CMS Urges State Involvement In Medicare Disease Management Programs

The Centers for Medicare & Medicaid Services is urging states to be involved in Medicare-sponsored disease management programs.

"If you're Medicaid only and you don't care about anything else, you should still be caring about this," CMS Associate Regional Administrator for Medicaid & Children's Health-Region 1 Bruce Greenstein said at a Sept. 22 Disease Management & Congress Exposition meeting in Boston.

Greenstein urged states to keep an eye on Medicare's chronic disease management program even though the program is funded by Medicare and will be overseen at the federal level.

Medicare-sponsored disease management programs could have an effect on Medicaid spending down the road since many Medicare beneficiaries will eventually qualify for Medicaid-sponsored long-term care programs.

"This could dramatically affect the most money you spend in your state in terms of your long-term care and your chronic and your elderly," he said.

"The better you take care of Medicare people before they're Medicaid, now, the better your state's going to be with regard to long-term liability for institutional care for the future," Greenstein said.

Under the Medicare law enacted in 2003, CMS is required to sign agreements by Dec. 8 with "chronic care improvement" organizations to develop, test and evaluate chronic care improvement programs for at least 10% of the Medicare population (¹ (Also see "Medicare Chronic Care Demonstration Proposals Request Expected Mid-April" - Pink Sheet, 5 Apr, 2004.), p. 14).

The program will encourage treatment adherence among patients with congestive heart failure, diabetes and COPD.

Greenstein also said that states should be interested in how the program would effect Medicare's coverage of dual-eligibles.

"States ought to be interested in how to ensure that a system that encourages cost-shifting to go on doesn't take place," but a program "to limit liability does take place. How to coordinate what Medicaid is going to pay for is part of the overall goal to have individual's health care be more coordinated, better quality and also efficient in terms of funds," Greenstein said.

Greenstein noted that even after Part D kicks in in 2006, state Medicaid programs will still have per member per month costs.

"In a conversation I had with a Medicaid director last week, I said give me your PMPM for dual-eligible non-institutional drug costs," Greenstein said. "It turns out it was $80."

"You still have another $80 that represents some liability to the state that could be increased if the incentives were on the other side to maximize what Medicaid would be paying for," he said.

"So, work that into your thinking and be thinking about that in the future when drugs are off the table from Part D; there's still something left," Greenstein said.

Similarly, Greenstein said that CMS should pay attention to Medicaid disease management programs since Medicaid recipients become Medicare's responsibility when reaching the age of 65.

"I've been using the argument that Medicare really ought to be interested in what Medicaid is doing, even for the non-dual eligibles because ultimately what we're doing is we're improving the risk for Medicare down the line," Greenstein said. "The money is coming from the same place obviously."

Greenstein noted that while Medicare has launched a chronic care improvement program, there has not been uniform adoption of similar programs at the state level.

CMS Director-Chronic Care Improvement Program Sandra Foote told the meeting that states have proposed disease management programs for dual eligible recipients and have asked CMS for funding.

"Often they have come to CMS and said, 'we want to do disease management on the duals and we want you to help pay for it because you're the ones who are going to have your costs dive if we get it right and the hospital admissions go down," Foote said.

"CMS has been very uncomfortable with, well, this is Medicare money and this is Medicaid money," Foote added. "I'm not sure they legally even have the right to do it."

Foote noted that in the case of the chronic care improvement program, CMS is the agency that is taking the lead on a disease management program.

"In this case, this is the opposite. This is Medicare stepping forward and saying, we're going to try this," she said. "We expect to have savings, but we also understand that these people may spiral down into Medicaid eligibility," Foote said.

Greenstein said that based on an internal study conducted by his office, one obstacle that states have encountered to developing programs is the limited horizon of funding appropriation by state legislatures.

"What we found is that states' ability to truly address these issues thoughtfully is hampered because state legislatures want actions soon, now usually, within the context of a fiscal year," he said.

Another factor is that many states lack sufficient personnel to develop the programs. "Many states are on hiring freezes," Greenstein said.

For states considering such programs, Greenstein urged them to carefully consider the program goals at the outset. "Really spend time developing what the goals are and what you're hoping to get out of the program, rather than just developing the program before you know exactly what you're going to get."

States could consider a variety of implementation models, he said. "We're looking at states that are interested not only in doing a complete buy- or vendor-oriented program, but rather, more hybrid models as well. In one case, we have a complete buy model, where it's going to be completely contracted out."

CMS said that it is hoping for "real-time" information sharing. Foote said that states may be a "tremendous source of drug data early on."

Foote said that the first step of the disease management demonstration programs will be to target health care providers to assist enrollment before contacting beneficiaries directly.

"We will probably do it as a very targeted campaign. We want to start with the providers in the community, to make sure they're aware of it, well informed about it, so we have some buy-in there when we turn to the beneficiaries," Foote said.

Foote noted that one challenge that the agency may face is convincing enough beneficiaries to enroll.

CMS' goal is to sell the program to a wide array of health care providers first so that when the beneficiaries are then contacted, they can be reassured by a variety of caregivers in the community.

"I don't just mean the physicians, I really don't. We're going to try to do broad outreach to the types of organizations that work with the kinds of beneficiaries we're going to be drawing in as target beneficiaries so that, essentially, wherever these people turn, they will be hearing 'you can trust this. This is something for you to try and this is a great idea.'" Foote said.

"What we will try to do is line up the influencers in the community who are likely to be interacting with these beneficiaries," then notify the beneficiaries.

Foote said that health care providers will also need to be convinced of the benefits of the program, which will entail presenting the program as "supportive" and not "a burden" to administering health care.

Chronic care improvement contractors will also promote the program, she said. "We will be turning those names and phone numbers and everything over to the chronic care improvement organizations who are going to be doing a ton more than we are because it's in their interests."

Under the demo program, contractor's fees will be at risk if they do not meet cost and quality targets (² , p. 21).

CMS hopes that the pilot will lead the agency toward developing large scale programs, noting in the past that many programs have been on a "very small scale."

"What we want is to be able to roll-out programs for beneficiaries across the United States, all ethnicities, all different kinds of problems, where we can find strategies that actually help them and their physicians," Foote said.