REVIEW ARTICLE

Dis Manage Health Outcomes 2008; 16 (6): 421-428 1173-8790/08/0006-0421/$48.00/0 2008 Adis Data Information BV. All rights reserved.

Assessing the Barriers to Engaging Challenging Populations in Disease Management Programs

The Medicaid Experience
Dylan H. Roby, Gerald F. Kominski and Nadereh Pourat
Center for Health Policy Research and the Department of Health Services, UCLA School of Public Health, Los Angeles, California, USA

Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421 1. State Medicaid Programs and Enrollees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422 2. Two Potential Models for Disease Management Programs in Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423 3. Barriers to Disease Management in Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424 4. Practical Strategies to Minimize Barriers for Medicaid Disease Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425 4.1 Conduct a Structured Needs Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425 4.2 Develop a Data Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425 4.3 Attempt to Preserve Eligibility Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426 4.4 Develop Relationships with Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426 4.5 Provide Support for Non-Medical Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426 4.6 Combat Disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427 5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427

Abstract

Disease management has gained popularity as a way to improve health status and control of chronic illness through the use of risk stratification, targeted nurse outreach, telephonic nurse advice, and evidence-based guidelines in managing illness. Disease management programs have been successfully implemented by commercial insurers and managed care plans, as well as in Medicare and state Medicaid programs. Although evidence regarding cost savings is inconsistent, it appears that disease management programs do impact health status and quality of care, and improve self-management among the chronically ill. Disease management programs can be customized to meet the needs of vulnerable subpopulations. This article explores the barriers to dealing with chronic illness and other factors faced by disease management programs for Medicaid populations. Barriers to participation and success in disease management for Medicaid beneficiaries are apparent due to lack of access to translation and interpretation services; difficulty with community outreach; achieving buy in from providers and beneficiaries; problems with housing; difficulties accessing primary and specialty care; problems with the availability of pharmacy, durable medical equipment, and other support services; as well as difficulties with Medicaid eligibility and churn. In order to create a successful disease management program that positively impacts health status, utilization, and cost, it is necessary to consider all of these barriers when designing an intervention for Medicaid beneficiaries. Some of the innovative ways to handle the difficulties of dealing with Medicaid or other lowincome populations with special healthcare needs include expanded interpretation and translation activities, extensive community outreach to patients and safety net providers such as clinics and public hospitals, providing support services related to non-medical problems experienced by enrollees, providing understandable written and verbal instructions and training related to health education and medication adherence, as well as efforts to

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track and maintain contact with eligible and enrolled individuals. Disease management programs can be successful in saving money and improving health in Medicaid populations. However, they must be carefully designed with the specific state Medicaid program and should target the needs of the states beneficiaries.

