GlaxoSmithKline
Situation
State Medicaid departments face a daunting task of delivering improved health care to patients without dramatically increasing spending. Some state Medicaid programs have implemented harsh access restrictions to contain costs without adequately protecting the quality of care ultimately delivered to patients. Under this approach, Medicaid focuses on silos of spending (e.g. separate line items for drug, hospital, and physician spending) rather than looking across the spectrum of care to see what combination of services delivers the best care to each patient at the lowest cost.Solutions
1. North Carolina’s Medicaid program has successfully developed an enhanced primary care case management (E-PCCM) model to address this problem. Known as Community Care of North Carolina (CCNC), this model is based on the medical home concept and it addresses the spectrum of healthcare services from acute illness to preventive care, and referrals to specialists for complex and chronic conditions. By preventing and catching illness early and encouraging healthy lifestyle changes, the medical home model brings great value to the state and quality care to Medicaid patients. The model has been successful because it provides physicians enhanced resources to help manage their patients. These resources include disease management protocols, case managers, practice-specific data and a reimbursement level that attracts participating physicians.Before implementing this model, it is necessary to build a framework of committed caregivers and physician involvement at all levels of care. North Carolina successfully built a county-wide partnership of physicians, hospitals, health departments and departments of social services to manage the care. Care management committees identify the clinical issues to be addressed and implement best practices. Each program has a medical director committed to a primary care-directed, evidence based delivery system. The committees meet every two months to review statewide data and discuss innovative programs. Then physician champions are chosen to attend care management meetings and to implement disease management initiatives in his/her practice. In North Carolina, this county wide model eventually evolved into regional networks of physicians. These networks have become a platform from which to launch innovative care and disease management programs.
Physicians developed disease management tools to tackle asthma, diabetes and congestive heart failure. Over the first four years of the asthma program alone, program utilization data revealed a savings of $27 million in reduced ED and hospital charges. In addition, case managers were assigned to each primary care practice, but they were housed in a central location to facilitate shared learning. Finally practices were encouraged to follow treatment guidelines to improve patient health.
Physicians are reimbursed at 95% of Medicare rates plus a $2.50 per member per month fee to serve as a medical home and implement disease management protocols.
Patients are encouraged to use their medical homes as the first contact for care. A nurse advice phone line gives patients access to immediate care and a community wide pediatric after-hours clinic provides parents broad access to primary care. These two initiatives reduced emergency room visits for Medicaid patients under 21 by 17% in the first year (1999).
2. Asheville Project – Disease Management The Asheville Project is a pharmaceutical care program that began in March 1997 as a partnership between the city of Asheville, North Carolina, and the North Carolina Center for Pharmaceutical Care (NCCPC). The city wanted to more effectively manage its healthcare costs, particularly in the area of diabetes treatment as well as bring real value and benefit to its employees who suffer from diabetes and other chronic diseases.
Under the program, NCCPC trained community pharmacists in diabetes management and offered pharmaceutical care services for city employees with diabetes. The city waived employee co-payments on prescription medicines and medical supplies and offered employees other incentives to participate in the program. Employees agreed to go through a diabetes education program and to meet regularly with a specially trained pharmacist. The pharmacist monitored the patient's condition, educated the patient on medications, and acted as a partner in managing all aspects of the disease.
Better Health Lower Costs
I. North Carolina Community Care ProgramA. Asthma Disease Management
- Hospital admissions of asthma patients decreased significantly from 8.2% to 5.3%.
- 28% increase in flu vaccines
- Over 90% of staged asthma patients are on appropriate preventive medication
- All practices adopted best practice guidelines from the National Institutes of Health
- 10% increase in referrals for eye exams
- 62% increase in flu vaccines
- All practices adopted best practice guidelines from the American Diabetes Association
- Conducted care management follow-up outreach and education on recipients with $25,000 or more in Medicaid expenditures over 6 months.
- In the process of defining a process to use predictive modeling to target individuals at greatest risk based on historical utilization and diagnoses.
- For the period July 2003 through June 2004, the CCNC program cost the state $10.2 million
- Savings for that period were $124 million as compared to 2003
II. The Asheville Project
Measuring key economic, clinical, and humanistic outcomes for the patient and payers, the project leaders reported five years into the project:
- Total prescription costs increased over five years from $762 per patient per year (PPPY) to $2,958 PPPY due to shifting of costs from inpatient and outpatient services to prescriptions.
- Mean insurance claims costs decreased by $2,704 PPPY in the first follow-up year and by $6,502 PPPY in the fifth follow-up year
- Payers realized significant reductions in overall direct medical costs ranging from $1,622 to $3,356 PPPY.
- Patients' A1c (glycosylated hemoglobin) concentrations, the primary clinical measure, decreased (improved) at every follow-up for more than 50% of the patients, and the number of patients with optimal A1c levels increased over time as well.
- Employees reported a greater quality of life and greater success in managing their diabetes; employers reported decreased absenteeism, dropping from 12.6 days PPPY to 6.2 PPPY, and resulting in increased productivity valued at $18,000 per year for the city.
