Voluntary Care Management in Private-fee-for-service Medicare

1

• Voluntary Care Management in Private-fee-for-servi
  ce Medicare

Patricia R. Salber, MD, MBA PRS Strategic Health
Care Consulting
2
Medicare basics

• Federal health insurance for people 65 and older,
  under 65 with disability, ESRD
• Part A Hospital benefits
• Part B Physician benefits
• Part C Medicare Advantage plans
• Part D Prescription drug plans

3
Part C Medicare Advantage Plans

• Medicare Advantage plan members are still
  enrolled in Medicare.
• The only difference is that providers payments
  come from a private insurance company rather than
  Medicare and a Supplement carrier.
• Includes HMOs, PPOs, PSOs, Medicare MSAs,
  Private-fee-for-service (PFFS).

4
Part C Medicare Advantage Plans Payment

• Plans are paid based on the CMS/Medicare Risk
  Adjusted Reimbursement Model
• It is called the CMS-HCC (Hierarchical Condition
  Category) model
• Payment is based on the severity of the medical
  condition of the member as documented by
  diagnoses submitted on claims and encounters from
  qualifying claims generated by face-to-face
  visits during the prior year
• Diagnoses must be re-documented every year

5
Part C Medicare Advantage Plans Payment

• Some, but not all HCC groups are additive
• Some conditions, like diabetes, have a hierarchy
  of severity
• HCC19 250.00 Diabetes with no complications
• HCC18 250.5x Diabetes w/ ophthalmic
  manifestations
• HCC17 250.1-3x Diabetes w/ acute complications
• HCC16 250.6x Diabetes w/ neurologic
  manifestations
• HCC15 250.4x Diabetes w/ renal or peripheral
  circulatory manifestations
• When this is the case, only the highest HCC is
  counted

6
Part C PFFS Plans

• PFFS includes the benefits of Parts A and B, plus
  additional benefits.
• Replaces the need for Medicare Supplements
• Eliminates some member out-of-pocket costs under
  Medicare A and B.
• Offers more freedom of choice than more managed
  health plans
• Members may go to any eligible doctor or hospital
  anywhere in the U.S. that is willing to provide
  care and accept Medicare PFFS terms and
  conditions.

7
Medicare Private Fee-For-Service (PFFS)

• Provides an option for Medicare beneficiaries
  who
• Dont want limitations on choice of doctors and
  hospitals
• Want supplemental coverage beyond traditional
  Medicare, but dont want or cant afford to pay
  for a Medigap plan
• Want an alternative to traditional Medicare, but
  HMO/PPO not available where they live

8
Medicare Private Fee-For-Service (PFFS)

• PFFS plans have become an increasingly viable
  alternative to traditional Medicare A B with
  Medicare Supplements.
• A strong middle-ground between HMOs and
  Supplement plans.
• Provide a Medicare health plan alternative to
  beneficiaries in rural areas or smaller
  metropolitan markets where none existed before.

9
Value Propositions

• Private Fee-for-Service
• Offer the best of both worlds!

HMOs
Medicare Supplements
Private-fee-for-service
Freedom to Choose Your own provider
Monthly Premium Savings
10
PFFS recently drawing fire
From Todays Wall Street Journal
11
PFFS recently drawing fire
From Yesterdays New York Times
Methods Used by Insurers Are Questioned By
Robert Pear Published May 7, 2007 WASHINGTON,
May 6 Insurance companies have used improper
hard-sell tactics to persuade Medicare recipients
to sign up for private health plans that cost the
government far more than the traditional Medicare
program, federal and state officials and consumer
advocates say.
12
Todays Options is the PFFS product of

• 2.8 billion total assets
• More than 180,000 covered lives in Todays
  Options PFFS product
• Enrollment growing at a rate of 4-5,000 members
  per week

13
UAFC has a comprehensive portfolio of senior
market products
HMO plans Private Fee-for-Service Special Needs Plans Individual and Group
Prescription Drug Plans Individual and Group
Medicare Supplement / Select Senior Acute Care and Dental Individual and Group
3rd Party Administration Medicare Supplement, Long Term Care, Medicare Advantage Part D ElderCare (non-risk)
Medicare Advantage
Medicare Part D
Senior Market Health Insurance
Senior Administrative Services
14
PFFS Todays Options Value Propositions

• Monthly premium less costly than Original
  Medicare plus Medicare Supplements.
• Balance billing prohibited
• Low co-payments
• Covers all services under Medicare Part A and B.
• Offers additional benefits (i.e. routine exams in
  both plans) beyond what Medicare Parts A and B
  provide
• Most claims can be handled between plan and
  providers, so there is almost no paperwork for
  member to complete.

