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Special Report: Medicaid Integrative Therapies Pilot Project for Chronic Pain - Part 1, Overview PDF Print E-mail
Written by John Weeks   
Monday, 22 October 2007

Special Report: Florida Medicaid Integrative Therapies Pilot Project with Licensed Acupuncturists, Massage Therapists - Part 1, Overview

Summary:  Medicaid costs are soaring. States are hurting. Strains from pain-related conditions factor in heavily. Meantime, surging prescriptions of pain medications create new sets of adverse consequences. Can an integrated care program featuring licensed acupuncturists, massage therapists and holistically-oriented nurse managers be part of the solution? Since 2002, via legislation and a Medicaid waiver, the state of Florida has engaged an "Integrative Therapies Pilot Project" to answer these questions. Chicago-based Alternative Medicine Integration Group (AMI) won the contract. This Integrator Special Report looks at AMI's clinical integration and payment model, patient and practitioner experience, and clinical and cost outcomes and controversies in the analysis of costs and cost-savings. Is this a model which Medicaid should widely promote? Part 1 of this 5-part exploration is an overview of issues and findings.

Send your comments to
for inclusion in a future Your Comments forum.

Introduction: Can Integrative Therapies Relieve Chronic Pain and Limit Costs in a Medicaid Population?

The belief that a population of low-income, high-utilizing patients can be managed successfully and at cost savings through integrated care approaches is strongly held by many integrated care practitioners.

alternativ medicine, medicaid, C AM, integative therapies, AMI, acupuncture, massage
Florida's Agency for Health Care Administration
Unfortunately, the assertion has remained largely untested. The NIH National Center for Complementary and Alternative Medicine has only recently announced a an exciting program which might fund explorations of the effectiveness and cost-effectiveness of integrative therapies in real-time settings.
Foundation funders have not stepped up. Only the rare complementary healthcare management company collects and publishes clinical and cost outcomes as part of their business model.

A unique Medicaid pilot project in Florida is beginning to give us some answers. In 2002, t
he Florida State legislature passed language in a budget bill to enable the creation of an integrative therapies pilot program. The program required a Medicaid waiver to cover services of licensed acupuncturists and licensed massage therapists. The program focus: "quality of care and cost-effectiveness of (an integrated) disease management initiative."

Adrian Langford, a long-time managed care executive who presently serves as a regional vice president
for the Chicago-based Alternative Medicine Integration Group (AMI), pitched the idea of potential benefits from such a project to legislators. AMI eventually won the contract to develop and manage the pilot in a 3-county area in the Tampa Bay area.

intetgrative therapies, acupuncture, Medicaid, cost savings, cost offsets, patient satisfaction
Vendor to AHCA on the pilot project
Since early 2004, AMI, an Integrator sponsor, has managed up to 500 patients per month out of a rotating pool of approximately 2500 eligible
patients through an integrated program managed by a holistically-oriented nurse-manager. Tools include self-help CDs and some group education. But what required a waiver are the services of licensed massage therapists and acupuncturists. The program's target population is a set of high-cost patients with back pain, neck pain, fibromyalgia and chronic fatigue who receive care under Florida's MediPass program, managed by Florida's Agency for Healthcare Administration. AMI was charged to gather and report data on clinical experience and costs.

The pilot program has generated strongly positive reviews from its target population as well as controversy among regulators. Ultimately, the program was renewed in 2007, with some changes in the management plan.
This 5-part Integrator Special Report examines AMI's clinical and outcomes strategy, experiences of patients and clinicians, cost controversies, and the potential value of the pilot in other regions and states.

  • Part 1: An overview
  • Part 2: Clinical management model.
  • Part 3: Experience and outcomes for patients and clinicians.
  • Part 4: Strategies and disputes in understanding cost outcomes.
  • Part 5: Perspectives from national leaders in integrative community medicine. 
_______________________________________

Florida Medicaid/MediPass Integrative Therapies Pilot Project:
Program Characteristics at a Glance


Basics

   
Sponsor

Medicaid/Florida MediPass
Contractor   Alternative Medicine Integration Group (AMI) 
Enabling legislation
  2002
Contract award

2003
Service began

2004
Contract renewal

2007
Region
  Pinellas and Pasco Counties
Population
  Chronic pain patients with MediPass
Conditions
 
  • Fibromyalgia
  • Chronic fatigue
  • Chronic back pain
  • Chronic neck pain
Services
  " ... the best practices of conventional
  and complementary alternative medicine"
Key CAM services
and practitioners
 
  • Holistic nurse manager
  • Licensed massage therapists
  • Licensed acupuncturists
  • Self-help brochures and CDs
  • Nutritional counseling
  • Pharmacy consulting
Integrated context

  • Coordination with conventional 
        primary care practitioners
  • Coordinated referral to a select
          chiropractic network
Original pilot years

2004-2007
Reporting
requirements

Annually to Florida State Senate
  Appropriations Committee
Current status

Extended for 3 additional years,
  with some changes

_______________________________________


1.   Adrian Langford, AMI and the Project's Origins

Adrian Langford, VP, AMI Florida, is blunt in his assessment of conventional management of chronic pain. The 20-year veteran of the managed care industry states: "Conventional primary care doctors don't know how to manage pain. They just throw drugs at them. Chronic pain is best managed through teaching people how to help manage their own pain." He adds: "Heck, in many instances, an $8 CD can be a lot better than sending someone to a pharmacist."