Medicaid is a federal-state partnership program that provides services to low-income families and people with special healthcare needs and physical or developmental disabilities. Eligibility for Medicaid is based on family income, assets, number and age of children, and health needs. However, each state is able to design their own Medicaid program, so there can be differences in eligibility and benefits depending on the state. For example, in California, an 8-year-old child can qualify for the California Medicaid program (Medi-Cal) if their family income is <100% of federal poverty level ($US17 170 for a family of three in 2008). However, an adult with no children also earning 100% of federal poverty level would be ineligible unless they were elderly or disabled. This is not the case in every state. As the Medicaid program provides healthcare for both children and adults with disabilities and special healthcare needs, there are a significant number of chronically ill individuals in state Medicaid programs. One of the many possible strategies to contain costs and improve health outcomes for Medicaid beneficiaries is the use of disease management programs. This study focuses on the characteristics of Medicaid beneficiaries, the barriers they face, and potential ways in which disease management programs can minimize those barriers. It is based on a review of existing barriers to care for Medicaid beneficiaries, previous disease management programs, and the strategies employed to deal with Medicaid populations. Disease management has been adopted by many health insurers, state Medicaid programs, healthcare providers, and Medicare demonstration projects as a method of achieving financial savings and improving the health of chronically ill individuals.[1] Recent evaluations of disease management programs in various settings have been inconsistent in demonstrating cost savings for the chronically ill.[2] However, some costs savings in specific diseases, in specific circumstances have been shown. For example, in a recent evaluation of a chronic disease management program for Indianas Medicaid beneficiaries with congestive heart failure (CHF) and diabetes, cost savings were achieved in the high-risk CHF population, but not in the high-risk diabetes population.[3] Furthermore, several studies indicate that disease management programs have improved health outcomes, self-management, and quality of care for the chronically ill in multiple settings.[4-7] Increasingly, states such as California, Oregon, Washington, Illinois, Florida, and Indiana have implemented disease management programs to deal with chronically ill Medicaid beneficiaries. These programs are sometimes contracted to third-party vendors
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who have existing strategies for managing chronic illness outcomes and costs.[8,9] Other Medicaid disease management programs are developed by the state using a primary or coordinated care management approach, using the chronic care model as the basis for the design of these customized disease management interventions.[3,10] In the case of third-party vendors with established disease management products, the connection between the state Medicaid department and the vendor should be assessed carefully. During the Florida disease management program, the state Agency for Health Care Administration was actively involved in program design and implementation with their third-party vendor, Pfizer Health Solutions.[11] There are various barriers that face disease management vendors in engaging Medicaid populations and although disease management programs present excellent opportunities for collaboration between state Medicaid departments and disease management experts, without effective communication, it would be difficult to provide vendors with adequate information in managing a Medicaid population. Developing a disease management program from scratch, even if it is based on an established disease management model, can be a challenge for a governmental entity. For example, in some cases, Medicaid managed-care plans and state Medicaid departments will use the widely accepted chronic care model to develop a new disease management program. However, because the chronic care model is based on a network of primary care-based teams who deliver care in a variety of settings, Medicaid departments attempting to implement such a program also face challenges in obtaining physician buy in, deciding on the services provided, and dealing with the diverse group of primary care providers that care for chronically ill Medicaid beneficiaries in the state.[12] 1. State Medicaid Programs and Enrollees Medicaid beneficiaries are primarily women, children, and people with disabilities and special healthcare needs. In the California Medi-Cal program, 48% of the 6.6 million beneficiaries are children, while 28% are adult parents, 13% are seniors, and 12% are non-elderly adults with disabilities. Of the $US30.2 billion spent by Medi-Cal from July 2005 to June 2006, 34% was incurred by non-elderly adults with disabilities and 27% by seniors. In summary, 25% of the Medi-Cal population was responsible for 61% of the total healthcare costs.[13] Similarly, authors have stated that 50% of total healthcare spending is due to the 25% of the
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population with four major chronic illnesses (heart disease, diabetes, asthma, and hypertension).[14] In addition, Medicaid beneficiaries in many larger states are more likely to be minorities than the general population. For example, in California in 2006, 53% of Medicaid beneficiaries were Latino, while African-Americans represented 10%, Asians and Pacific Islanders represented 10%, and Caucasians made up less than one-quarter of the Medicaid beneficiary population.[13] Furthermore, Medicaid populations are also more likely than the general population to face language barriers. A recent study regarding enrollment barriers for Medicaid-eligible children found that one-third of families with enrolled children were limited English proficient (LEP).[15] Because state or federal disability eligibility often results in a low-income, chronically ill, uninsured individual becoming eligible for Medicaid, the chronically ill population in state Medicaid programs is sizable.[16] Depending on the state, these chronically ill beneficiaries may be enrolled in managed care, or receive Medicaid benefits through a fee-for-service (FFS) arrangement. Medicaid beneficiaries are increasingly being enrolled in private managed-care plans that are contracted to provide health insurance via capitation. According to the Kaiser Family Foundation,[17] in 2005, several states had most of their Medicaid population in a managed-care plan with at least a partial capitation arrangement 96% in Georgia, 90% in Pennsylvania and Michigan, and 50% in California. The US Medicaid managed-care penetration rate across all states was 63%. However, in some states, such as California, the remainder of the beneficiaries who are in FFS Medicaid are likely to be disabled, elderly, and have special healthcare needs due to chronic illness. In California, although 48% of the population is in fully-capitated managed care, they represent only 18% of Medi-Cal expenditures. Conversely, the 52% in FFS Medi-Cal are responsible for 82% of Medi-Cal spending.[13] 2. Two Potential Models for Disease Management Programs in Medicaid Disease management programs for chronic illness often fall into two major categories. One is a primary care focused strategy based on the chronic care model.[2] These types of programs can be operated by community primary care clinics, medical groups, hospitals, and health systems. They are relatively flexible programs that focus on providing uninsured, Medicaid, Medicare, or even privately insured patients and their providers with the tools to manage chronic disease using evidence-based guidelines, health education, disease registries, enabling services, and a supportive

