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Remarks by Thomas Kline, M.D.
Town Hall Meeting at the AHRQ 2007 Annual Meeting
September 27, 2007
Morning to everyone. I'd like to thank you for the opportunity to talk to you about
the state of Iowa's Medicaid program. Actually, the transformation of this Medicaid
Until a few years ago, the Medicaid program in Iowa was essentially a payer of claims.
There were some prioritization criteria that had to be met. There was some pre-payment
review, but here we had essentially the state's most needy population—the
catastrophic cases, oftentimes those that no one was able to deal with or manage. It
really had no direction—had no management to their care. The Medicaid director
recognized that this had to change. The care was fragmented, it was incomplete, it had
gaps. So what he decided to do is transform from a situation where we had one fiscal
agent into a situation where we had "best of breed" in nine categories of the
Medicaid program. Those would include: medical services, pharmacy services, member
services, provider services, etc.
I'm actually employed by the Iowa Foundation for Medical Care, which is the state's
key Q.I.O. organization. And it was determined that the Foundation submitted the
"best of breed" application for medical and pharmacy services, so my
major responsibility is for medical and pharmacy oversight or services. But
otherwise, I'm a consultant for the entire Medicaid Enterprise.
What was determined was that the management had to occur and, as part of that program,
it was essential for us to develop disease-management programs, care-management programs,
pharmacy programs, utilization oversight, and programs to manage it. Our first program
was a disease-management program. In the disease-management area was asthma—we
thought this would allow us the best benefit to reduce cost and improve care.
We learned a lot of lessons in that area. This population is a challenge. There are
lots of reasons why they cannot engage in the program. There's transportation issues;
economic issues; even, in some cases, eligibility issues. So we noted that, if a patient
was well, even though they had a chronic disease, they didn't want to engage in the
program. But if they had an acute or a chronic situation where they required ongoing
care, they did, in fact, participate. I suspect in our early programs, we had an
acceptance rate of comparable to any state, about 20-25 percent. However, in our
care-management area, where we had the acutely and chronically ill people, it was
more like 80 and 90 percent.
So the transformation was occurring from a payer of claims to a manager of health
care services; from a situation where we were reactive to disease to a situation where
we're going to become proactive to the diseases and care. We started our program, and
after about six or nine months, we were getting ready to try to evaluate the program,
and we were uncertain as to "What are we going to measure? How are we going to
determine whether our last nine months efforts have been beneficial or fruitful? How
are we going to determine if, in fact, we improved the health care of the members of
the State of Iowa Medicaid programs?"
We were fortunate at that time—we were accepted into an AHRQ care management
learning network. As a result of that network, we received care in determining how to
measure that program. But more importantly, we received direction and guidance as to
how we should go forward with our future programs. We were introduced to the chronic
care model; we were introduced to the concept of the medical home. And I think in our
state, as probably in every state, the medical home concept is very important. We had
to ensure that every member in the State of Iowa Medicaid program had access to good
quality medical care regardless of where they lived, what culture they were, what
language they spoke, or the cost of that care.
We are a relatively rural state. We have primary care providers in some areas that
just don't really have a lot of services at their access, and we had secondary level of
care, we had tertiary level of care.
Oftentimes there are so many barriers to our members to access those areas. We had
to be sure that that could be accomplished.
We had to be sure that the member received continuous care—that the professional
had an ongoing relationship. It wasn't, "I want to go to Doctor 'A' one day and
Doctor 'B' the next day, and maybe go to some other provider the third day." We tried
to develop a consistency in the care that they received.
We had to be sure that the providers were compassionate, meaning that they understood
the unique needs of each individual and the care that they needed. And the care had to
be coordinated. And this is really where the medical services area came, probably
played their most important role. We had eight nurse care managers, and it was their
responsibility to ensure all the components of this medical home were met, because we felt
that that would be the best opportunity to provide a positive outcome. We had seven
nurses and one licensed social worker. And what they did is they addressed the patient's
needs. They developed a care plan. They created a rapport; they identified with the patient
and were able to activate them into participation into their own health care. We felt that
that was the important thing, to get them involved, as providers in the state brought to
our attention that this population isn't necessarily the most compliant population. They
don't make appointments; they don't follow the treatment plan. Their treatment in the
hospital is not continued outside the hospital, and this was the major goal of what our
care managers were designed to do.
Also through this AHRQ learning network, we really understood the concept of the chronic
care model, and in Iowa, as you know, there are four components to that. One would be a
community component; one would be a health care delivery component; the provider component;
and the members (his or herself). So we had to get the member involved, the community involved,
the health system involved, and that's where care managers are really, were successful
and beneficial. They have a pretty heavy caseload, and they do a fine job.
