The Centers for Medicare & Medicaid Services' Office of Research, Development, and Information (ORDI) strives to make information available to all. Nevertheless, portions of our files including charts, tables, and graphics may be difficult to read using assistive technology. Persons with disabilities experiencing problems accessing portions of any file should contact ORDI through e-mail at [email protected]. Evaluation of Care and Disease Management Under Medicare Advantage Contract HHSM-500-2006-0009I/TO4 Interim Report - FINAL Prepared for: Gerald Riley, Project Officer Centers for Medicare & Medicaid Services DHHS/CMS/OA/ORDI/REG/DRHPD 7500 Security Blvd Baltimore, MD 21244 Prepared by: L&M Policy Research, LLC Attn: Lisa H. Green, Ph.D. P.O. Box 42026 Washington, DC 20015 240.476.6663 [email protected] With subcontractor: Mathematica Policy Research, Inc. May 18, 2009 TABLE OF CONTENTS ACKNOWLEDGMENTS ........................................................................................................................................ III EXECUTIVE SUMMARY ...................................................................................................................................... IV LITERATURE REVIEW ............................................................................................................................................... V KEY INFORMANT INTERVIEWS ................................................................................................................................. VI SURVEY OF MEDICARE ADVANTAGE PLAN CONTRACT HOLDERS .......................................................................... VII Care Management Program Features ............................................................................................................... vii Disease Management Program Features .......................................................................................................... viii MA Plan Electronic System Features ................................................................................................................ viii Plan-Provider Roles ............................................................................................................................................ ix Special Needs Plans ............................................................................................................................................ ix Measuring Effectiveness....................................................................................................................................... x PRELIMINARY CONCLUSIONS ................................................................................................................................... X INTRODUCTION ....................................................................................................................................................... 1 Study Aims ............................................................................................................................................................ 3 Conceptual framework ......................................................................................................................................... 4 CHAPTER 1: METHODS .......................................................................................................................................... 7 LITERATURE REVIEW ................................................................................................................................................ 7 KEY INFORMANT INTERVIEWS ................................................................................................................................... 8 C/DM Experts and Professionals ......................................................................................................................... 8 Patient Interviews ................................................................................................................................................ 8 SURVEY OF MEDICARE ADVANTAGE PLAN CONTRACT HOLDERS ............................................................................. 9 ORGANIZATIONS, CONTRACTS AND PLANS .................................................................................................................... 9 SAMPLING FRAME ..................................................................................................................................................... 10 DATA COLLECTION ................................................................................................................................................... 10 FILE PREPARATION ................................................................................................................................................... 10 RESPONSE RATE........................................................................................................................................................ 11 NON-RESPONSE WEIGHTS ......................................................................................................................................... 11 CHAPTER 2: LITERATURE REVIEW ................................................................................................................ 13 THE NEED FOR CARE AND DISEASE MANAGEMENT PROGRAMS .............................................................................. 13 CARE AND DISEASE MANAGEMENT PROGRAMS ...................................................................................................... 14 Care and Disease Management Program Effectiveness .................................................................................... 15 CARE AND DISEASE MANAGEMENT IN A MANAGED CARE SETTING ....................................................................... 16 Implementation, Models, and Techniques within Managed Care ...................................................................... 16 SUMMARY OF STUDY FINDINGS ............................................................................................................................... 17 General Studies of C/DM Programs .................................................................................................................. 17 Results ................................................................................................................................................................ 18 STUDIES OF CARE AND DISEASE MANAGEMENT PROGRAMS IN MANAGED CARE ................................................... 18 Results ................................................................................................................................................................ 19 METRICS FOR CARE AND DISEASE MANAGEMENT SUCCESS ................................................................................... 20 DISCUSSION ............................................................................................................................................................. 22 CHAPTER 3: KEY INFORMANT INTERVIEWS .............................................................................................. 23 KEY STAKEHOLDER INTERVIEW FINDINGS .............................................................................................................. 23 CHARACTERIZING C/DM PROGRAMS IN MA PLANS ................................................................................................ 24 General Features of C/DM Programs ............................................................................................................... 25 Role of Managed Care Organizations ............................................................................................................... 27 Population Management and Patient Interaction .............................................................................................. 28 Communications with Physicians....................................................................................................................... 33 Advances in Technology ..................................................................................................................................... 34 i Trends in C/DM ................................................................................................................................................. 34 EVIDENCE OF EFFECTIVENESS ................................................................................................................................. 35 Overview of Measurement Metrics .................................................................................................................... 35 Areas of Success ................................................................................................................................................. 36 Difficulty in Measuring Effectiveness ................................................................................................................ 37 Unmeasured Benefits and Uncaptured Positive Externalities ........................................................................... 38 C/DM PATIENT INTERVIEWS ................................................................................................................................... 38 Outreach ............................................................................................................................................................ 39 Range of Services Received ...............................................................................................................................