provider structure.[18] One of the main proponents of this approach was the US Health Resources and Services Administrations Bureau of Primary Health Care (BPHC), which encouraged clinics to use the chronic care model in their Health Disparities Collaboratives to care for uninsured individuals as well as chronically ill Medicaid and Medicare enrollees. Participating clinics were largely Federally Qualified Health Centers who designed their own disease management interventions with technical assistance from the BPHC and the Institute for Healthcare Improvement.[19-21] While this approach has worked well at the provider level,[22] state Medicaid departments may have difficulties implementing a primary care model for disease management in their states due to the poor geographical distribution of primary care clinics, specialists, and physicians; lack of providers due to lower reimbursement rates;[23,24] and the number of disabled and elderly beneficiaries in their chronically ill population.[25] Of course, this may depend on the structure of the states Medicaid program. If a majority of chronically ill patients are in managed care, the private health plan contracted to provide healthcare to the Medicaid beneficiaries assigned to them could develop a primary care based, integrated disease management model. In contrast, if a large portion of the chronically ill Medicaid population is in an FFS delivery system (similar to Illinois or California), a private insurer would not be able to provide disease management services to the chronically ill population. Instead, the state would be responsible for paying all of the claims, with very little oversight or utilization review. The FFS provider network is made up of physicians, clinics, hospitals, and pharmacies who agree to accept Medicaid FFS rates rather than contracted providers who are paid capitated fees through a third-party insurers managed-care network.[26] Several studies have demonstrated that FFS Medicaid beneficiaries are more likely to experience ambulatory care-sensitive hospitalizations[27] and to have lower levels of quality measures and appropriate care than enrollees in Medicaid managed care.[28] Some states have used primary care case management (PCCM) with their FFS beneficiaries to provide episodicand continuous-care management for chronic illness and other health needs.[13] Because of Medicaid provider fees that are far below market rates,1 it is difficult for some states (such as Colorado, Indiana, California, Arkansas, and Minnesota) with low Medicaid FFS reimbursement to build a provider network that includes primary care and specialists willing to care for chronically ill Medicaid patients. In addition, if these providers were tasked with participating in a new primary care-based disease management program,

1 A Colorado primary care physician would have been paid $US24.78 for seeing a new Medicaid patient with a diagnosis in 2007,[29] while Medicare paid more than twice that amount for the same service.
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they could resist the program and cease providing care to Medicaid beneficiaries. State Medicaid departments often employ an alternative to primary care-based disease management. This second mode of delivery is through a private disease management vendor.[2] These privately run programs focus on improving chronic illness outcomes and saving money by utilizing telephonic nurse triage, outbound telephonic coaching, educational mailings, community outreach specialists, use of evidence-based guidelines, and risk stratification to target those individuals at highest risk. Financial performance is often linked to a cost savings calculation required by the state.[30] These third-party disease management programs, which have been implemented in several states, including Illinois, California, Oregon, Florida, and Washington, are operated by private vendors with extensive knowledge of care coordination and managing chronic diseases. However, because they are often large national organizations, they may not be familiar with how a specific state Medicaid program runs. Success of their program with one Medicaid population may not be indicative of success in another Medicaid population because of different numbers of enrollees, benefits, reimbursement rates, claims processes, delivery systems, and participating providers. In addition, levels of state bureaucracy can be a concern. If a state Medicaid department cannot make and approve changes quickly, it could compromise the ability of the program to adapt to the needs of the population.[31] 3. Barriers to Disease Management in Medicaid Regardless of the method chosen to implement disease management in a state Medicaid program using a primary care-based model run by a group of providers or using a third-party vendors existing disease management program the problems in dealing with the population will be similar. Medicaid beneficiaries are more likely than the general population to face issues with churn, which results from problems with eligibility redetermination resulting in beneficiaries becoming uninsured for a period of time.[32] They are also more likely to lack phone lines or valid phone numbers and addresses in administrative or eligibility databases than people with commercial insurance, or even enrolled in a Medicaid managed-care plan.[11] In addition, Medicaid beneficiaries report difficulties with finding a healthcare provider, and have trouble communicating with their providers due to language barriers, literacy, or disability. Medicaid eligibility requirements mean that chronically ill beneficiaries are likely to have some level of disability, ranging from behavioral health diagnoses, through to developmental or physical problems and sensory disabilities.[25,32]
2008 Adis Data Information BV. All rights reserved.

