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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: Employee of: Optum Services, Inc. ©AAHCM ©AAHCM 5% of the population drives 50% of the medical spend An average of 8+ conditions An average of 10+ medications 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 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 ©AAHCM 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% ©AAHCM 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 Supports quality metrics, including Star ratings and HEDIS Guides patients into right care at right time Improves quality of life and satisfaction Decreases caregiver burden while retaining involvement Enables home situation and safety assessment ©AAHCM 7 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 ©AAHCM 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 9 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. 13 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 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 Address patients without visits Must be based on face to face encounter with provider (physician, NP, or PA) Must be documented in medical record Requires monitor, evaluate, assess, or treat At least annually Highest level of specificity (training is critical) 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