Targeting High Cost Medicare Beneficiaries. Thomas J. Foels, MD, MMM Chief Medical Officer, Independent Health March 9, 2012

Transcription

1 Targeting High Cost Medicare Beneficiaries Thomas J. Foels, MD, MMM Chief Medical Officer, Independent Health March 9, 2012

2 Independent Health Regional not-for profit health plan upstate NY 370,000 members 172,000 Commercial 72,000 Medicare Advantage 51,000 Medicaid 74,000 Self-funded Open network PCP (1,200) and SCP (2,500) 2

3 The challenge we face From , the US population is expected to see 73% increase among yr olds and 54% increase > 65 yrs of age. Erie county is home to the nation s 9 th oldest population By 2015, 1 in 4 residents locally will be over age 65 The local aging population is 57% poorer 38% more disabled 65% more at risk and living alone than national averages 3

4 The challenge we face Home bound and isolated Increasing dependencies on care givers Family caregivers increasingly live outside of WNY Increasing dependency: women outlive their decision to stop driving by 10+ years men by 6 years. 4

5 The challenge we face Need for transformational workforce PCP and Geriatrician shortage Lacking team-based care Poorly coordinated care Poorly aligned incentives In Erie county, expecting 30% nursing homes to close Shortage of nurse and aids to provide in-home care Tendency to solve social problems with medical solutions 5

6 What would we hope to achieve? Improve health status Coordinate care: align activates and consultations among practitioners Collaborate: engage community partners and social resources Reduce dependency on hospitals, nursing homes, and long-term care facilities Aging in place maintain frail individuals in their homes longer and safer 6

7 Innovative Programs Care Partners Town Square for the Aged 7

8 Care Partners Established 2008 Eligibility Frail, Medicare Advantage population Single or multiple chronic diseases that impairs member s healtha Program Goals Improve member function, safety Coordination of care Avoidance of unnecessary ER, admission, readmission Linkage to community and financial resources Psycho-social support to member and caregiver Advance directives to align care with member wishes Provides link for member isolated in the community 8

9 Care Partners: Benefits and Services Comprehensive in-home assessment Functional/cognitive status Home safety Pharmacology review 24/7 access to RN provided in the home On-going social service visits/phone communication Coordinates and facilitates visits with PCP Linkage to other health plan programs Facilitates transition to higher level of care when appropriate 9

10 Care Partners: Patient Identification Predictive Modeling Software Delays in identification (claims data) Inaccurately over-identified high functioning members with a single highcost surgical event Direct referrals Identification via longitudinal assessment of patient's declining functional status, cognition, and health by experienced physicians and case managers Provides real-time identification Highly predictive of subsequent decline in clinical status and total cost of care 10

11 Care Partners: Patient Identification Leading Diagnoses History of falls (sentinel diagnosis) Dementia CHF CVA CAD COPD DM 11

12 Care Partners: Outcomes 550 enrolled over 2 years Average length of time in service = 6.9 months Patient satisfaction = 97.5% 12

13 Care partners: Outcomes Baseline Active Participant % Reduction ER visits / 1,000 2,092 1,440-45% Admissions / 1,000 1, % Readmissions (30 days) % Overall PMPM Costs 2,451 2,057-19% Median PMPM Costs 1,686 1,459-16% Pre / Post intervention study; Source: 2010 claims; 12 month retrospectives; Mean Ingenix Risk Score on enrollment 9.5; 13

14 Innovative Programs Care Partners Town Square for the Aged (Opening 2013) 14 14

15 Town Square for the Aging Geriatric Medical Home Provider Practice 15

16 Town Square for the Aged Referrals Multiple provider entry points Geriatric Medical Home PCP, SCP Health plan CM, health coach Referral from one existing community provider to another Direct referrals 16

17 Town Square for the Aged Alzheimer s Assoc Olmstead Center Visually Handicapped Lions Club Belmont Shelter Food Pantry Meals on Wheels Buffalo Wellness Center Dementia Program Guidance WNY Coalition for Service Living Wheelchair / Walker Exchange Geriatric Medical Home Provider Practice Red Cross Emergency Services Erie County Emergency Preparedness Catholic Charities Jewish Family Services Wellness Institute 17

18 Thomas J. Foels, MD, MMM Chief Medical Officer Independent Health (716)