One of the major problems in developing and implementing a primary care-based disease management program is provider buy in. The chronic care model is partially based on the idea that a team of primary care providers will adopt evidence-based guidelines; make use of electronic data registries to track chronically ill beneficiaries utilization, outcomes, and lab results; and integrate components of health education and case management into their practice. It is highly uncertain whether all of these elements can be quickly adopted into a primary care setting or practice. A case study of an asthma utilization program in pediatric primary care practices and clinics theorized that the five major predictors of disease management adoption in a primary care setting were (i) provider characteristics; (ii) organizational characteristics; (iii) patient characteristics; (iv) the disease management program itself; and (v) regional (urban vs non-urban) differences.[33] The providers who were questioned about their participation in the program voiced doubts about their own ability to effectively implement the program. They also felt that some patients would not cooperate, while others would be unmotivated. Some providers suggested that they would need better mentorship and coaching from disease management experts to successfully participate in the program. Primary barriers in terms of organizational characteristics were staff turnover, lack of appropriate educational materials, and lack of dedicated education staff. Providers questioned the ability of patients to adhere to medication and change their behavior. Lastly, the providers expressed disagreement with the clinical guidelines upon which the program was based. These barriers to implementing disease management programs certainly have to be dealt with proactively, whether by a state Medicaid department implementing a primary care-based disease management program, or by a disease management vendor trying to establish relationships with the primary care providers for their disease management enrollees. The authors suggested conducting a diagnostic analysis of the physician practice to assess clinician beliefs and attitudes.[33] In a recent evaluation of the Florida Medicaid disease management program, focus groups and qualitative interviews with providers, patients, program staff, and state Medicaid stakeholders revealed a variety of problems faced by the vendor, the Medicaid department, and its beneficiaries before and during the program.[11] Patients reported experiencing food shortages, financial barriers, possible eviction, disconnected phone lines, childcare problems, transportation and inflexible work schedules, and mental health crises. The care managers tasked with providing disease management support reported issues with patient distrust and skepticism about the program, low literacy levels, language barriers, and a lack of important durable medical equipment (DME) that would encourage self-management. Problems faced
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by the vendor included getting providers to buy in to their disease management program without having any financial incentives or leverage. Data issues also plague many state Medicaid programs. Contact information for eligible beneficiaries is often incomplete, outdated, or incorrect. Claims databases are usually subject to claimsreporting delays of 36 months, making it difficult for disease management program vendors to use risk stratification algorithms and for care managers to intervene in real time when a hospitalization or emergency department visit occurs. Vendors also face political pressures to prove effectiveness and achieve cost savings during the program period, which may vary from 1 to 3 years. Another barrier experienced by disease management vendors relates to getting eligible beneficiaries to enroll and become engaged in the program. Depending on the state, a program may require a patient to opt in to qualify for services.[34] This can be difficult with a Medicaid population, especially if recruitment of eligible beneficiaries is hindered by incomplete and incorrect contact information, distrust of healthcare providers, language barriers, and lack of phone lines.[32] Other disease management programs enroll eligible patients through an opt-out system, in which the vendor or state Medicaid department sends each beneficiary a letter informing them that they will be automatically enrolled in the program unless they decide to opt out at that time or in the future via telephone or mail.[33] This method may generate a higher number of enrollees; however, the enrollees may be less likely to actually become engaged and participate in self-management and disease management coaching than those who actively opt in. In a recent study,[35] only 25% of the targeted eligible patients in four different diseases participated in an employerbased disease management program, and after the first year, only 7% of those originally targeted remained in the program. This finding is not unusual, as disease management programs often enroll a proportion of those eligible, and only a small proportion of the enrollees may actually be inclined to actively participate.[31,34] Another barrier that has not been mentioned previously is medication adherence. While providers, pharmacists, and disease management care managers may reconcile medications and obtain the correct dosage and prescription for a beneficiary, there is no guarantee that patients will actually collect, refill, or take the medication in the correct manner. Recent evidence indicates that African-American Medicaid beneficiaries and under-served individuals are less likely to adhere to instructions and obtain prescribed medications than Medicaid-enrolled Caucasians or the privately insured.[36,37] This can be complicated by lack of transportation, lack of pharmacies that will accept Medicaid reimbursement, and problems with health literacy or comprehension of medication instructions.
2008 Adis Data Information BV. All rights reserved.

