commonwealth care alliance the case for primary care redesign and enhancement as the critical...

COMMONWEALTH CARE ALLIANCE

The Case for Primary Care Redesign and Enhancement as the Critical Strategy to

Improve Care and Manage Costs

© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information

Alliance for Health Reform BriefingAugust 11, 2011

Lois Simon, M.P.H. Co-Founder and Chief Operating Officer

What is Commonwealth Care Alliance?

Commonwealth Care Alliance is a Massachusetts, state-wide, not-for-profit, consumer governed prepaid care delivery system. Fully Integrated Dual Eligible Medicare Advantage Special Needs

Plan ACO prototype 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

2© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information

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Commonwealth Care Alliance Programs - 2010

Senior Care Options Program: Medicaid Only and Dual Eligible Elders $135M Blended Medicare/Medicaid “Risk Adjusted Premiums” 3000+ Dual and Medicaid Only seniors (Avg. RS = 1.72)

■ 69% nursing home certifiable - Avg. RS 1.98■ 64% primary language other than English■ 57% with diabetes, 18% with CHF

25 primary care sites with integrated multidisciplinary teams RN/NP/SW■ $16.1M increase in primary care expenditures over FFS Medicare, in 2010.■ 82RN/NPs, 34SW/BH/PTs in practices, not there in 2004.

Medicaid Programs for Chronically Ill Individuals with Complex Care Needs 2300 Medicaid and Connector eligible individuals with complex care needs (CCN).

■ 6 NP’s, 2 behavioral health clinicians, 11 community health workers integrated into 10 primary care practices – for complex care needs members.

300 Medicaid and dual eligible individuals with Severe Physical Disabilities. $45M Risk Adjusted Medicaid and “Connector” premiums (both patient populations).

*Jencks et al NEJM, Vol. 360: pp.1418-1428, 2009 ***JEN Associates study for MassHealth 2004-2005


Primary Care Redesign Elements

Comprehensive (often home based) multidisciplinary assessments, replace typical physician “history and physical”.

Individualized care plans, resource allocations, monitoring and modulating by the clinical teams for long term care, durable medical equipment, behavioral health services, replaces impersonal “rule based” benefits.

Primary care team comprised of licensed personnel and paraprofessionals; team required to go beyond purely medical services to address a broad array of psycho-social and poverty alleviation issues.

Clinical team empowerment to “order and authorize” all services, replaces inefficient supplications to a distant Medicaid or behavioral health carve out bureaucracies for “approval”.

Elastic NP home response capability, to assess and manage new problems, replaces the Ambulance and 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 “vanilla BH carve out options”.

24/7 clinical availability and continuity management replaces “going it alone”. Web based EMR support replaces total absence of clinical information transfer

capabilities; serves as critical communication vehicle to support very comprehensive interdisciplinary teamwork.

© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 4

Time Risk ScoreRisk Adjusted

Hospital Days per 1000

CCA: Nursing Home Certifiable (NHC)

2010 1.86 1,634

CCA: Ambulatory 2010 1.10 511

Medicare FFS: Dual Eligible

2008 1.27 2620

Hospital Utilization is Markedly Lower Than

Comparable Medicare FFS

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Commonwealth Care Alliance NHC hospital utilization is 62% of Dual Eligible Medicare FFS

Commonwealth Care Alliance Ambulatory hospital utilization is 20% of Dual Eligible Medicare FFS

*Lewin Associates study 2010/SNP Alliance


For CCA’s Nursing Home Certifiable (NHC) enrolled elders living in the community, fewer become long term Nursing Home residents:

46% of Medicaid’s FFS Experience for a comparable population

CCA NHC (2010)

Medicaid FFS (2005) *

% Reduction

Annual nursing facility placement as a % of NHC community living members

1.7% 3.3% 46%

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NHC: meeting Medicaid’s Nursing Home Certifiable criteria

* JEN Associates, 2009


Enhanced Primary Care: Central to the CCA Model of

CareNursing Home Certifiable Enrollees

Ambulatory Enrollees

Multidisciplinary physician/nurse practitioner/social worker team visits per enrollee per year (2010)

20 12

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Dual EligibleOther Medicare Beneficiaries

FFS Avg. primary care visits/Medicare beneficiary/ per year (1999-2002)

3.7* 6.7**

*Medicaid/SCO Procurement Document**MedPac Medicare Beneficiary file analysis 2006


Bending of the “Cost Curve”

Commonwealth Care Alliance

Timeframe

Nursing Home Certifiable

(NHC) Enrollees

AmbulatoryEnrollees

Average annual medical expense increase

2004-2010 3.3% 2.6%*

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Medicare FFS Timeframe

Average annual Medicare medical expense increase**

2005-20099.3%

* 2005-2010 period due to insufficient enrollment in 2004**NHE Fact Sheet https://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp


Quality Metrics

Commonwealth Care Alliance Overall Plan Rating: (4 Stars) Health Plan Rating (Part C): (4 Stars)

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

Drug Plan Rating (Part D): (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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The Calculus is Simple


+ +

=Reductions in more costly services

(hospital and institutional care)

Prudent and creative provision of community

based supports/long term care

Increased investment in primary care (Teams)

Medicare and Medicaid Risk Adjusted premium

to redesign care

What is Needed to Achieve These Results?

Program and financing models that enable creative approaches to care and that are integrative and comprehensive – primary, acute, behavioral, pharmacy and long term care.

Federal/state collaboration to promote integrated policy, financing and operations.

Appropriate risk adjusted reimbursement for individuals with complex care needs.

Public policy that promotes collaborative models of care at the provider level – not competitive.

Recognition that individuals who are Medicaid-only and dually eligible for Medicaid and Medicare are clinically indistinguishable.

More opportunities for innovation and shared learning….


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