Transforming Service Delivery, Producing

Quality, Cost-Effective Outcomes

In Maine’s Medicaid Program

Presented by Mary C. Mayhew, Commissioner

Maine Department of Health and Human Services

Robert Wood Johnson Foundation

Super-Utilizer Project

Year Two Summit

July 31, 2013

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Camden Coalition’s Snapshot

Of Maine’s High-Cost Users

• 1 percent of all MaineCare patients accounted for over 30 percent of

total hospital costs across the three counties

• 20 percent accounted for 87 percent of costs.

• Most prevalent diagnoses:

– Alcohol-related disorders (over twice as likely as non-High Utilizers)

– Mood disorders

– Chronic obstructive pulmonary disease and bronchiectasis (almost twice

as likely)

• 1.8 times more likely to have an IP diagnosis of diabetes compared

to non-High Utilizers

• 72% of all IP High Utilizers were over age 34

Camden Coalition Snapshot

Of Maine’s High-Cost Users

ED High Utilizers

• Almost 1.5 times more likely to have an ED diagnosis of "anxiety

disorders”

• Almost 1.5 times more likely to have an ED diagnosis of

"spondylosis; intervertebral disc disorders; other back problems”

• 1.4 times more likely to have a diagnosis of "Headache; including

migraine“

• 67% of all ED High Utilizers were under age 35

• A relatively small number of MaineCare members are responsible for a large percentage of the costs

• High utilizers cluster in “hot spots” across the state

• Improved integration of behavioral and physical health is a necessity

• Many high utilizers’ health may be improved through access to primary care, preventive care, and chronic disease management

Our strategy must be:• Community-based• Address integration of behavioral and physical health • Strengthen access to and use of patient-centered primary care• Provide care management for high need members• Social service agencies must address social/environmental barriers

What the Data

Tells Us

Emergency Department

Care Management Collaborative

• Began as a one-hospital

pilot project in 2011

• Identified 30 frequent ED

users

• Managed care with

delivery in most

appropriate setting

• Recognized more than

$100,000 in savings

Emergency Department

Care Management CollaborativeExpectations for participating hospitals:

– Investment of available care management resources for monthly case conferences

– Daily sharing of ED and inpatient census data

The State’s responsibilities:

– Bringing all resources together

– Providing care management resources

for hospitals/communities with insufficient capacity

– Daily census analysis

– Sharing of diagnosis, medical compliance,

PCP provider visits, and other utilization data

– Technical assistance

Emergency Department

Care Management Collaborative

As of June 2013

– All hospitals in Maine have

constructed their lists of high

utilizers.

– Now working with 1,700 members

– State staff dedicated to the

program.

– We are working with the larger

health systems to help

standardize processes and

facilitate clear communication

– Savings of over $4 million

annually.

Liz’s

Story

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• Introduced to program after 13 inappropriate hospital visits

• Took her case to upon referral of a local hospital

• Type II Diabetes, anemia, chronic pain, COPD, tobacco use,

drug abuse, epilepsy, incontinence, adult failure to thrive and

anxiety; suicidal.

• Recent right hip fracture and repair, neurogenic bladder, Bell’s

palsy, opioid dependence, deficits in mobility, which have been

helped by a wheelchair

• -Discharged from nursing home about a year ago

Liz’s

Story

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So Far,

So Good

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• In-home supports have allowed Liz to remain independent.

• Behavioral health services are provided in her home.

• No longer has thoughts of suicide.

• Has not visited the Emergency Department since February.

• Credits this program with saving her life.

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Maine’s High-Cost Utilizers

Cost Per Member

Cost PMPM Top 5 90 to 95% 80 To 90% Bottom 80%

$5,713 $1,750 $766 $78

Annual Cost

The Top

Five Percent

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The High

Five Team:

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• Form a group with at least two representatives from each of

the offices within DHHS

• Empower this group to act and ensure a holistic approach is

considered when services are made available

• Focus on services delivered and needs present NOT cost

• Benchmark is to bring the top 5 percent closer to the second

5 percent in service and cost by improving quality of care and

services provided

The High Five Team:

An Example

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• Two adult females

• Both receiving rent subsidy and MaineCare

• SSI disabled

• Diagnosis: depression

• Risk scores comparable

• Medical costs 2011

– Member #1 : $12,530

– Member #2 : $47,254

Maine Health Homes

A Key to Long-Term Sustainability

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Stage A (ongoing):

•Health Home = Medical Home primary care practice + CCT

•Currently have 150 enrolled practices and 10 CCTs

•Payment weighted toward medical home

•Eligible Members:

• Two or more chronic conditions

• One chronic condition and at risk for another

Stage B (Fall Implementation):

•Health Homes = CCT with behavioral health expertise + primary care practice

•Payment weighted toward CCT

•Eligible Members:

• Adults with Serious Mental Illness

• Children with Serious Emotional Disturbance

Other Keys

To Sustainability

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• ROI; Quality Outcomes; Cost Effectiveness

• Federal Medicaid Policies Reflective of Social/Medical Model;

& Community-based services: Homemaker services/Peer

Supports; Any Willing Provider

• State Policy Reforms; Payment Reform

• Standardized practices/systems

• Commitment to Continual Process Improvement

• State Investments in the Model

• Integrated DHHS System

• Robust Data Systems/Data Analytics/Predictive Analytics

Thoughts from the Field:

Sustainability

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