4. Practical Strategies to Minimize Barriers for Medicaid Disease Management

4.1 Conduct a Structured Needs Assessment

Understanding the targeted population is extremely important to successful implementation of a disease management program, whether it is a primary care-based program or a telephonic intervention delivered by an outside vendor. Collecting stakeholder input from area providers, including public hospitals and primary care clinics and physicians who currently care for chronically ill Medicaid beneficiaries is vital to physician buy in, program planning and development, and understanding of the target population. The findings from this needs assessment conducted prior to program implementation will allow program developers to understand the language capacity, DME needs, level of eligibility churn, health status, and unmet need for specialty care and other healthcare services for the target population. In addition, interviews with local providers and patients will allow the vendor or Medicaid department to understand the structure of the local safety net and predict potential barriers before program implementation. It is also important to remember that every state Medicaid program is different. It would be incorrect to assume that the exact implementation of a program in one state will work perfectly in another state. Acknowledging the cultural, political, and financial issues in a state and in their Medicaid program will allow the development of targeted interventions that will work in the context of specific state Medicaid programs.
4.2 Develop a Data Strategy

Access to eligibility data, claims data, lists of Medicaid physicians in the area, and data regarding other resources that could be helpful to the disease management program is very important to program operations and coordination of services, but it is often an afterthought. As previously mentioned, claims data is often 36 months old by the time a disease management program can use it in risk stratification or provide it to physicians so that they can intervene with patients. In addition, eligibility data collected by state or county Medicaid enrollment offices may lack important contact information such as telephone numbers and addresses for eligible patients.[11] Medicaid patients will occasionally use homes of friends or families, homeless shelters, or government addresses and phone numbers when completing a Medicaid application.[38] Accurate information is vital to a disease management program that relies on health education materials being delivered by mail, and telephonic health assessments or care manager coaching. Developing a strategy to deal with those shortcomings by conducting community outreach to homeless shelters, most recent
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providers based on claims data, public hospitals, or other community groups prior to program implementation will help to establish relationships with the local community, as well as to obtain contact information with which to contact potential eligible patients. The use of outside tracing services to find current phone numbers and addresses are helpful in obtaining contact information for beneficiaries who cannot be reached through conventional methods. Disease management programs should be proactive in asking for pertinent data fields from claims datasets, provider lists, and other data sources to which the Medicaid department may have access. Providing guidance in extracting the historical data will be helpful in understanding what is available, and also assist in limiting the delays in claims data deliveries. Most importantly, the disease management program should expect a claims lag of 36 months, and develop a way to collect important service delivery information quickly from alternative sources. For example, a successful disease management program may be able to establish an alert system with the public hospitals and trauma centers in the area, so that care managers are informed if one of the enrolled patients is admitted to the hospital, or visits the emergency department. These real-time interventions are helpful in providing teaching moments to change health behaviors and prevent future hospitalizations and emergency visits, thereby reducing costs. It will also help in risk-stratification processes, which are often dependent on claims data being delivered in a timely manner.
4.3 Attempt to Preserve Eligibility Status

help them maintain continuity of care and increase adherence to medication and appropriate care. A disease management vendor or primary care physician might also consider providing services temporarily for those beneficiaries who do lose Medicaid eligibility, and are in need of chronic care services. Requesting detailed information on each eligible beneficiarys recertification date, category of eligibility, and potential reasons why the beneficiary could lose eligibility (i.e. changes in income or disability status) would be useful in monitoring and ensuring that participants remain in the program for as long as required. Issuing reminders to beneficiaries to turn in their recertification paperwork before the due date could potentially improve retention in the program, as well as health outcomes and health status.
4.4 Develop Relationships with Providers