   
  "Conventional primary care
doctors don't know how
to manage pain. They just
throw drugs at them.

"Chronic pain is best managed
through teaching people how
to help manage their own pain."

- Adrian Langford, VP,
AMI Florida

Ten years ago, when complementary and alternative medicine began to gain some interest among managed care firms, Langford developed a network of complementary and alternative healthcare practitioners in Florida. He began promoting a project with employers which focused on potential cost reductions. But it wasn't until linking up with Chicago-based AMI that Langford had a chance to test his beliefs and passions.

AMI was a good fit for him, according to Langford. "AMI's strategy has typically been to go straight to employers and other payers. Targeting the Florida MediPass population - our Medicaid program here - followed that model."

AMI is known nationally for a managed care program with HMO Illinois, a Blue Cross Blue Shield company. AMI found significantly less use of conventional pharmacy, procedures, and hospital days in a population for which care is managed care through a network of non-pharmacologically-oriented primary care practitioners. (See related Integrator story here.) That AMI network includes broad scope chiropractors and integrative medicine-oriented medical doctors and osteopaths.

States Langford: "After what (AMI was) already doing, developing a program for managing and measuring the outcomes of a high-cost Medicaid population with integrative therapies was right up their alley." Langford had a vision, and now he had a partner. What was needed was a client.


2.   Florida Legislature Enables Medicaid Waiver to Cover Unique Services


acupunture, Medicaid, massage, integrative medicine, covered benefits
Florida prorgam from which pilot participants were drawn
An article last year on the pilot in the St. Petersberg Times ("Yes, Medicaid Pays for This," October 2, 2006) captured the context of the Florida legislature's decision to go outside the box of conventional treatment succinctly: "With Medicaid gobbling ever-larger chunks of state revenue, the Legislature is experimenting."

AMI's integrative therapies demonstration project was enabled by the Florida State legislature in 2002 through a clause in the state's Fiscal Year 2002-03 General Appropriations Act, Chapter 2002-225 of the Laws of Florida. The target of the appropriation was the improvement of the "quality of care and cost-effectiveness of a disease management initiative" in a localized area. The state was authorized to seek "federal Medicaid waivers or state plan amendments" if the disease management initiative would offer services not typically covered by Medicaid. The initial plan was for a 3-year pilot.

The initiative was engaged at a time that Florida's Agency for Health Care Administration identified chronic pain as the leading cost driver of any chronic disease. According to Langford, these costs outpaced those related to HIV/AIDS, asthma, hypertension and diabetes.

After approval by the legislature, management of the program was eventually granted on May 6, 2003, to Chicago-based Alternative Medicine Integration of Florida, LLC (AMI). The AMI proposal was for a AMI set about building its care model and networks of practitioners.

3.   Covered Services and Management Model

In the first phase of the program, patients were recruited through communication with conventional primary care providers (PCPs). Once the physicians agreed to have their patients participate, AMI had the opportunity to directly solicit participation of patients via mail and phone through lists provided regularly by MediPass.

Image
Care Manager Tracy Woolrich, RN, HHP - nurse and holistic health practitioner
Holistically-trained nurse case managers took the lead in the recruitment and communication effort and then with patient management. Langford underscores the importance of these nurses in the AMI model: "The key to the program is the nurse case manager. These nurses have become trusted guides to most of the patient population."

The lead nurse case-manager for the AMI program is
Tracy Woolrich, RN, HHP (Holistic Health Practitioner). Woolrich, who has extensive experience in conventional case management, describes her job as a dream come true: "What is so wonderful is that I am finally doing what I wanted to do. AMI is giving me the opportunity to do healing.  It's not like anything I've been able to do before, not like traditional nursing, that's for sure."

AMI's two nurses help triage patients among a variety of information options and therapeutic services. These include conventional disease management strategies such as dispensing informational fliers, support in accessing community services, offering nutritional counseling and managing communication with PCPs.  Patients can also be guided, under a separately-covered benefit, to area chiropractors.

But what most distinguishes the the pilot program is that participating MediPass beneficiaries have access to a controlled number of massage treatments or acupuncture treatments each month. Participant Richard Adams, a disabled medical assistant, recalls receiving the solicitation:
"I said, what have I got to lose. I had nothing but time on my hands." Adams chose acupuncture rather than massage and began a series of treatments.

