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COMMONWEALTH CARE ALLIANCE
The Case for Primary Care Redesign and Enhancement as
the Critical Strategy to Improve Care and Manage Costs
Alliance for Health Reform Briefing
August 11, 2011
Lois Simon, M.P.H.
Co-Founder and Chief Operating Officer
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information
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
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
© 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
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$135M Blended Medicare/Medicaid “Risk Adjusted Premiums”
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3000+ Dual and Medicaid Only seniors (Avg. RS = 1.72)
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69% nursing home certifiable - Avg. RS 1.98
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64% primary language other than English
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57% with diabetes, 18% with CHF
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25 primary care sites with integrated multidisciplinary teams RN/NP/SW
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$16.1M increase in primary care expenditures over FFS Medicare, in 2010.
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82RN/NPs, 34SW/BH/PTs in practices, not there in 2004.
Medicaid Programs for Chronically Ill Individuals with Complex Care Needs
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2300 Medicaid and Connector eligible individuals with complex care needs (CCN).
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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
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information
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Primary Care Redesign Elements
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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
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Hospital Utilization is Markedly Lower
Than Comparable Medicare FFS
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Time
Risk Score
Risk 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
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
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information
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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
Annual nursing facility
placement as a % of
NHC community living
members
CCA NHC
(2010)
Medicaid FFS
(2005) *
% Reduction
1.7%
3.3%
46%
NHC: meeting Medicaid’s Nursing Home Certifiable criteria
* JEN Associates, 2009
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information
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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
Medicare FFS
Average annual
Medicare medical
expense increase**
Timeframe
Nursing Home
Certifiable
(NHC)
Enrollees
Ambulatory
Enrollees
2004-2010
3.3%
2.6%*
Timeframe
2005-2009
9.3%
* 2005-2010 period due to insufficient enrollment in 2004
**NHE Fact Sheet https://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information
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Quality Metrics
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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
Drug Plan Rating (Part D):
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(4 Stars)
(4 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
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information
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The Calculus is Simple
Medicare and Medicaid
Risk Adjusted premium
to redesign care
+
=
Increased investment in
primary care (Teams)
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Prudent and creative
provision of community
based supports/long
term care
Reductions in more costly services
(hospital and institutional care)
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information
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What is Needed to Achieve These
Results?
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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….
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information
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