Disease management programs should be aware of state Medicaid eligibility guidelines and processes for enrollment and eligibility recertification. Churning from Medicaid to uninsured status and back can be detrimental to controlling chronic disease because of lack of accountability to care managers, disruptions in regular care and pharmacy access, as well as inability to seek healthcare in urgent situations. Integrating information on eligibility determination and requirements would be highly useful to care managers, primary care physicians, and their patients. If possible, care managers and primary care physicians providing disease management services should have access to eligibility data (including re-determination date) or should ask the patient for that information at initial enrollment. The care manager should remind their disease management enrollees of what is needed to maintain their Medicaid coverage, and should provide linkages to social services offices and advice on maintaining enrollment. Making sure that enrollees are able to maintain Medicaid eligibility should be a priority for disease management programs, because it will
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Outreach to providers should begin before outreach to Medicaid beneficiaries. Medicaid providers often work in larger, community-based safety net clinics that have existing chronic care strategies in place. Any early information that can be provided to inform providers of the new program, how it can help them, how many of their patients will be enrolled, and if there are any incentives for participating will be important for getting their support and buy in. Allowing physicians with existing relationships with the Medicaid patient population to critique the planned educational materials and promotional materials being used to recruit patients eligible for enrollment into the disease management program will also be helpful. Using local providers as informants regarding the language capacity of their clients, the DME needs, and other environmental barriers to care (such as specialty referrals and pharmacy access) can provide the opportunity for early planning and development of strategies to mitigate barriers for enrollees in obtaining the services they need to manage their chronic illness.
4.5 Provide Support for Non-Medical Situations

As evidenced in the Florida Medicaid disease management program, issues such as upcoming evictions, inflexible work schedules, childcare, family crises, and inability to pay the telephone bill can have a serious impact on the ability of a disease management program to provide coaching and advice, as well as on the patient to self-manage their disease and change their health behaviors.[11] Although the disease management program is not required to coordinate payment of rent or childcare, the care managers and primary care physicians should have direct linkages with county social services and community resources to assist enrollees with any of these issues. Family or social crises should trigger the involvement of mental health professionals who can
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handle the situation and keep the care manager informed. Support services are far more important in the low-income, chronically ill Medicaid population than in a commercially insured population in order to maintain medication adherence, continue healthy behaviors and self-management, and control chronic disease.
4.6 Combat Disparities

Acknowledgments
The authors are employees of the UCLA School of Public Health, Center for Health Policy Research (CHPR). The UCLA CHPR is under contract to the California Department of Health Care Services to evaluate two Medicaid Disease Management pilot programs in the state. Gerald Kominski is the Principal Investigator and Nadereh Pourat is the Co-Principal Investigator for these evaluations. Gerald Kominski has received honoraria from Pfizer Health Solutions to analyze and evaluate their Florida Medicaid Disease Management Program.

Several evaluations of disease management programs have identified the issue of racial/ethnic disparities relating to medication adherence and appropriate utilization of services as a potential obstacle to improved outcomes for Medicaid beneficiaries in a disease management program.[36,39,40] Because a Medicaid disease management program is likely to provide services to a diverse population with multiple cultures, races/ethnicities, and languages, it is important to assess these prior to enrollment and program implementation, as well as during the program. Allowing care managers to access interpretation services and translated written materials for their patients to achieve language concordance will empower Medicaid beneficiaries to communicate with their care manager, primary care physician, and other healthcare providers. Medicaid has a more diverse population than an employer-based population, and as such a disease management program must take these differences into consideration when planning interventions as well as culturally appropriate communication and educational materials, and conducting outreach to Medicaid beneficiaries and their providers. 5. Conclusions Despite facing significant barriers in terms of language, literacy, culture, racial/ethnic disparities, disability, mental illness, poverty, and finding a primary care provider, Medicaid disease management programs can succeed in improving health status, reducing unnecessary hospitalizations, increasing appropriate primary care utilization, and improving medication adherence and selfmanagement. The strategies provided in this article (conducting a needs assessment, developing a data strategy, implementing measures to decrease eligibility churn, developing relationships with existing providers, providing non-medical support related to daily life and maintenance of Medicaid eligibility, and combating racial/ ethnic, cultural and linguistic disparities) will be helpful in developing disease management interventions catering to the diverse Medicaid population. Disease management programs can be successful in saving money and improving health in Medicaid populations. However, they must be carefully designed with the specific state Medicaid program and should target the needs of the states beneficiaries.
2008 Adis Data Information BV. All rights reserved.

