP was a 2-year $2.8 M national initiative funded by Kaiser Permanente, with additional funding from the Robert Wood Johnson Foundation. • Ten competitively selected teams designed and tested interventions targeted at a range of comorbid conditions. • Rigorous study designs, including randomized controlled trials.

11. Why was MVP Important? • Traditional disease management programs often fall short in Medicaid because: • Presence of comorbidities • Need for non-medical (wrap-around) social service supports • Fragmentation of physical and behavioral health care • Core elements of effective care models: • Service integration • Multi-disciplinary care teams led by a “go-to” person • Consumer and provider engagement

12. MVP Innovation Teams

13. MVP Evaluation • Independent evaluation conducted by Mathematica Policy Research • Mix of qualitative and quantitative analysis • Research Questions: • What interventions did grantees implement and what were they trying to achieve? • Were grantees successful in implementation and what factors facilitated or impeded this? • Did the interventions achieve the outcomes or impacts sought? What could have made the interventions more successful? • How generalizable is the MVP experience? What was learned about the various models as well as their replicability and utility?

14. MVP Evaluation: Critical Factors for Implementation • Leadership commitment • Favorable environmental conditions • Staff, patient, and provider buy-in • Medicaid support and leadership • Intervention standardization

15. MVP Evaluation: Analysis of Outcomes • Two grantees had a rigorous design to support assessment of their impacts: Washington State, Comprehensive NeuroScience • Easier to implement interventions than rigorously test effects: • Issues with comparison group • Small numbers • Statistical tests • Design weaknesses and/or implementation problems limited the results, but all of the interventions generated important insights on changing care processes

16. Key Takeaways • Efforts to integrate care across services are promising • Multi-faceted, well-targeted interventions have greater potential to affect outcomes • Intervention intensity matters • Growing interest in focusing on high-need, high-cost patients • Building an empirical evidence base is challenging • There is a critical need for rigorous evaluation in Medicaid

17. Additional Resources @ www.chcs.org • The Faces of Medicaid II: Recognizing the Care Needs of People with Multiple Chronic Conditions • Medicaid Value Program Evaluation, Pilot Project Case Studies and Logic Models • Subscribe to CHCS eMail Updates for news about CHCS programs and resources • www.chcs.org