Current and Future Directions in Medi-Cal Chronic Disease Care Management: A View From the Top

Objective: To determine the extent to whichMedicaid managed care (MMC) organizations areengaged in chronic disease care management(CDCM), tailor CDCM for diverse populations,or plan to expand CDCM.

Study Design: Web-based survey of 23 eligibleCalifornia MMC health plan executives in fall2005.

Methods: Frequency distributions of surveyresponses.

Results: Nineteen (83%) of 23 executives responded,representing 2.5 million beneficiaries. Eighteen(95%) MMC plans reported implementing 1 ormore elements of CDCM. Although plans used awide range of CDCM strategies to reach performancegoals, most implemented provider awarenessactivities such as offering guidelines or diseasespecificfeedback to physician groups. More thanhalf of the plans reported interest in expandingCDCM to include more active interventionssuch as disease registries, pay for performance,telephone counseling to patients, and other selfmanagementsupport programs. Few plansreported tailoring their CDCM to vulnerablemember populations such as those with limitedliteracy or limited English proficiency. Executivesreported that insufficient financial resources atthe plan level, lack of organizational leadershipand commitment in physician organizations,and limited information technology in physicianoffices were barriers to CDCM expansion.

Conclusions: California MMC health plans reportedsubstantial interest in CDCM and a desire toincrease CDCM. Representatives reported intentionsto expand to strategies that more directlyengage providers and patients. To ensure thatthe growing number of vulnerable enrollees withchronic disease receive high-quality care, policyefforts should focus on enabling MMC healthplans to more consistently implement and targetpopulation-based strategies such as CDCM.

(Am J Manag Care. 2007;13:263-268)

As Medicaid managed care (MMC) expands to vulnerable patients withchronic conditions, there is a growing need among plans to incorporatechronic disease care management (CDCM) strategies.

• Experts recommend incorporation of cultural and linguistic competencyand health literacy principles into CDCM to engage diverse patientswithin their own cultural context.
• The most common barriers to expanding CDCM faced by MMC planswere prohibitive cost, absence of physician leadership support, and lackof information technology.
• Recent changes in federal regulations allow hospitals and health systemsto pay for some of the costs associated with installing informationtechnology in physicians' offices.

Chronic disease care management (CDCM) improves qualityof care across a range of chronic conditions^1-11 and enablesmore frequent and productive patient interactions, leadingto improved patient outcomes.¹² Such results have even beenobserved for more vulnerable "hard-to-reach" populations such as thosewith limited literacy or limited English proficiency.^13-15 Physician organizationsand managed care plans serving non-Medicaid commerciallyinsured populations are implementing CDCM strategies.^2,16

There is a need for CDCM in Medicaid programs as well. Federal andstate governments spend almost $300 billion per year on behalf ofMedicaid recipients, 70% of which is spent on disabled and aged populations.¹⁷ As states continue to enroll disabled beneficiaries, many withchronic illnesses, into Medicaid managed care (MMC), CDCM forlow-income vulnerable populations will be critical to providing qualitycare.^18,19 Experts recommend incorporation of cultural and linguisticcompetency and health literacy principles into CDCM to enhanceprovider and system efforts to engage diverse patients within their owncultural context.^20-22 However, the extent to which CDCM strategies aretailored for and implemented with Medicaid recipients or those with limitedliteracy or limited English proficiency is unknown.^23,24

We designed a study with California MMC plan executives to (1) assessthe extent to which MMC plans in California are using CDCM, (2) evaluatethe extent to which MMC plans that use CDCM target their effortstoward vulnerable populations, (3) identify MMC plans that anticipateexpanding CDCM in the future, and (4) describe perceived barriers to theexpansion of CDCM.

METHODS

Design

We administered an online survey to California MMC plans betweenSeptember and October 2005. The study was approved by the Universityof California, San Francisco, Committee on Human Research.

Study Population

Executives from all 23 general (nonspecialized) MMC health plans inCalifornia were eligible to participate, including local initiative commercialplans, county-organized health systemplans, and geographically definedplans (designations particular to theCalifornia health plan market). The 7specialized MMC plans serving specific populations or services(eg, dental, behavioral health, and persons with humanimmunodeficiency virus) were excluded. We surveyed themedical director or the quality director from each eligibleMMC plan.