References
1. Villagra VG. Perspective: integrating disease management into the outpatient delivery system during and after managed aare. Health Aff 2004 May; W4: 281-3 2. Geyman JP. Disease management: panacea, another false hope, or something in between? Ann Fam Med 2007 May/June; 5(3): 257-260 3. Holmes AM, Ackermann RD, Zillich AJ, et al. The net fiscal impact of a chronic disease management program: Indiana Medicaid. Health Aff 2008; 27 (3): 855-64 4. Mattke S, Seid M, Ma S. Evidence for the effect of disease management: is $1 billion a year a good investment? Am J Manag Care 2007 Dec; 13 (12): 670-6 5. Rossiter LF, Whitehurst-Cook MY, Small RE, et al. The impact of disease management on outcomes and cost of care: a study of low-income asthma patients. Inquiry 2000; 37 (2): 188-202 6. Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care 1999 Jan; 37 (1): 5-14 7. Afifi AA, Morisky DE, Kominski GF, et al. Impact of disease management programs on health care utilization: evidence from the Florida: A Healthy State (FAHS) Medicaid program. Prev Med 2007 Jun; 44 (6): 547-53 8. Thiebaud P, Demand M, Wolf SA, et al. Impact of disease management on utilization and adherence with drugs and tests. The case of diabetes treatment in the Florida: A Healthy State (FAHS) program. Diabetes Care 2008; 31 (9): 1717-22 9. Linden A, Berg GD, Wadhwa S. Evaluation of a Medicaid asthma disease management program. Dis Manag 2007 Oct; 10 (5): 266-72 10. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, part 2. JAMA 2002 Oct; 288 (15): 1909-14 11. White C, Fisher C, Mendelson D, et al. State Medicaid disease management: lessons learned from Florida. 2005 Mar [online]. Available from URL: http:// www.avalerehealth.net/research/docs/Duke_DM-Florida.pdf [Accessed 2008 Jun 28] 12. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002 Oct; 288 (14): 1775-9 13. California HealthCare Foundation. Medi-Cal facts and figures: a look at Californias Medicaid program. 2007 May [online]. Available from URL: http:/ /www.chcf.org/documents/policy/MediCalFactsAndFigures2007.pdf [Accessed 2008 Jun 28] 14. Druss BG, Marcus SC, Olfson S, et al. Comparing the national economic burden of five chronic conditions. Health Aff 2001 Jun; 20 (6): 233-41 15. Feinberg E, Swartz K, Zaslavsky AM, et al. Language proficiency and the enrollment of Medicaid-eligible children in publicly funded health insurance programs. Matern Child Health J 2002 Mar; 6 (1): 5-18 16. Tobias C, Maisels L, Andrew J. How health plans identify and serve Medicaid special needs populations. Health and Disability Working Group. Boston University School of Public Health. 2000 Jun [online]. Available from URL: http://www.bu.edu/hdwg/pdf/reports/HPlanbackground.pdf [Accessed 2008 Jun 21] 17. The Henry J. Kaiser Family Foundation. State health facts [online]. Available from URL: http://www.statehealthfacts.org [Accessed 2008 Jun 28] 18. Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Manag Care Q 1996 Spring; 4 (2): 12-25
Dis Manage Health Outcomes 2008; 16 (6)

428

Roby et al.