At the same time we were developing this care management program, I also had the
opportunity to participate in an AHRQ-sponsored Medicaid medical directors' learning
network. This began in August 2005 as some teleconferences and then developed into
a face-to-face meeting. I was looking for it as an opportunity to find out what other
states were doing and how other Medicaid medical directors were directing the care of
their members in their state. However, when I attended the first meeting, one of the
more seasoned medical directors made a statement that if you see one Medicaid program,
you've seen one Medicaid program. I didn't know what was my direction from that statement.
But essentially, the object was for us to get together to exchange ideas, to exchange
experiences, to collaborate, to share with others. We coined a phrase: "Share
senselessly, steal shamelessly." Meaning that, if I had a program that you were
interested in, I was going to share all the information with you whether it be at that
meeting or at any time, and if you had something, I was going to take it and apply it to
my membership and my patient population. And this not only helped me become more aware of
what the medical needs were, but it also enabled me to take back to the staff and instill
in them the fact that you have challenges in what you're doing, but you're doing it right;
you're doing it consistent with the other Medicaid programs throughout the country. So that
we're elevating the level of care of the people that normally only had their claims paid
to a situation now where now we're managing their care. They knew that if they had an
issue, whether it be: "Where am I going to get the dollar for the pharmacy co-pay?"
to "How am I going to get to the doctor?" or, you know, "I can't leave
because something else catastrophic is happening." We have people in place. We're
developing a system where those issues can be taken care of.
The Medicaid medical directors' program was really actually very good. We had
the opportunity to bring up issues that are confronting states on an individual basis.
And as a result, AHRQ provides us with experts in those areas, and we have the latest
information regarding those issues. In addition, we have the ability to sit at a table
and to discuss anything that may be of importance to an individual state or an individual
medical director. Even when we're in our social settings, Medicaid medical services are
being discussed, and it's getting to the point where there's more consistency, I think.
I feel that in Iowa being a rural state, if I looked around at other states in our area
such as Nebraska, Missouri, Illinois, Minnesota, that they're developing some similarities
in the delivery of the health care and in the quality of health care that the members
are receiving. Partly because of the efforts through the care management, but also through
the efforts of this Medicaid medical directors' learning network.
A couple of really important issues that was instilled in me is the fact that Medicaid,
because it's so often under-funded and just don't have the resources to provide the services
that they like to provide—it's very important for them to collaborate. So, I mean,
partner with anybody and everybody within the state that you possibly can.
Currently, we have a congestive heart failure disease-management program. We have
roughly 300 patients that are enrolled in the program. But we partner with Des Moines
University. We partner with the Iowa Chronic Care Consortium, and we partnered with a
Pharos, a telephonic disease management company.
We have, as a result of that program, developed a depression-screening program, where
we partnered with our behavioral health provider. What started off as a small part of
our congestive heart failure program has now developed into a much larger program. To
date we've screened almost 1,000 patient members in our disease-management/care-management
program. We've discovered close to 200 patients that had signs and symptoms of clinical
depression that we subsequently referred on to our behavioral health provider, who has,
in fact, provided care and treatment. And after six months of re-screening, there's been
a significant drop in their depression scores. I feel that's a very successful program,
because it certainly has probably impeded the healing of or their management of their
chronic diseases in the past.
We started a smoking cessation program. We partnered with the Iowa Department of
Public Health and the University of Iowa "Quit Line," so that we were able
to utilize their resources and to provide a higher level of care for the members in
our population that need to quit smoking.
Currently, in our Care Management Program, we're able to partner with the Iowa/Nebraska
Primary Care Association, which is the Federal clinics in our state—there are a
dozen of them. And we utilize their care managers and health care coaches within their
clinics to provide ongoing service for our members. As I say, we only have 8 care
managers—4 onsite and 4 out state, but by utilizing these other 12 entities, we're
able to address more patients, more issues, and provide better care.
The other thing that we would note is the importance of our resources. Obviously,
AHRQ has been a tremendous resource, but CMS has helped us, the University of Public Health,
the Iowa/Nebraska Primary Care. We still have a ways to go; like I say, we started off
in a situation where we were paying claims. Now we're moving along that continuum to
the fact that we are managing a percentage of our patient population relative to their
chronic and acute situations in many cases. But we have a ways to go.
I think the bigger direction that we have to go in may be more in identification of the
member before they become catastrophic, so we're looking at trying to develop a
predictive modeling resource. Of course, screening and prevention is also important.
We currently have applied for and hoping that we receive a transformational grant,
where we'll be able to continue all of our programs. And probably the last thing is that
we are in the process of networking and partnering with the other major commercial providers
in the state.
But today, quality of care received by Medicaid members in the State of Iowa is better
than it was a year ago, or two years ago. Thank you.
Current as of July 2008