Designing and Implementing Medicaid Disease and Care Management Programs



As the health care industry heightens its focus on quality initiatives, chronic illness has become a target for payers and providers seeking to improve care quality. Today in the United States, more than 90 million Americans live with a chronic illness, and many have multiple chronic illnesses. The rate of chronic illness is even higher among Medicaid beneficiaries; approximately 14.4 million Medicaid beneficiaries (30 percent) have a chronic illness. For the individual, the burden of chronic illnesses results in decreased quality of life, lower productivity, and major limitations in activity. For the Nation, the burden of chronic illness is higher costs of care. Currently, the costs of treating chronic illness account for 75 percent of the Nation's aggregate health care spending. For Medicaid, approximately 83 percent of spending is dedicated to people with multiple chronic conditions.1 This Medicaid Care Management Guide is designed to help States design, implement, and evaluate care management programs for the chronically ill.

More than half of the Nation's States have implemented Medicaid care management programs. These programs seek to improve the quality of care for people with chronic conditions. Medicaid beneficiaries receive care management services through the States' contracted managed care organizations (MCO) or as part of the State's fee-for-service (FFS) or primary care case management (PCCM) program. To assist States offering care management to their FFS and PCCM populations, the Agency for Healthcare Research and Quality (AHRQ) developed the Medicaid Care Management Learning Network in 2005.

The Learning Network seeks to provide expertise to participating States in four areas critical to ensuring a quality-driven care management program:

  • Helping patients become active in their care.
  • Encouraging provider participation in care management programs.
  • Developing program interventions and corresponding measurement strategies that impact patient care.
  • Designing valid, reliable evaluations to determine the program's success.

Since 2005, a total of 18 States have reviewed and analyzed the experiences of other States, best practices, and evaluation methodologies to identify the best solutions for their State. This Medicaid Care Management Guide reflects the experiences of the initial 13 Learning Network States.

The Guide is designed to be a resource for decisionmakers involved with designing and implementing care management programs. These decisionmakers may include care management program directors, Medicaid Medical Directors, program evaluators, program analysts, Governor's office staff, or State legislative staff.

Each section of the Guide can be used independently, allowing interested audiences to focus on specific development and implementation activities individually. However, each topic may include references to related sections that can provide context or illustrate examples. In addition, the Guide strives to incorporate as many State examples, lessons learned, and checklists as possible.

The Guide is organized to address five stages of care management program development, supplemented by three key topics that should be considered at every development stage. These topics span all stages of development and are crucial for program success and continuation. Brief descriptions of each section follow.

Planning a Care Management Program. Through dedicated planning, a State reviews various program design options and assesses available options against its particular needs. This section reviews considerations for developing a care management program, readiness for care management, and considerations for program design.

Engaging Stakeholders in a Care Management Program. Stakeholder support, beginning with program design and continuing through the evaluation, is critical to a successful Medicaid care management program. This section provides information about the importance of engaging key stakeholders (such as physicians), strategies for developing relationships with key stakeholder groups, and communication strategies for demonstrating program value.

Selecting and Targeting Populations. When designing a care management program, a State must consider the population the program will affect. Selecting a care management population includes choosing diseases and eligibility groups. This section reviews mechanisms for selecting, identifying, stratifying, and enrolling members.

Selecting Care Management Interventions. When designing a care management program, a State must understand which interventions—the methods used in care management programs to impact member health—are possible, tested, and successful. This section provides information about the different types of interventions, factors for selecting interventions, and considerations for implementing interventions.

Selecting a Care Management Program Model. In designing a care management program, States must consider which type of care management program model is most appropriate. Depending on the availability of State resources and staff, States can choose to contract with a vendor, operate a program internally, or choose a hybrid method to operate its care management program. This section provides information about selecting a care model and considerations for contracting with a vendor.

Operating a Care Management Program. After a State selects an appropriate care management program, it must plan a program implementation strategy. By carefully planning program rollout, identifying eligible members, designing monitoring strategies, and using measurement for program improvement, States will be able to maximize resources and build support for the program. This section provides information about implementation strategies, program monitoring, data systems, and continuous quality improvement.

Measuring Value in Care Management Programs. Demonstrating the value of care management programs is essential, both to ensure that Medicaid recipients are benefiting from the program and to garner support from the State legislature and other stakeholders. This section provides information on measurement strategy design, examples of measures, and strategies for communicating results to stakeholders.

The Care Management Evidence Base. Considering the evidence on efficacy of different care management interventions is important for States as they plan and design their own programs. States can use the evidence base for care management to gain support from stakeholders, choose diseases, and select interventions. This section presents a review of published literature relating to care management programs in the public and private sectors for asthma, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and diabetes. 

In this Guide, we share the experiences of the initial 13 Learning Network States from 2005 through 2007. Many of the trends occurring in care management, such as population-based approaches and managing comorbid conditions, are not conveyed throughout the Guide due to limited State experience. Future supplements to the Guide will share State experiences as they implement new program models and interventions.

1. Chronic Conditions: Making the Case for Ongoing Care, September 2004 Update, Partnership for Solutions.

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Page last reviewed October 2014
Page originally created March 2008
Internet Citation: Introduction. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.