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The Third National Medicaid Congress
Strategies for Navigating the
New Medicaid
Sam Willcoxon
CEO
Fidelis SeniorCare
Challenge
The Challenge:
 How to manage the growing cost and improve the quality of care in the most
expensive Medicare beneficiaries: the most functionally impaired frail elders.
The Demographics:
 The institutionalized frail elder comprise a significant portion of the Medicare
population. Today:
– 3.5% of the Medicare population resides in a nursing facility - 1.6 million
beneficiaries
– 1.5% of the population resides in assisted living - 800 thousand beneficiaries
– Up to 3 million beneficiaries with similar levels of impairment still reside in the
community many receiving inadequate care.
 The nursing facility population has a life expectancy of 18 – 24 months, and
consumes the most significant resources
– Medicare annual expenditures of $30 Billion
– Medicaid annual expenditures of $65 Billion
 The frailest-of-the-frail, those 85 years old and older, will double in population from
4.7 million today to 9.6 million by 2030.
The Thesis:
 Highly focused care, applied to discrete segments of the Medicare beneficiary
population, dramatically improves both the cost and quality of care
Solution


Change the paradigm. Encourage the growth and adoption of
companies such as Fidelis, that;
– Manage Medicare resources on a risk basis; thus reducing
Medicare expenditures
– “Marry” expert physicians practicing evidence based medicine to a
care management model; thus improving the quality of care.
– Partner with those physicians to deliver demonstrably better care at
lower cost to high risk population.
Allow companies that prove this paradigm to expand into the
community, overlay comparable clinical models on institutional status
members living outside of traditional nursing facilities, thus preventing
migration of these individuals into increasingly more expensive sites of
residence and service.
Outcomes
The typical Fidelis Member reflects population of
institutionalized Medicare beneficiaries

Median age 82
–
–

9% < 65 years old
Low income (97.2% Medicaid)
Multiple overlapping chronic diseases
–
–
84% of our members have 5 or more active chronic disease conditions
Of these; the most common chronic disease conditions






–
Activity of Daily Living (ADL) Impairments:


–
72% have Dementia
54% suffer from major psychiatric disorder such as Depression
39% have had Strokes
39% have had Diabetes
38% have had a previous Heart Attack and 34% suffer from Congestive Heart Failure
26% have chronic respiratory disease such as COPD or Asthma
91.3% impaired in more than 2 ADL’s
33.3% impaired in more than 4 ADL’s
Average Medicare risk score of 2.1
Fidelis Model at a Glance
 A Medicare Advantage Special Needs Plan that:
– Partners with expert geriatricians within a market
– Focuses on detailed, individualized care planning for each
patient which includes family members, physicians, facility
team and Fidelis
– Ensures a minimum metric of 5 team visits (physician,
extender, Fidelis) per patient, per month. Members are seen
more often (frequently daily) as warranted by their clinical
need.
– Treats change of condition in the member’s home, the
nursing facility, where clinically appropriate
– Frequently communicates with family members
Fidelis Care Model Comparison
The Fidelis Nursing Facility (NF) experience demonstrates the results of superior
clinical care
2.
3.
4.
1.
2.
3.
4.
FIDELIS CARE MODEL
Condition deteriorates from baseline;
diagnosed immediately on-site
Stable for several months; gets skilled
services on-site
Aging/progressive deterioration over
time; BUT remains comfortable and
cared for on-site
End-stage disease; receives comfort,
care until death
Long Term Care Facility Resident with
Multiple Chronic Conditions
Clinical Status
1.
USUAL NF CARE MODEL
Lack of early diagnosis and treatment
results in deterioration, eventual
hospitalization
Delirium, confusion from transfer results
in chemical or physical restraints
Inevitable second hospitalization
exacerbates problems (high-tech
medicine has poor risk/benefit ratio)
Accelerated deterioration to end-stage
disease, death
Time
A Snapshot of Fidelis Quality Indicators
# of
Medications
Baseline: various, Medicare FFS data
Lessons & Implications
 Highly focused care applied to discrete
segments of the Medicare beneficiary
population dramatically improve both the cost
and quality of care.
 Solutions, like Fidelis SeniorCare, when more
broadly applied across the continuum, could
have significant impact on Medicare and
Medicaid budgets.
 How?
Fidelis Value to Medicaid
 Today…
– Reduction in Medicare Copayments/Coinsurance
 Skilled Nursing Care – covered 100%
 Primary Care Services – covered 100%
 Transportation Benefit – accompanied transportation as needed
for outside clinical services
 Basket of services – Dental, Vision, Hearing – provides
additional services beyond Medicare and Medicaid
– Clinical Value
 Reduced Hospital stays – reducing copayment amounts
covered by Medicaid
 Reduced Prescription Drug use – less drug interaction, lower
overall costs.
 Overall better quality of life – lower overall service utilization
Medicaid and Fidelis Integration Opportunities
 Today/Tomorrow…
– Capitation for Current Medicare Products
 Medicaid currently covers Coinsurance/Copay for Medicaid recipients
enrolled in Fidelis Medicare product
 Capitation for those services would benefit Medicaid
– Decrease administrative burden of paying claims
– Normalize cost of services for those enrolled in the program
 Support Aging in Place Efforts
– Diversion Programs
 Where waivers exist, Fidelis can be the Medicare alternative for
Medicaid enrollees
– Currently offered in Nursing Facilities and Assisted Living Facilities
– Fully Capitate for All Medicaid Services
 Inclusive of all amounts paid for housing
 Utilize current eligibility criteria
 Allow Fidelis to place the individuals in the housing most appropriate for
their condition,
– Reducing housing costs
– Clinical program ensures higher quality care in the most appropriate setting
Medicaid HMO’s and Fidelis
 Fidelis has significant clinical expertise in Nursing
Facilities
– Those members that are sent to Skilled Nursing Facilities for
short term stays can be managed by Fidelis onsite clinicians
– Pro-active post acute/rehab management through Fidelis
Physicians and team vs. telephonic case management
 Improves outcomes
 Reduces length of stay
 Members Resident in Assisted Living Facilities
– Fidelis provides onsite care
– Willing to accept risk based payments