Recruitment

An e-mail describing the goals of the survey was distributedby the California Department of Health Services officeto the medical directors and the quality directors of all 23 eligibleMMC plans. The message referred consenting individualsto a confidential web-based survey on CDCM. A remindere-mail was sent to nonresponding plan directors. We contacteddirectors who did not respond to either e-mail by telephoneand, if requested, sent them paper surveys.

Survey Design

The web-based survey explored the following 4 contentareas: (1) current CDCM goals and activities, includingwhether the plan had implemented any of 11 specific CDCMstrategies; (2) whether these CDCM activities were targetedto specific populations such as those with limited literacy orlimited English proficiency; (3) future goals and plannedimplementation of CDCM activities; and (4) perceived barriersto future development or expansion of CDCM activities.The survey incorporated content from previous surveys andconceptual work on chronic illness care, health literacy, andcultural and linguistic competence.^20,21,25,27 An externalMMC executive reviewed the survey to improve its clarityand appropriateness. The design used closed-ended questionsrequiring a response to continue to the next item. The 26-item survey can be viewed in the online Appendix (availableat www.ajmc.com).

Analysis

We performed descriptive analyses of responses to the surveyquestions. For convenience of presentation and interpretation,we organized the 11 CDCM strategies into thefollowing 3 overarching categories, grouping together strategiesthat feature broadly similar approaches to qualityimprovement: (1) increasing provider awareness of best practicesand current performance, (2) developing provider skillsor creating enabling structures within physician organizationssuch as provider or staff training, or (3) improving patient andprovider engagement with CDCM activities directly such assupporting self-management support groups and connectingpatients to community resources. Although we are aware thatthe current research support for some of these strategies isweak and that the groupings do not reflect the actual groupingsof CDCM strategies or the order in which they might beimplemented by health organizations, these strategies are frequentlymentioned as potentially useful for treating patientswith chronic illness, and grouping similar strategies togethermakes it easier to compare response patterns.²⁸ Our analysesdescribe the extent to which these strategies were targeted tovulnerable populations (such as those with limited literacy orlimited English proficiency) and indicate the future directionof CDCM in MMC.

RESULTS

Executives from 19 (83%) of 23 eligible managed careplans completed the survey, representing approximately 76%of the 2.5 million California MMC members in the nonspecialty-based plans.^29,30 Plan size ranged from 14 000 to 744 000members, with beneficiaries representing 21 (84%) of 25California counties. There were no substantial differences inplan size, geographic areas, or plan organization between participatingand nonparticipating plans.

Current CDCM Strategies

The MMC plan executives reported a wide range of currentCDCM strategies (Figure). Eighteen (95%) of 19 respondentsreported that their plan was engaged in 1 or morecomponent of CDCM, and 14 (74%) reported CDCM programswere among their plan's top 3 current quality improvementobjectives. Most MMC plans supporting any CDCMactivities were offering strategies that built provider awarenessof best practices and current performance. These includeddeveloping and disseminating guidelines to providers (95%)and providing feedback directly to providers (79%). A substantialnumber of MMC plans also supported strategies developingproviders' skills and enabling structures. Twelve plans(63%) supported the generation of disease-specific registries,and 9 (47%) supported provider or staff training aboutCDCM. The MMC plans frequently attempted to improvedirectly patient and provider engagement with CDCMthrough mailed patient reminders (95%), self-managementsupport programs (53%), and connecting patients to communityresources (47%). Automated telephone support andreminders (26%), reimbursement for group medical visits(16%), pay for performance (37%), and financial support foroutreach workers (16%) were used less frequently.

Although most plans reported targeting CDCM strategiesfor diabetes mellitus (84%) and asthma (100%), few plansreported targeted CDCM strategies for congestive heart failure(21%), coronary artery disease (21%), or depression(21%). Moreover, few plans had defined priority populationsto receive CDCM strategies (Table). Five MMC plans (26%)reported targeting CDCM strategies toward populations withlimited English proficiency and 1 (5%) toward populationswith limited literacy.

