Structuring the Integration of Care Management Services For Medicaid Enrollees Recipients With Chronic Illness, Substance Abuse Problems and Possible Psychiatric Disorders

Problem in context. In an environment of increased competition for governmental funding,
Medicaid programs in every state are bracing for decreased resources being available for the
care of their enrollees. A possible result of less funding is reduced quality of healthcare.
In response to this threat, The Center for Health Care Strategies, Inc, (CHCS) a non-profit
organization dedicated to improving the quality of publicly financed health care, issued an
RFP for participation in a multisite project to expand or enhance existing efforts to improve
the way care for Medicaid enrollees with multiple chronic conditions is delivered,
integrated, measured and financed.

Present knowledge. While there is strong documentation of improved population health status
with care management, the evidence for the immediate economic effects of care management
initiatives is mixed for commercial and absent for Medicaid populations. CHCS is presently
conducting a multisite study (in which we participate) of whether or not a business case
(return on investment) can be made for quality improvement initiatives in a Medicaid
population.

Research question. What is the effect of increased coordination of care on medical costs,
treatment utilization and selected clinical indicators among a Medicaid population with
chronic medical conditions and substance abuse problems? We shall address this question by
conducting a demonstration project consisting of the provision of integrated care management
(somatic and behavioral) to Medicaid enrollees living on the Eastern Shore of Maryland and
who have both chronic medical conditions and problems with substance abuse. A specific
component of the study will be the participation of Maryland's Mental Health Administration
(MHA) and MAPS, the administrator of psychiatric services for the Medicaid enrollees in
Maryland. We shall compare the results of the integrated care management for the study sample
on the Eastern Shore with a control group from the counties of western Maryland.

The primary goal of the project will be to improve the coordination of medical, substance
abuse and mental health services for a group of Medicaid beneficiaries with chronic medical
conditions. We hypothesize that the recipients of integrated care management (on the Eastern
Shore) will have lower total medical costs (pharmacy, inpatient and outpatient), higher
utilization of mental health and substance abuse services and lower use of emergency
department services than those who received customary care (in western Maryland).

The secondary goal of this project will be to assist in the further development and piloting
of information systems within MHA that will facilitate sharing of clinical information
necessary for the coordination of behavioral (mental health and substance abuse) and medical
care management between a Medicaid MCO (JHHC's PPMCO) and the mental health carve-out ASO,
MAPS-MD. The outcome measurement for the secondary objective will be the extent to which an
information system for coordination of care and population based queries has been established
within MHA and is, with proper oversight by MHA, accessible to responsible entities.

Significance. The project targets a vulnerable population within Medicaid enrollees that are
challenged when accessing care and are responsible for high total medical costs. The results
of the project should be helpful to other the MCOs in Maryland's Health Partners, as well as
to states with similar Medicaid systems as they seek to provide integrated healthcare
services to their populations.

Inclusion Criteria:

1. 21 years of age or older;

2. Resident of one of the following Maryland counties: Caroline, Cecil, Kent, Queen
Anne's, Talbot, Dorchester, Somerset, Wicomico, Worcester, Allegheny, Frederick,
Garrett, Washington, Calvert, Charles, or St. Mary's; or

3. Chronic medical condition(s) identified by ACG Case Mix software (e.g. an ACG score =>
0.10) as likely to incur high costs in the following year; and

4. Substance use problem in the past 27 months as indicated by an ICD-9 code or CPT code
on DHMH list for Special Needs Population.

Exclusion Criterion.

1) Enrolled in or eligible for enrollment in a Special Needs disease management program at
JHHC: HIV/AIDS, Partners with Mom, Omega Life. It is necessary to exclude these programs
because PPMCO members are already receiving intensive care management.