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Impact of the Coventry Complex Case Management Program in the Kentucky Medicaid Population

Kenneth J. Snow, MD, MBA
A case management program implemented by Coventry Healthcare in one of the nation's poorest areas produced positive, measurable results among patients with diabetes.
INTRODUCTION

Diabetes is an increasingly common and costly issue for both the state of Kentucky and the United States, as a whole. According to the National Diabetes Sta­tistics 2014 Report, prepared by the CDC, 29.1 million, or 9.3% of Americans had diabetes in 2012.1 This was an increase of 3.3 million Americans with diabetes just since 2010. While there is no large statistical difference between the incidences in men (15.6 million) versus women (13.5 million), there are large discrepancies by race/ethnicity in terms of who is more at risk for diabetes. In descending order, the age-adjusted percentage for individuals 20 years of age or older, with a diagnosis of diabetes, is as follows: American Indians/Alaska Natives (15.9%), non-Hispanic blacks (13.2%), Hispanics (12.8%), Asian Americans (9.0%), and non-Hispanic whites (7.6%).1

In addition, the risk of having diabetes is independently related to socioeconomic status. Comparing prevalence by education level, high school dropouts are twice as likely to have diabetes as men who have attended college.2 Having less than a high school education is associated with a 2-fold higher mortality rate from diabetes. Having a family income, below the federal poverty level, is also associated with a 2-fold higher mortality rate compared with adults with the highest family incomes. These relationships hold true even after controlling for well-known risk factors, such as age, race/ethnicity, and body mass index.3 Many effective therapies exist to control blood glucose levels in people with diabetes and to control comorbidities, such as hypertension, and high cholesterol that contribute to the complications associated with diabetes. However, left inadequately controlled, diabetes is a leading cause of blindness, kidney failure, amputation, heart attack, and stroke.

The rise in the prevalence of diabetes in Kentucky has been faster than the national rate. According to the 2013 Com­monwealth of Kentucky Diabetes Report,4 the percentage of residents with diabetes has nearly tripled from 3.5% in 1995 to 10% in 2010. Among Kentucky's Medicaid population, the prevalence of diabetes is 18%. The highest rates of diabetes are in the rural eastern counties, where the prevalence of diabetes exceeds 20%. This region is home to 26% of members involved in the CoventryCares Comprehensive Diabetes Care HEDIS® Measure.5 (HEDIS refers to the Healthcare Effectiveness Data and Information Set, a tool of 81 measures created by the National Committee on Quality Assurance. It used by most major health plans to measure care and service.)

COVENTRY COMPLEX CASE MANAGEMENT PROGRAM
Coventry Healthcare, a subsidiary of Aetna, initiated the Complex Case Management (CCM) program to strive for excellence in case management. The CCM program provided quality services to members, met industry and accreditation standards, and supported Coventry's goals for cost manage­ment. CCM is a collaborative process based on assessment, planning, implementation, coordination, monitoring, and assessment of options and services to meet an individual member's healthcare needs. Communication with the indi­vidual member or caregiver, and healthcare provider, combined with the availability of resources, assists in promoting quality cost-effective outcomes.

Members eligible for CCM were identified through a variety of referral sources, including, but not limited, to the use of a predictive modeling tool, disease management, concurrent review, self-referrals, and provider referrals. HEDIS data were integrated into each member's record in the care management system, providing a snapshot of compliance for each case manager. As part of the case management process, HEDIS measures were then addressed accordingly. This process included educating members on the importance of cond­tion-specific testing through direct contacts and mailers, as­sisting members to locate specialists, and assisting members with the scheduling of appointments. CoventryCares was an opt-out option offered by Kentucky's CCM program, in which every eligible member could choose to decline participation.

The purpose of the Coventry Health CCM Program is to improve members' adherence to appropriate indicators, including glycated hemoglobin (A1C) screening (assessing diabetes control), diabetic retinal exams (DRE) (assessing eye involvement and the need for therapy to prevent blindness), and nephropathy screening (assessing kidney involvement and the need for therapy to prevent kidney failure). These indicators are taken from the Comprehensive Diabetes Care (CDC) HEDIS Measure diabetes submeasures.

RESULTS
The CDC HEDIS member data showed 5917 CDC submeasures reported for 2013. Of these, 1881 were contacted by CCM and another 1881, who were not contacted, were randomly chosen to serve as a comparator group. The improvement in compliance was significant enough to move to a higher percentile in 2 of the 3 measures. The results are shown in TABLE 1.

Members enrolled in CCM showed compliance rates that were higher for all 3 of the submeasures compared with members not in CCM. Members in CCM had a compliance rate of 80.28% (25th percentile) compared with 77.99% (10th percentile) for the members not enrolled in CCM for A1C screening, 33.86% (<10th percentile) compared with 31.53% (<10th percentile) for DRE screening, and 78.47% (50th percentile) compared with 73.68% (25th percentile) for nephropathy screen­ing. See FIGURE 1.
 
In 2014, the CDC HEDIS member data showed 9186 CDC submeasures had been reported. Of these, 1022 were contacted by CCM. The remaining 8164, not contacted by CCM, were used as the comparator group. Once again, higher levels of compliance were seen in all 3 measures among those members contacted by CCM compared with those who were not. The improvement was great enough to increase the percentile for all 3 measures. The results are shown in TABLE 2.

Members in CCM had a compliance rate of 84.09% (50th percentile) compared with 82.9% (25th percentile) for the members not enrolled in CCM for A1C screening; 38.6% (10th percentile) compared with 29.0% (<5th percentile) for DRE screening; and 83.9% (75th percentile) compared with 75.2% (10th percentile) for nephropathy screening. See FIGURE 2.

Comparison of year-to-year change is shown in TABLE 3. Performance in all 3 submeasures improved in the CCM group. A1C screening increased from the 25th to 50th percentile, digital retinal exams increased from less than the 10th percentile to the 10th percentile, and nephropathy screening increased from the 50th to the 75th percentile. While the performance in A1C screening also improved in the group without CCM (from the 10th to the 50th percentile), performance on retinal exams and nephropathy screening actually declined. These observations suggest that the improvement seen in the CCM group was not simply an improvement in the entire population, but was related to the CCM program.

SUMMARY
Diabetes is an increasingly common and expensive disease nationwide, and especially for populations such as those covered by Kentucky Medicaid. The implementation of the Coventry CCM program demonstrated the ability to improve compliance rates to HEDIS submeasures in this challenging population. This improved compliance rate exceeded the improvement in the population, as a whole, resulting in a higher percentile performance.
REFERENCES
1. CDC. National Diabetes Statistics Report: estimates of diabetes and its burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services. http:// www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf.

2. Smith JP. Diabetes and the rise of the SES health gradient. NBER working paper 12905. 2007. http://www.nber.org/papers/w12905.pdf. Accessed February 10, 2016.

3. Saydah S, Lochner K. Socioeconomic status and risk of diabetes-related mortality in the US. Public Health Rep. 2010;125(3):377-388.

4. Kentucky Diabetes Report, 2013. http://chfs.ky.gov/NR/rdonlyres/03F86F3B-93E­2-4BEA-89C0-25DD9C1FB1FC/0/ReporttotheLRCFINAL1172013totheSecretary.pdf. Published January 10, 2013. Accessed January 2016.

5. Comprehensive Diabetes Care HEDIS Measure from QSI (Quality Spectrum Insight) demo­graphics data from the May 2014 measure profile. Coventry Healthcare.
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