Future CDCM Strategies

All but 1 MMC plan executives reported intentions toexpand their CDCM programs. Although 22% planned tocontinue expanding their CDCM programs without focusingon particular beneficiary populations, most reported intentionsto expand CDCM toward specific groups such as thosewith Supplemental Security Income or disabilities (53%),patients with multiple chronic diseases (47%), and frequentusers of the medical service (42%).

Barriers to CDCM Expansion at MMC Health Plan andProvider Group Levels

The MMC plans reported different barriers at the healthplan, physician organization, and physician office levels. Themost common barriers to expanding CDCM faced by MMCplans were the prohibitive cost of implementing the CDCMstrategies at the health plan level (37%), absence of physicianleadership support for implementing CDCM at the physicianorganization level (42%), and lack of information technology(IT) at the provider level (37%).

DISCUSSION

Most California MMC executives reported that theirhealth plans are engaged in CDCM and that they intend toshift the focus of their programs to incorporate more CDCMstrategies that directly engage providers and patients. TheMMC plans incorporated many of the CDCM strategies thatare used by other commercial plans, particularly those focusingon guideline dissemination,^31,32 physician feedback,³³ diseaseregistries, and mailed patient reminders. Although usefulas educational and benchmarking tools, these strategies haveonly modest effects on physician and patient behaviors whenused alone.^32,34,35 However, their effectiveness would likely beincreased if multiple mutually reinforcing strategies such asregistries, guideline dissemination, and physician feedback,were implemented.³⁶

Our results indicate that the strategies aimed at increasingprovider awareness were likely to be in place already.Strategies to develop provider skills and to create enablingstructures such as establishing disease-specific registries andtraining providers in CDCM, were less consistently adopted,with about half of the plans reporting these activities.Strategies that directly aimed to improve provider andpatient engagement and that require more intensive patientplaninteractions or financial expenditures (such as automatedtelephone reminders, reimbursement to providers forgroup medical visits, pay-for-performance programs, andfinancial support for outreach workers) were the least likelyto be implemented.

With regard to future plans, most MMC plan executivesreported intending to implement or expand pay-for-performanceprograms, automated telephone reminders, and selfmanagementsupport. Only a small number indicated thatthey planned to reimburse for group medical visits or to providefinancial support for lay outreach workers.

It has been estimated that more than one half to two thirdsof Medi-Cal beneficiaries have limited English proficiency orlimited literacy,³⁷ which are strongly correlated with higherrates of chronic illness andworse chronic disease control.^38-42 Unfortunately, onlya few MMC plans reportedtargeting or tailoring theirCDCM interventions to patientswith limited Englishproficiency or limited literacy,and few executives reportedintentions to expand or tailorCDCM programs to specificallyaddress the needs of thesepopulations. Increasing thefocus of CDCM programs toaddress language and literacyneeds of MMC beneficiariesmay help reduce healthcaredisparities observed betweenvulnerable and less vulnerablepopulations.⁴³

The most important barriersto expanding CDCM programsreported by MMC planexecutives were the cost ofimplementing the CDCMstrategies, the lack of physicianleadership support forimplementation CDCM, andthe perceived absence of IT atthe provider level. These are similar to barriers reportedamong physician organizations to the expansion of CDCM.⁴⁴There are potential remedies for each of these barriers. Recentchanges in federal regulations allow hospitals and health systemsto pay for some of the software, implementation, andtraining costs associated with installing IT in physicians' offices, reducing the effective cost to physicians.⁴⁵ Leadershipdevelopment programs and technical assistance for implementingCDCM strategies are available from external qualityimprovement organizations such as the Institute forHealthcare Improvement.⁴⁶ These activities are encouragedby federal or state funded pay-for-performance programs thatprovide incentives at the MMC plan level or at the individualprovider level to acquire appropriate IT and to implementCDCM strategies.