15
Todays Option Differentiator

• Todays Options Health Wellness Services
• A voluntary care management program
• Provides a range of services, including disease
  management and case management

16
Todays Options Health Wellness Services

• Program goal
• to have meaningful impact on members in need of
  complex case management disease management
  focused on COPD/CAD/HF/Diabetes and unmanaged,
  yet high risk people (frequent hospitalizations,
  ER visits, poly-pharmacy etc.)

17
Components of the voluntary care management
program

• A 24/7 nurse line to assist members with their
  healthcare concerns and needs.
• Post-hospitalization Welcome Home calls
• Eldercare Services
• Complex case management and care coordination
• Chronic condition management
• Pharmacy support for individuals with a linked
  Part D benefit

18
Implementation Challenges

• Rapid growth
• Increased from 20 K at the end of 2006 to 170 K
  members currently
• Geographic dispersion
• 35 states and 2600 counties
• No provider networks
• Limited ability to get providers attention
• Many providers
• Few members/provider
• FFS payment

19
Implementation Challenges

• Many rural members
• Limited experience with care management processes
• Limited data
• Many new members with no prior claims
• No lab data
• Limited pharmacy data
• Existing internal care management program
  comprehensive, but not at the same scale as new
  membership
• Need to ramp up rapidly to accommodate explosive
  plan growth

20
The TO approach

• Divide the work between three different programs
• Internal program 55,000 members in 13 states
• Vendor A 83,000 members in 18 states
• Vendor B 32,000 members in 4 states
• Three programs will be compared to determine
  which ones bring the most value (quality/cost)
• Very rapid implementation
• Vendor selection in late Jan./early Feb
• First health coaching calls with members by end
  of February

21
Jump start the program with outbound telephonic
HRAs

• Used HCC data to prioritize the outreach
• Members with 2 or more of the big four chronic
  condition HCC codes are being called first
• By end of January, there were 100,488 members
• Telephonic HRAs on 26,829
• Mailed HRAs to 34,916 with 9,214 returned
• Currently, about 20 of the population have
  completed HRAs

22
Jump start the program with outbound telephonic
HRAs

• Secure electronic transfer of HRA results to
  vendors and the internal program
• The programs used these results to identify
  members with the following
• Acute or immediate needs that would benefit from
  complex case management/care coordination
• Chronic illnesses that could benefit from health
  coaching

23
Developed a leadership team and sub-teams to get
the work done quickly

• Weekly telephonic implementation lead call to
  review progress and problem solve barriers
• Communications team to customize member materials
  and address web portal issues
• Data team to rapidly format data feeds needed to
  support the program
• Eligibility, medical claims, hospital
  pre-notification, pharmacy (when available), and
  MOR files (ICD9 codes that track to HCCs)

24
Incentives and accountability

• Initial payment is PMPM, but working towards a
  risk arrangement
• Initially required daily reporting of touches,
  now weekly
• Allowed rapid identification of problems
• Monthly impact reports to begin next month
• Full clinical and utilization reporting once
  claims begin to be populated (6-8 months after
  implementation)

25
Accomplishments to date

• Varies by program
• Vendor A has completed a general awareness mail
  campaign and several rounds of automatic outbound
  telephone campaigns. They have also completed
  more than 5,500 outbound health coaching calls
  (6 of the population) and more than 500
  follow-up calls

26
Accomplishments to date

• Vendor B has completed more than 200 complex case
  management calls
• The internal program has completed 2,000 health
  coaching calls, 1200 care management calls, and
  55 onsite assessments
• Feedback from front line coaching staff is that
  members are pleased with the program formal
  member satisfaction surveys are planned

27
Lessons learned

• Early health assessments are an effective means
  of getting the program started while waiting for
  claims databases to get populated
• Frequent communication, including data reporting,
  between plan and vendors key to rapid
  implementation
• Both vendors and plan must be accountable for
  addressing identified issues in a timely fashion
  this is not implementation as usual

28
What is on the horizon?

• Assessment of enrollment to determine high volume
  clusters of members
• Outreach to high volume providers
• Complete physician engagement strategy and
  roll-out plan
• Partnerships with community-based programs
• Roll-out of member web portals
• Continual evaluation of results to make the
  programs more efficient and effective
• Moving towards a risk-share arrangement

29

• Questions