19. Chin M, Drum M, Guillen M. Improving and sustaining diabetes care in community health centers with the Health Disparities Collaborative. Med Care 2007 Dec; 45 (12): 1135-43 20. Maizlish NA, Shaw B, Hendry K. Glycemic control in diabetic patients served by community health centers. Am J Med Qual 2004; 19 (4): 172-9 21. Chin MH, Cook S, Drum ML, et al. Improving diabetes care in Midwest community health centers with the Health Disparities Collaborative. Diabetes Care 2004; 27 (1): 2-8 22. McCullough DK, Price MJ, Hindmarsh M, et al. A population-based approach to diabetes management in a primary care setting: early results and lessons learned. Eff Clin Pract 1998; 1 (1): 12-22 23. McManus M, Kelly R, Flint S. The adequacy of physician reimbursement for pediatric care under Medicaid. Pediatrics 1991; 87 (6): 909-20 24. Bindman A, Yoon J, Grumbach K. Physician participation in Medi-Cal, 2001. Medi-Cal Policy Institute; California HealthCare Foundation. 2003 Jun [online]. Available from URL: http://www.chcf.org/documents/policy/Medi CalDisabilitiesMMCvsFFS.pdf [Accessed 2008 Jun 28] 25. Master RJ, Taniguchi C. Medicare, Medicaid, and people with disability. Health Care Financ Rev 1996; 18 (2): 91-7 26. Chimento L, Forbes M, Sander A, et al. Medi-Cal beneficiaries with disabilities: comparing managed care with fee-for-service systems. California HealthCare Foundation Issue Brief 2005 Aug [online]. Available from URL: http:// www.chcf.org/documents/policy/MediCalDisabilitiesMMCvsFFS.pdf [Accessed 2008 Jun 28] 27. Bindman AB, Chattopadhyay A, Osmond DH, et al. The impact of Medicaid managed care on hospitalizations for ambulatory care sensitive conditions. Health Serv Res 2005; 40 (1): 19-38 28. Roohan PJ, Butch JM, Anarella JP. Quality measurement in Medicaid managed care and fee-for-service. Am J Med Qual 2006; 21 (3): 185-91 29. American Academy of Pediatrics. AAP Medicaid reimbursement survey, 2007/08: final report. 2008 Apr [online]. Available from URL: http://www.aap.org/ research/medreimpdf0708/49state_DC.pdf [Accessed 2008 Jun 28] 30. Linden A. Use of the pre-post method to measure cost savings in disease management: issues and implications. Dis Manag Health Outcomes 2007; 15 (1): 13-8 31. Patric K, Stickles JD, Turpin RS, et al. Diabetes disease management in Medicaid managed care: a program evaluation. Dis Manag 2006; 9 (3): 144-56 32. Short PF, Graefe DR. Battery-powered health insurance? Stability in coverage of the uninsured. Health Aff 2003; 22 (6): 244-55 33. Brazil K, Cloutier MM, Tennen H, et al. A qualitative study of the relationship between clinician attributes, organization, and patient characteristics on implementation of a disease management program. Dis Manag 2008 Apr; 11 (2): 129-37

34. MacStravic S. The challenge of participation in disease management. Dis Manag 2007 Nov; 10 (5): 247-51 35. Lynch W, Chen CY, Bender J, et al. Documenting participation in an employersponsored disease management program: selection, exclusion, attrition, and active engagement as possible metrics. J Occup Environ Med 2006 May; 48 (5): 447-54 36. Dickson M, Plauschinat CA. Racial differences in medication compliance and healthcare utilization among hypertensive Medicaid recipients: fixed-dose vs free-combination treatment. Ethn Dis 2008; 18 (2): 204-9 37. Horswell R, Butler MK, Kaiser M, et al. Disease management programs for the underserved. Dis Manag 2008; 11 (3): 145-52 38. Institute of Medicine (US) Committee on Health Care for Homeless People. Homelessness, health and human needs. Washington (DC): National Academies Press, 1988 39. Gary TL, McGuire M, McCauley J, et al. Racial comparisons of health care and glycemic control for African American and White diabetic adults in an urban managed care organization. Dis Manag 2004; 7 (1): 25-34 40. Kominski GF, Morisky DE, Afifi AA, et al. The effect of disease management on utilization of services by race/ethnicity: evidence from the Florida Medicaid Program. Am J Manag Care 2008 Mar; 14 (3): 168-72

About the Author: Dylan Roby is an Assistant Professor of Health Services in the UCLA School of Public Health and a Research Scientist in the UCLA Center for Health Policy Research. His research interests are in evaluation of disease management and coordinated care management, as well as healthcare affordability, access to care, and the uninsured. Gerald Kominski is a Professor of Health Services in the UCLA School of Public Health and Associate Director of the UCLA Center for Health Policy Research. His research focuses on program evaluation, cost effectiveness, quality of care, and healthcare financing. Nadereh Pourat is an Associate Professor of Health Services in the UCLA School of Public Health and Director of Research Planning in the UCLA Center for Health Policy Research. Her research interests include program evaluation, access to medical and dental care, care for the uninsured, and disparities. Correspondence: Dr Dylan H. Roby, UCLA Center for Health Policy Research, 10960 Wilshire Blvd, Suite 1550, Los Angeles, CA 90024, USA. E-mail: droby@ucla.edu

2008 Adis Data Information BV. All rights reserved.

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