Our study has several limitations. We surveyed onlyCalifornia MMC executives, potentially limiting the generalizabilityto other states. We were unable to validate the beliefsand opinions of executive representatives. The fact that theCalifornia Department of Health Services was involved in therecruitment of health plans for the survey may havebiased the executives' responses, motivating them toreport higher levels of involvement in CDCM thanactually exist or to exaggerate their intentions toexpand CDCM strategies. However, the fact that wemaintained the anonymity of the respondents mayhave reduced this bias. Although our response rate of83% was high and was consistent with that of othersurveys of high-level executives, not all plansresponded.⁴⁷ While we did not find differences inplan size or design between respondents and nonrespondents,nonrespondents may have differed intheir CDCM strategies and goals. Finally, our closedendedsurvey, while permitting more uniformresponses to specific questions, did not allow for more detailedquestioning and deeper understanding of CDCM strategies.

In conclusion, MMC health plan executives report thattheir plans are engaging in various CDCM strategies, particularlythose aimed at increasing provider and beneficiaryawareness and at developing skills and enabling structures.Plan executives report a desire to shift future CDCM strategiesto those that would directly engage providers and beneficiariesbut face barriers to this expansion, including limitedplan finances and perceived lack of physician organizationleadership and IT infrastructure. Despite the interactionbetween social and clinical factors that is common amongMedi-Cal beneficiaries, few plans report focusing theirCDCM efforts toward vulnerable beneficiaries such as thosewith limited literacy and limited English proficiency. Toensure that the growing number of vulnerable enrollees withchronic disease receive high-quality care, policy efforts shouldfocus on enabling MMC health plans to more consistentlyimplement and target population-based strategies such asCDCM.

Author Affiliations:

From the University of California Department ofMedicine, San Francisco (LEG, MH, DS), Department of Family Medicine(MH)and University of California, Berkeley School of Public Health,Department of Health Policy and Management (TGR).

Funding Sources:

This study was supported by National Research ServiceAward training grant T32 HP19025 (LEG), by grant R21 HS014864 (MH,TGR, DS) and K23 award RR16539 (DS) from the Agency for HealthcareResearch and Quality, and by a grant from The California HealthcareFoundation (DS).

Correspondence Author:

L. Elizabeth Goldman, MD, MCR, Universityof California, San Francisco, 533 Parnassus Ave, Box 0131, San Francisco, CA94143. E-mail: goldmanl@medicine.ucsf.edu.

Author Disclosure:

The authors (LEG, MH, TGR, DS) report no relationshipor financial interest with any entity that would pose a conflict ofinterest with the subject matter discussed in this manuscript.

Authorship Information:

Concept and design, analysis and interpretationof data, drafting of the manuscript, and critical revision of the manuscript forimportant intellectual content (LEG, MH, TGR, DS); acquisition of data(LEG, DS); statistical analysis (LEG); obtaining funding and administrative,technical, or logical support (DS); supervision (MH, DS).

Med Care.

1. Rittenhouse DR, Robinson JC. Improving quality in Medicaid: theuse of care management processes for chronic illness and preventivecare. 2006;44:47-54.

Ann Intern Med.

2. Chodosh J, Morton SC, Mojica W, et al. Meta-analysis: chronic diseaseself-management programs for older adults. 2005;143:427-438.

J Am Board Fam Pract.

3.Yabroff KR, Mangan P, Mandelblatt J. Effectiveness of interventionsto increase Papanicolaou smear use. 2003;16:188-203.

Dis Manag.

4. Campion FX,Tully GL, Barrett JA, Andre P, Sweeney A. Improvingquality of care using a diabetes registry and disease managementservices in an integrated delivery network. 2005;8:245-252.

Am J Med.

5. Kim CS, Kristopaitis RJ, Stone E, Pelter M, Sandhu M,WeingartenSR. Physician education and report cards: do they make the grade?results from a randomized controlled trial. 1999;107:556-560.

Chest.

6. Baumann MH, Dellert E. Performance measures and pay for performance.2006;129:188-191.

Prev Med.

7. Burack RC, Gimotty PA, Simon M, Moncrease A, Dews P.The effectof adding Pap smear information to a mammography reminder systemin an HMO: results of randomized controlled trial. 2003;36:547-554.

