Transcript Slide 1

Dual Integrated Financing and Its
Opportunity to Fundamentally Improve Care
and Reduce Costs:
The Commonwealth Care Alliance, Primary Care
Redesign and Enhancement Experience
NHPRI/RIHCA Policymaker Breakfast
November 16, 2011
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information
Case Vignette
Anna C. is a 65-year-old woman, SSI then Dually eligible for 10+ years. She
has long standing Multiple Sclerosis with complete paralysis in both legs,
impaired bladder function, weakness and increasing spasticity in her arms.
Chronic depression, a prior major suicide attempt and a history of severe
asthma exacerbated by heavy smoking, predated her MS.
For many years, Anna was able to use a manual wheelchair and perform self
catheterizations but with progression of upper extremity weakness, this became
increasingly difficult. Anna has received 4 hours of Personal Care Assistant
(PCA) care for the past five years without adjustment despite functional decline.
In the two years prior to enrollment, there have been multiple hospitalizations
for urinary tract infections, asthma exacerbations, pneumonias and two long
sub acute hospital stays for pressure sore management caused by extended
hours in bed and a poorly fitted manual wheelchair.
Anna has never had a primary care or behavioral health relationship. At
enrollment she was emotionally withdrawn, functionally bedbound, incontinent,
with rapidly worsening decubitus ulcers.
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Why Does Anna C’s Experience Cry Out for a
Fundamental Primary Care Redesign that is only
Possible with Medicare and Medicaid Integration
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Anna is an example of Medicaid and/or Dual Eligible beneficiaries
whose care is totally inadequate and as a consequence
unnecessarily costly.
Predictable and preventable secondary complications, such as,
urinary tract infections, asthma exacerbations, pneumonias and
decubitus ulcers drive recurrent hospital contacts, declining health,
poor outcomes and most costs.
Primary care as resourced and organized in both FFS or MCO
iterations is hopelessly ineffective. Payer based care coordination
strategies also have very limited effectiveness, particularly for
beneficiaries with complex needs.
Needed long term care, durable medical equipment and behavioral
health services are allocated (or not) without any kind of an
individualized care plan, monitoring or sensitive modulation over
time.
Continuity clinical management through all settings at all times, is
non-existent.
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What Do We Know About the Costs and Service Use
Patterns of Individuals with Complex Care Needs
and Anna C.?
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They represent about 15% of Dual beneficiaries accounting for
about 65% total expenditures.
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They are the reason that the “dual eligible” population
representing 15% of Medicare beneficiaries account for about
36% of Medicare expenditures.
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Primary care is grossly under resourced in both current FFS and
managed care iterations.
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30-50% of total medical expenditures are for recurrent hospital
care, as a consequence of the missed opportunities to effectively
intervene on predictable complications. With effective
interventions, the percentage of total medical expenses going to
hospital care should be closer to 12%.
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Primary Care Redesign Elements
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Primary care multidisciplinary teams with professional and non professional
components with abilities to assess, manage and coordinate in multiple
settings, REPLACES the 20 minute medically focused physician office visit.
Individualized care plans, and resource allocations, for long term care,
durable medical equipment, and behavioral health services, REPLACES the
widespread “under resourcing” and “over resourcing” that characterizes “rule
based” benefits management.
Elastic nurse practitioner home response capability, to assess and manage
new problems, REPLACES physician telephone management, the
Ambulance and the ED.
For those with physical disabilities– integrated durable medical equipment
clinical assessment and management, REPLACES distant prior approval
processes and months of delay.
For those in need of behavioral health service, integrated behavioral health
clinician assessment, individualized care plan development, implementation
and management REPLACES inaccessible “BH carve out options”.
24/7 clinical availability and continuity management REPLACES “going it
alone”.
Web based EMR support REPLACES absence of clinical information
transfer capabilities.
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Anna C.
Primary Care Redesign Experience
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Comprehensive in-home nurse practitioner, behavioral health clinician, physical
therapy and durable medical equipment assessment produced the
development, implementation and monitoring of the following individualized care
plan:
 56 hours of personal care assistant support/week instituted for assistance
with daily living activities, subsequently reduced to 40 hours/week over time.
 In-home wound care nurse specialist consultation provided with a clinical
management plan instituted.
 Specialized air mattress delivered within 24 hours and motorized wheelchair
with needed seating adaptations quickly arranged.
 In-home behavioral health assessment with individualized care plan created;
includes medication and counseling.
 Transportation arranged for specialty appointments, dental care and other
activities.
 Smoking cessation strategies instituted.
 Primary care physician identified with continuous support by a nurse
practitioner provided as a first responder to, and clinical manager of, new
problems via home visits.
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Anna C. - One Year Later
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Engagement with life, family, community and in self management;
greatly improved. Withdrawal and despondency diminished.