Part 2 of this Special Report will explore AMI's individualized care management process.

_______________________________________

The Florida  Medicaid Integrative Therapies Pilot Project:
Clinical & Cost Outcomes at a Glance


Measures

  Findings
SF 12 - Mental function

16% increase, year 1
20% increase, year 2
SF 12 - Physical function
  20% increase, year 1
24% increase, year 2
"Program treatment providers helped
  to reduce my levels of pain."
  86% yes, year 1
94% yes, year 2
Changes in prescription drug use

20% lower, year 1
Per Member Per Month (PMPM) Costs

9% decrease
PMPM costs in the population with
  usual care

15% increase
Overall possible PMPM benefits, AMI
  group compared to usual care

25% lower costs

All data from reports provided to the Florida legislature
by Alternative Medicine Integration Group of Florida.
_______________________________________


4.    Patient and Clinician Experience

Adams provided the Integrator with a personal window on his experience with acupuncture: "I never had acupuncture before. I never believed in it. I was totally skeptical."

Adams has now had what he estimates as 12-15 visits. How has it gone? He references the perspectives of his conventional doctors: "M
y GI doc, my podiatrist, my endocrinologist [Adams is a diabetic] - they all think it's a step in the right direction. They've seen the change in me. My endocrinologist said, 'whatever you are doing, keep with it.'"

disabled, acupuncture benefits, covered services
Rick Adams, program beneficiary
As part of the contract, AMI is required to gather outcomes on patient perceptions of their experience. These must be reported annually to the legislature. To date, AMI's reports suggest that Adams' experience is the norm. For instance, in a 2006 patient survey, AMI found that 94% of respondents (30% response rate) agreed that "program treatment providers help (me) to reduce (my) levels of pain." This is up from 86% in a prior reporting period. An AMI-conducted analysis, based on functional outcomes gathered with each visit, found that on the Physical Component Summary of the SF-12, participants showed a 24% improvement over baseline.


Langford points to the mental health portion of the SF-12 as further compelling evidence of the value of the model.
He states: "Our first year measure on the SF-12 saw 16% increase on the mental health portion and 20% in the second year." He reflects: "I really find the mental health improvements very interesting. They speak to the value of patient-centered, relationship-oriented care systems. These improvements are very significant especially when you weigh in on the fact that we don't use any shrinks."

Part 3 of this Special Report will include methods, data and comments from AMI's patient surveys together with details from Integrator interviews with Medipass participants and with their massage and acupuncturist clinicians.

5.   AMI's Analysis: Nearly 25% Lower Costs in Their Managed Population

Pleased patients alone
will not float and extend the pilot program. The Florida's legislature's primary concern, which led to granting the waiver, was the crushing cost of chronic pain. The legislators wanted to know if integrative therapies might make a difference on their bottom line. The potential for expanding services throughout the state, and gathering interest in other jurisdictions throughout the country, also rests on the business model.

AMI's analysis of the cost of treatment of the participants, relative to the MediPass norms, suggests that significant savings are flowing from this program. States Langford: "
Our managed group realized a reduction of (per member per month) costs of over 9 percent while a comparable non-managed population realized an increase of PMPM costs of 15.1 percent."  Extrapolated for larger populations, this nearly 25% cost differential amounts to potentially tens of millions of potential Medicaid savings.

Langford provides some breakdown of the savings: "Pharmaceutical savings during the early months of the program indicate a 20% reduction in prescription drug expenditures. Cohort populations not managed by AMI experienced a 23% increase in pharmaceutical usage over the same time frame."


In a series of interviews for this feature, Langford noted that the analysis of cost outcomes has been a highly politicized process.
Yet analysts for the state have chosen different markers and have reached different conclusions. Clarity on cost outcomes has been obscured by dueling methodologies for analysis and will be examined in Part 4 of the Special Report. We will walk through the analysis and back-and-forth over measurement of the program's impact on the costs which the Florida legislature is seeking to control.

6.   Going Forward, in Florida and Beyond ...

Whatever the debate over outcomes, the Florida legislature has chosen to amend and extend the AMI pilot program. In Part 5 of the Special Report, the Integrator will first examine features of the new model. Then leaders in community medicine and integrated public health delivery will be interviewed on their perspectives on this pilot. Is it worth emulating? What can be learned from the model?

Along the way, the Integrator will be interested in any perspectives you might have on the Florida Medicaid pilot and other strategies for integration of non-pharmacological approaches into care of the underserved.

Disclosure: AMI is an Integrator sponsor.

Send your comments to
for inclusion in a future Your Comments forum.


Last Updated ( Monday, 22 October 2007 )
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