Cancer Detect Prev.

8. Luckmann R, Savageau JA, Clemow L, Stoddard AM, Costanza ME.A randomized trial of telephone counseling to promote screeningmammography in two HMOs. 2003;27:442-450.

J Rheumatol.

9. Mulligan K, Newman SP, Taal E, Hazes M, Rasker JJ. The designand evaluation of psychoeducational/self-management interventions.2005;32:2470-2474.

Congest

Heart Fail.

10. Flynn KJ, Powell LH, Mendes de Leon CF, et al. Increasing selfmanagementskills in heart failure patients: a pilot study. 2005;11:297-302.

J Natl Cancer Inst.

11.Taylor VM, Hislop TG, Jackson JC, et al. A randomized controlledtrial of interventions to promote cervical cancer screening amongChinese women in North America. 2002;94:670-677.

JAMA.

12. Bodenheimer T,Wagner EH, Grumbach K. Improving primary carefor patients with chronic illness: the chronic care model, part 2. 2002;288:1909-1914.

JAMA.

13. Rothman RL, DeWalt DA, Malone R, et al. Influence of patient literacyon the effectiveness of a primary care-based diabetes diseasemanagement program. 2004;292:1711-1716.

BMC Health Serv Res.

14. DeWalt DA, Malone RM, Bryant ME, et al. A heart failure self-managementprogram for patients of all literacy levels: a randomized, controlledtrial [ISRCTN11535170]. 2006;6:e30.

Diabetes Care

15. Philis-Tsimikas A,Walker C, Rivard L, et al. Improvement in diabetescare of underinsured patients enrolled in Project Dulce: a community-based, culturally appropriate, nurse case management andpeer education diabetes care model. . 2004;27:110-115.

J Card Fail.

16. Baker DW, Asch SM, Keesey JW, et al. Differences in education,knowledge, self-management activities, and health outcomes forpatients with heart failure cared for under the chronic disease model: theimproving chronic illness care evaluation. 2005;11:405-413.

N Engl

J Med.

17. Rowland D. Medicaid: implications for the health safety net. 2005;353:1439-1441.

18. Lewin Group. Actuarial assessment of Medicaid managed careexpansion options. Available at: http://www.lewin.com/NR/rdonlyres/9E5CD369-AC23-4D3A-B70D-0FDBBAEDB830/0/TxMgdCareExpansion.pdf. Accessed March 15, 2007.

19. Lewin Group. Performance standards for Medi-Cal managed careorganizations serving people with disabilities and chronic conditions.Available at: http://www.chcf.org/documents/Medi-CalPerfStandardsRecommendations112205.pdf. Accessed March 15, 2007.

Health Aff

(Millwood).

20. Betancourt JR, Green AR, Carrillo JE, Park ER. Cultural competenceand health care disparities: key perspectives and trends. 2005;24:499-505.

N Engl J Med.

21. Betancourt JR. Cultural competence: marginal or mainstreammovement? 2004;351:953-955.

Health Literacy: A Prescription to End Confusion.

22. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds; Committee onHealth Literacy. Washington, DC: Institute of Medicine, National Academies Press;2004.

Health Serv Res.

23. Lozano P, Grothaus LC, Finkelstein JA, Hecht J, Farber HJ, Lieu TA.Variability in asthma care and services for low-income populationsamong practice sites in managed Medicaid systems. 2003;38(pt 1):1563-1578.

Health Aff (Millwood).

24. Rittenhouse DR, Grumbach K, O'Neil EH, Dower C, Bindman A.Physician organization and care management in California: from cottageto Kaiser. 2004;23:51-62.

Med Care.

25. Glasgow RE,Wagner EH, Schaefer J, Mahoney LD, Reid RJ, GreeneSM. Development and validation of the Patient Assessment of ChronicIllness Care (PACIC). 2005;43:436-444.

Pediatrics.

26. Lieu TA, Finkelstein JA, Lozano P, et al. Cultural competence policiesand other predictors of asthma care quality for Medicaid-insuredchildren. 2004;114:e102-e110.