Decubitus ulcers entirely healed.
Effective BH psychopharmacology and LICSW in-home counseling
relationship established.
Smoking cessation efforts partially effective, frequency of asthma
exacerbations greatly diminished.
Continuity relationship established with a PCP (though most primary
care occurs via NP home visits) and with a neurology consultant.
One year service use.
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2 ED visits for asthma exacerbation management.
One three day hospitalization for urinary tract infection management.
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What is Commonwealth Care Alliance?
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Commonwealth Care Alliance is a Massachusetts,
state-wide, not-for-profit, consumer governed prepaid
care delivery system.
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Fully Integrated Dual Eligible Medicare Advantage Special Needs
Plan; began as a demonstration program in 2004 under a three
way contract with CMS and MassHealth
Focuses exclusively on the care of Medicare and Medicaid’s
most complex and expensive beneficiaries
Relies on Medicare and Medicaid risk adjusted premium to
redesign care with a focus on investment in primary care
Care Model - enhanced primary care and care coordination
capabilities through deployment of multi-disciplinary Primary Care
Teams
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Commonwealth Care Alliance
Programs - 2011
Senior Care Options Program: Medicaid Only and Dual Eligible Elders
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$170M Blended Medicare/Medicaid “Risk Adjusted Premiums”
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3400+ Dual and Medicaid Only seniors (Avg. RS = 1.68)
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71% nursing home certifiable - Avg. RS 1.98
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62% primary language other than English
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56% with diabetes, 23% with CHF
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25 primary care sites with integrated multidisciplinary teams RN/NP/SW
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$16.9M increase in primary care expenditures over FFS Medicare, in 2010.
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82 RN/NPs, 44 SW/BH/PTs in practices, not there in 2004.
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554 Full-time in home personal care assistants funded as per individualized care
plans.
Medicaid Program for Disabled Individuals with Complex Care Needs
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600+ Medicaid and Dual individuals with Severe Physical Disabilities.
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Plans in place for statewide expansion of this program – roll out in 2012
Program development underway to respond to anticipated state procurements to
serve other individuals with complex care needs under the age of 65
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Hospital Utilization is Markedly Lower
Than Comparable Medicare
FFS Experience
Time
CCA: Nursing Home
Certifiable (NHC)
CCA: Ambulatory
Medicare Dual Eligible
FFS Experience
2010
2010
2008
Risk Adjusted
Hospital Admits
per 1000/yr.
Risk
Adjusted
Hospital
Days 1000/yr.
332
141
671
1634
511
2620
*Lewin Associates study commissioned by the SNP Alliance of member risk adjusted hospital utilization experience vs.
Medicare benchmark
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Fewer “At Risk” NHC Frail Elders Become Long
Term Nursing Home Residents: 34% of
Medicaid FFS Rate for Comparable NHC
Frail Elders
% of Post hospital SNF
Facility stays becoming
Long Term Residents
CCA NHC
(2008-2010)
Medicaid FFS
(2005) *
10.7%
31.2%
* JEN Associates, 2009
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Enhanced Primary Care: Central to the
CCA Model of Care
Multidisciplinary physician/nurse
practitioner/social worker team visits
per enrollee per year (2010)
FFS Avg. primary care visits/Medicare
beneficiary/ per year (1999-2002)
Nursing Home
Certifiable
Enrollees
Ambulatory
Enrollees
20
12
Dual Eligible
Other Medicare
Beneficiaries
3.7*
6.7**
*Medicaid/SCO Procurement Document
**MedPac Medicare Beneficiary file analysis 2006
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information
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Bending of the “Cost Curve”
Commonwealth
Care Alliance
Average annual
medical expense
increase
Timeframe
Nursing Home
Certifiable (NHC)
Enrollees
Ambulatory
Enrollees
2004-2010
3.3%
2.6%*
* 2005-2010 period due to insufficient enrollment in 2004
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Quality Metrics - 2010
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Commonwealth Care Alliance
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Overall Plan Rating:
Health Plan Rating (Part C):
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Staying Healthy: Screenings, Tests & Vaccines
Managing Chronic Conditions
Rating of Health Plan Responsiveness & Care
Health Plan Member Complaints & Appeals
Health Plan’s Telephone Customer Service
Risk adjusted 30 day hospital readmission rate = 4% vs 13%,
the MA median, >95th percentile
Drug Plan Rating (Part D):
(4.5 Stars)
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(4.5 Stars)
(4.5 Stars)
Drug Plan Customer Service
Drug Plan Member Complaints, Members Who Choose to Leave, and Medicare
Audit Findings
Member Experience with Drug Plan
Drug Pricing and Patient Safety
Medicare Star Ratings - Over 80% of Medicare Advantage plans
score 3.5 Stars or below
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