Download In Medicare Advantage - American Academy of Home Care Medicine

Ronald J. Shumacher, MD FACP CMD
Chief Medical Officer, Optum Complex Population Management
©AAHCM
Ronald J Shumacher MD has the following
financial relationship to disclose:
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Employee of: Optum Services, Inc.
©AAHCM
©AAHCM
5% of the population drives
50% of the medical spend
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An average of 8+ conditions
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An average of 10+ medications
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Most members have both functional
impairment plus chronic medical
conditions
Frequent ambulatory visits,
emergency room visits (3 plus/ year)
Require an extremely high level of
care, attention and time
Do not regularly engage with doctor
or look to payer for health support/
management
Stanton MW. The High Concentration of U.S. Health Care Expenditures. Research in Action, Issue 19. AHRQ
Publication No. 06-0060, June 2006. Agency for Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/research/findings/factsheets/costs/expriach/index.html
©AAHCM
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Medically complex members frequently present with multiple chronic
conditions, associated cognitive issues and psychosocial complications that
render them high-risk
Multiple providers and medications produce disjointed, confusing and
sometimes contraindicated care plans
Traditional in-office medical care delivery is insufficient — in time and
quality — to establish the patient insight and relationship depth that
medically complex members uniquely require
Under the current care delivery model, primary provider and specialist
practices are not structured or equipped to provide the urgent, 24/7
response proven to be critical in preventing chronic illness escalation and
exacerbation
The accompanying gaps in care — along with a common lack of patient
adherence — leave members vulnerable to frequent escalations and
exacerbation; these, in turn, devolve into excessive medical crises requiring
ER visits, acute hospitalizations, readmissions and unnecessary medications
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Post-Acute Transitions
Chronic Care Management
• Bridges gaps in care after
discharge from hospital
• Use predictive modeling to
identify highest risk patients
• Readmission rates typically
>17% for Medicare Advantage
• Longitudinal care and care
management improves selfcare and better manages
triggers
• Readmissions often result from
poor communication, noncompliance, etc.
• Transition program can reduce
avoidable hospital
readmissions by 30 – 45%
• Care is coordinated with PCP
• Prevents avoidable ER visits
and hospitalizations by 50 –
65%
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Reduces overall health costs, including reduced
hospitalization/re-hospitalization rates, emergency
department (ED) visits and costs associated with end of life
Supports accurate diagnosis resulting in appropriate coding
 risk adjusted payments and MA plan revenue
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Supports quality metrics, including Star ratings and HEDIS
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Guides patients into right care at right time
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Improves quality of life and satisfaction
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Decreases caregiver burden while retaining involvement
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Enables home situation and safety assessment
©AAHCM
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A house call program with 91 clients in a
Nevada Social HMO produced a 62% reduction
in hospital days and savings of $439,825 per
year in acute, skilled and sub-acute days,
with net savings of $261,2251
A randomized controlled trial explored inhome, post-discharge care for the elderly
showed 65% reduction in hospital days and
50% cost savings2
At $1,500 per
ED visit, the cost
of 10 house calls
can be offset by
preventing one
ED visit. 4
One study of post-hospital care for high-risk
CHF patients produced 50% reduction in
rehospitalization when in-home,
multidisciplinary program implemented3
1 Phillips SL, et al. Chronic home care: a health plan’s experience. Annals LTC. 2004.
2 Naylor MD, et al. Comprehensive discharge planning and home follow-up of hospitalized elders.
JAMA. 1999;281:613-620.
3 Rich MW, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with
congestive heart failure. N Engl J Med 1995;333:1190-1195.
4 Costs and cost-effectiveness of home medical care. AAHCM. Accessed online:
http://go.nationalpartnership.org/site/DocServer/Costs_and_Cost_effectiveness_of_home_medical_
care.pdf?docID=6850
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Acute admits/1,000 comparison
1,975
1,690
1,623
1,567
1,465
633
715
1,403
633
1,608
1,529
677
630
502
593
563
354
1
2
3
4
5
Months
Control Group
6
7
Home-based Medicine Group
Seven
month
average
Combined
next 12
months
Optum CarePlus outcomes study on dual skilled nursing population’s inpatient admissions
compared to actuarial equivalent matched cohort (n=15,000 members), Jan. 2008 – Jul. 2008.
Arizona health plan. Data compiled by Optum Data Analytics.
©AAHCM
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Baseline Admits/1,000
Program Admits/1,000
3,426
3,277
3,000
2,872
2,607
1,271
2,574
2,574
2,500
1,242
1,177
914
627
1
2,696
2
3
4
771
5
973
858
580
6
7
8
Combined
Markets
Optum CarePlus outcomes study for high-risk Medicare Advantage health plan members
(n=20,000 members), Jan. 2007– Dec. 2008. Florida Medicare Advantage health plan. Data
compiled by Optum Data Analytics.
©AAHCM
10
3500
2865
3000
2500
2000
1500
1660
1476
994
1000
500
746
497
0
Admits/1000
Baseline
Skilled days/1000
ED/1000
First 6 months post-implementation (Year 1)
Optum CarePlus outcomes study: cost of high-risk Medicare Advantage members (2+ chronic
conditions and 1+ hospital admission) during the first six months of the program inception
compared to the previous six months (n=35,000 members), Jan. 2009 – Dec. 2010. Alabama
Medicare Advantage health plan. Data compiled by Optum Data Analytics.
©AAHCM
$2,792
2,442
$1,694
1,141
PMPM Cost
Admits/1000
Baseline
Year one
Optum CarePlus outcomes study: cost of high-risk Medicaid members (2+ chronic conditions
and 2+ inpatient admissions) claims during the CarePlus program (n=20,000 members), Jan.
2008 – Dec. 2009. Tennessee health plan. Data compiled by Optum Data Analytics.
$20,000
All Medicare
$17,559
Medicare High Risk
Home-care managed
$16,000
$12,000
$11,037
$10,104
$7,449
$8,000
$5,316
$4,000
$3,826
$2,662
$–
$4,323
$5,412
$3,845
$4,665
$3,142
$2,491
$2,042
$2,172
Month 6
Month 5
$2,691
Month 4
$3,400
$3,391
Month 3
Month 2
Month 1
Outcomes study: cost of members during the last six months of life measured against
both an actuarial equivalent cohort and the average medicare advantage costs in the
Michigan and Alabama Medicare Advantage health plans (n=70,000 members; 35,000
members), Jan. 2010 – Aug. 2010. Data compiled by Optum Data Analytics.
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In-home visits have huge impact downstream
on HEDIS/Stars and quality outcomes
Screening, tests, vaccinations, management of chronic
conditions can all be influenced by home-based
provider
Robust outcome studies not performed but many MA
plans leveraging home provider visits to augment Star
strategy
©AAHCM
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Patients highly satisfied with in-home medical
care/perception of improved quality of life
High levels of provider satisfaction with home care
delivery models
Enhances reputation for caring and compassion
Medicare Advantage Star ratings driven by CAHPS,
HEDIS and HOS patient satisfaction survey measures
©AAHCM
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Address patients without visits
Must be based on face to face encounter with provider
(physician, NP, or PA)
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Must be documented in medical record
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Requires monitor, evaluate, assess, or treat
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At least annually
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Highest level of specificity (training is critical)
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Main reason for visit and coexisting conditions are
documented
Much more effective than network based physician coding
©AAHCM
Ronald J Shumacher, MD FACP CMD
Chief Medical Officer, Optum Complex Population Management
[email protected]
©AAHCM