J Am Board Fam Med.

27. Handley M, MacGregor K, Schillinger D, Sharifi C,Wong S,Bodenheimer T. Using action plans to help primary care patients adopthealthy behaviors: a descriptive study. 2006;19:224-231.

Am J Manag Care.

28. Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis ofinterventions to improve care for chronic illnesses. 2005;11:478-488.

29. Centers for Medicare and Medicaid Services. Medicaid eligibility.Available at: www.cms.hhs.gov/MedicaidEligibility/. Accessed March14, 2007.

30. Centers for Medicare and Medicaid Services. Medicaid datasources: general information. Available at: http://www.cms.hhs.gov/MedicaidDataSourcesGenInfo/. Accessed September 19, 2006.

PLoS Med.

31. Fretheim A, Oxman AD, Havelsrud K,Treweek S, Kristoffersen DT,Bjorndal A. Rational prescribing in primary care (RaPP): a cluster randomizedtrial of a tailored intervention. 2006;3:e134.

J Gen Intern Med.

32. Grimshaw J, Eccles M,Thomas R, et al.Toward evidence-basedquality improvement: evidence (and its limitations) of the effectivenessof guideline dissemination and implementation strategies 1966-1998.2006;21(suppl 2):S14-S20.

Med Teach.

33.Veloski J, Boex JR, Grasberger MJ, Evans A,Wolfson DB. Systematicreview of the literature on assessment, feedback and physicians' clinical performance: BEME Guide No. 7. 2006;28:117-128.

JAMA.

34. Cabana MD, Rand CS, Powe NR, et al.Why don't physicians followclinical practice guidelines? a framework for improvement. 1999;282:1458-1465.

Med J Aust.

35. Sanson-Fisher RW, Grimshaw JM, Eccles MP.The science ofchanging providers' behaviour: the missing link in evidence-basedpractice. 2004;180:205-206.

Int J Med Inform.

36. Green CJ, Fortin P, Maclure M, Macgregor A, Robinson S. Informationsystem support as a critical success factor for chronic diseasemanagement: necessary but not sufficient. 2006;75:818-828.

J Health

Care Poor Underserved.

37.Weiss BD, Blanchard JS, McGee DL, et al. Illiteracy amongMedicaid recipients and its relationship to health care costs. 1994;5:99-111.

J Gen Intern Med.

38. Mancuso CA, Rincon M. Impact of health literacy on longitudinalasthma outcomes. 2006;21:813-817.

JAMA.

39. Schillinger D, Grumbach K, Piette J, et al. Association of healthliteracy with diabetes outcomes. 2002;288:475-482.

Am J Public Health.

40. Baker DW, Gazmararian JA, Williams MV, et al. Functional healthliteracy and the risk of hospital admission among Medicare managedcare enrollees. 2002;92:1278-1283.

Med Care.

41. Epstein AM,Weissman JS, Schneider EC, Gatsonis C, Leape LL,Piana RN. Race and gender disparities in rates of cardiac revascularization:do they reflect appropriate use of procedures or problems inquality of care? 2003;41:1240-1255.

JAMA.

42. Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality:addressing socioeconomic, racial, and ethnic disparities in health care.2000;283:2579-2584.

Patient Educ Couns.

43. Glasgow RE, McKay HG, Piette JD, Reynolds KD.The RE-AIMframework for evaluating interventions: what can it tell us aboutapproaches to chronic illness management? 2001;44:119-127.

Jt Comm J Qual Saf.

44. Bodenheimer T,Wang MC, Rundall TG, et al. What are the facilitatorsand barriers in physician organizations' use of care managementprocesses? 2004;30:505-514.

45. US Department of Health and Human Services. Health informationtechnology. Available at: http://www.hhs.gov/healthit/framework.html.Accessed March 14, 2007.

46. Institute for Healthcare Improvement. Programs by category. Availableat: http://www.ihi.org/ihi/programs. Accessed February 5, 2007.

BMJ.

47. Rundall TG, Shortell SM,Wang MC, et al. As good as it gets? chroniccare management in nine leading US physician organisations. 2002;325:958-961.

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