You asked for information on a recently established disease management program in the Texas Medicaid system.

SUMMARY

HB 727 of Texas' 78^th regular legislative session (2003) created the Medicaid disease management program (legislation attached). This program, also referred to as the “Texas Medicaid Enhanced care Program”, began November 1, 2004 and is expected to cover about 55,000 Medicaid fee-for-service clients. Clients in Medicaid managed care plans are already eligible to receive disease management services. (SB 283 of the 77th Legislature required the state to ensure that contracted managed care organizations develop and implement disease management programs to address chronic health conditions such as asthma and diabetes.)

The program's overall goals are to increase focus on preventive care, increase compliance with physician guidelines, and decrease unnecessary hospital and outpatient services. It targets five chronic conditions that affect Medicaid clients: asthma, diabetes, congestive heart failure, coronary artery disease, and chronic obstructive pulmonary disease. It includes disease and self-management education; establishing health goals, such as an asthma action plan implemented by the client's provider; monitoring weight or lowering salt intake; and managing the medications and supplies necessary to treat and stabilize chronic conditions. Under the disease management program, registered nurses (RNs) contact Medicaid clients in person or by phone.

The Texas Health and Human Services Commission (HHSC), the state Medicaid agency, has contracted with the McKesson Corporation to provide disease management services to eligible state Medicaid clients. The program is expected to result in significant cost savings to the state.

PROGRAM BASICS AND OPERATION

What is the Texas Medicaid Disease Management Program?

The Texas Medicaid Disease Management program is designed to help improve the health and quality of life of Medicaid clients with chronic conditions while reducing costs for the state. The program will assist Medicaid fee-for-service beneficiaries with asthma, diabetes, heart failure, coronary artery disease and chronic obstructive pulmonary disease. These five chronic conditions represent the “lion's share” of total Medicaid spending in the state, according to state representative Dianne White Delisi, sponsor of the legislation creating the Texas initiative. To identify eligible clients, the Texas Medicaid agency (HHSC) examined inpatient, outpatient, and pharmacy claims data for condition or condition-related codes. Health care providers can also refer participants to the agency for program participation.

How Does the Program Work?

The program is administered by McKesson Health Solutions, a provider of care management and comprehensive disease management services. (It was awarded the contract in July 2004 following an RFP process.) The program includes community-based and triage components. In the community-based part, RNs and promotoras (community health workers; Texas is developing a program for certification of promotoras) are responsible for ensuring that the enrollee's health care is provided in a timely and culturally sensitive manner. McKesson will employ four promotoras and eight community-based RNs who will focus their outreach efforts on underserved areas in the state.

The community-based RNs operate in a collaborative effort with community providers and clinics. RNs work closely with the client's existing physicians and treatment teams to assist in implementing the client's treatment plan.

McKesson also has established a Texas call center near Dallas that includes 10 RNs providing disease management and triage services to Medicaid clients. For the nurse triage portion of the program, the RNs receive incoming telephone calls from Medicaid clients and then provide recommendations, ranging from at-home self-care to visiting the emergency department, for acute conditions based on symptoms described by the caller. The call center is available 24 hours a day, seven days a week. Additional RNs and disease management specialists will work at the center.

McKesson also provides disease management services to state Medicaid programs in Colorado, Florida, Mississippi, Montana, Oregon, and Washington. (An article on disease management programs in other states is attached.)

What are the Expected Cost Savings to the State?

A $28.6 million dollar savings to the state is estimated in the current biennium. Overall savings are estimated at 6% in costs associated with treating Medicaid fee-for-service clients.

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