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Care Management for HighCost Beneficiaries CMHCB Demonstration

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Title: Care Management for HighCost Beneficiaries CMHCB Demonstration


1
Lexus Hybrid
2
  • Long Term Care Integration Project
  • San Diego
  • Personal Visiting Physician Delivery System
  • the
  • Care Management
  • for High Cost Beneficiaries Demonstration
  • Presented by
  • Joseph W. Spooner, MD, MBA
  • SVP Outcomes, Academic Government Relations

3
  • Presentation
  • Components of the Personal Visiting Physician
    Delivery System
  • Discussion of the Care Management for High Cost
    Beneficiaries (CMHCB) CMS Demonstration

4
  • 2005 CBO Report
  • High Cost Medicare Beneficiaries
  • Top 25
  • Top 5 43 total expenditures
  • Av. annual group cost 64,000
  • Av. annual cost 7,300
  • High vs. Low Cost Beneficiary Profile
  • MD visits 11 vs. 6 per year
  • Hospital admit 75 vs. 2.5
  • SNF admit 16 vs. 0.1
  • ER visit 63 vs. 14
  • High Cost Trend
  • 14 die annually, 40 in 4 years
  • 50 survivors were high cost for 4 years

5
Care Level Management
  • Patient Care Stratification

Single Disease
Healthy
Multi Disease End of Life Hospice
 
2
100
Figure 5
6
THE STEP DOWN PRINCIPLE
Care Level Management
  • ICU
  • M/S LEVEL OF CARE
  • SNF
  • HOME
  • SPECIALIST
  • CCRN MD LEVEL OF PROVIDER
  • RN RN
  • LVN NON SKILLED

 
Figure 6
7
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8
  • Components of the Personal Visiting Physician
    Delivery System
  • 24/7 coverage by board-certified internists,
    family physicians geriatricians
  • Direct cell phone contact
  • Routine maintenance and urgent home
    interventions by the PVP

9
  • Components of the Personal Visiting Physician
    Delivery System
  • Intensive home pharmacy management
  • Intensive on-going education in the home by the
    PVP and by phone by the PCAN
  • Post-hospital follow-up
  • Post-ER follow-up


10
  • Components of the Personal Visiting Physician
    Delivery System
  • Home Hospitalization


11
  • Home Hospitalization
  • In-home physician management of medically stable
    patients with community-acquired, uncomplicated
    pneumonias urinary tract infections cellulitis
    and/or dehydration
  • Patient always given options

12
Home Hospitalization
  • CLM CLINICAL RESULTS
  • 1407 AVOIDED ADMISSIONS
  • 378 HOME HOSPITALIZATIONS
  • FINANCIAL RESULTS
  • ALOS FOR HOME HOSPITALIZATION 4 DAYS
  • AVERAGE COST OF HOSPITAL ADMIT 6,000.00
  • COST OF HOME HOSPITALIZATION 1,190.00
  • NET SAVINGS PER CASE 4,810.00
  • TOTAL SAVINGS FOR 378 HOME HOSPITALIZATIONS
    1,818,180.00

13
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14
Care Level Management
  • PCP

PCP OFFICE
Stand By
Referral
SNFist Case Manager
ER MD Hospitalist Case Manager
Rapid Diagnosis Rapid Treatment
ER
HOME
SNF
Referral
 
Logistic issue or Uncontrollable
Referral
Out Patient Services
Referral
Unmanageable Event
HOSPITAL
Hospitalist / Case Manager
Figure 13
15
Care Management for High-Cost Beneficiaries
(CMHCB) Demonstration
16
CMHCB DemonstrationBackground
  • Section 721 of the Medicare Modernization Act,
    2003 provided for the Chronic Care Initiative
    Program (CCIP) now known as Medicare Health
    Support (MHS).
  • Became very clear that CCIP was not designed to
    demonstrate the value of physician-based methods
    of managing chronic illness in the elderly

17
CMHCB DemonstrationBackground
  • CCIP was designed specifically for Disease
    Management companies approaches to chronic
    illness
  • The only option given CLM by the Centers for
    Medicare and Medicaid Services (CMS) was to
    contract with a DM company

18
CMHCB DemonstrationBackground
  • Robert Berenson, MD, internist, Urban Institute,
    testimony to the House, Health Subcommittee, May,
    2004 in my opinion it CCIP is insufficient
    for truly addressing chronic care needs in
    Medicare because it lacks a focused physician
    component our emphasis

19
CMHCB DemonstrationSolicitation Components
  • Finally, in October, 2004 CMS released a
    Solicitation for the Care Management for High
    Cost Beneficiaries (CMHCB) Demonstration
  • Solicitation This voluntary demonstration is
    part of an effort to develop and test multiple
    strategies to improve the coordination of
    Medicare services for high-cost FFS
    beneficiaries

20
CMHCB DemonstrationSolicitation Components
  • However, one approach which remains to be
    studied is intensive medical management for
    high-cost beneficiaries with various medical
    conditions to reduce cost as well as improve
    quality of care and quality of life for those
    beneficiaries

21
CMHCB DemonstrationSolicitation Components
  • Eligible organizations 1) physician groups 2)
    hospitals 3) integrated delivery systems. Other
    organizations may apply but only as a part of a
    consortium that includes physician groups,
    hospitals, or integrated delivery systems..

22
CMHCB DemonstrationSolicitation Components
  • Population-based study, with Intervention Group
    and Control Group
  • Risk-based Awardee has to produce at least 5
    net savings to CMS in 3 years or must return all
    administrative fees paid the awardee not fees
    paid for actual physician visits/services

23
CMHCB DemonstrationAwardees, July 1, 2005
  • ACCENT - Consortium of physician clinics in
    Oregon Washington, Health Hero Network (home
    monitoring technology company), and American
    Medical Group Association
  • Care Level Management- 24/7 physician home
    visiting physician program.

24
CMHCB DemonstrationAwardees, July 1, 2005
  • Mass General Hospital/Mass General Physicians
    Organization
  • Montefiore Medical Center, Bronx, NY
  • RMS DM, LLC renal disease mgmt org., LI, NY
  • Texas Senior Trails -Consortium of Texas Tech
    Univ. Health Sciences Center, Texas Tech
    Physician Associates

25
CMHCB DemonstrationCLM Implementation
  • Began enrolling beneficiaries October, 2005
  • Intervention Group 15,000 high-cost benies in
    California, Texas, and Florida. Approx. 13,000 to
    be enrolled in CA.
  • Approximately 6,000 in Control Group
  • Established CLM Enrollment Center in Phoenix, AZ.

26
CMHCB DemonstrationImplementation
  • Expanded Networks
  • Physicians 17 to 91 (74 new hires)
  • Overall Staff Increase -- gt350
  • Geographic Footprint -- Increased area gt 25
    times
  • Engaged Independent External Experts
  • Milliman, Incactuarial support
  • RAND---ACOVE measurement tool
  • Sullivan / Luallin satisfaction survey

27
California Geographic Reach for Care Levels CMS
Demonstration
28
California Geographic Reach for Kaiser Permanente
29
CMHCB DemonstrationCLM Implementation
  • Expanded Existing Services and Systems
  • CLM University / Academic Programs / Residency
    Programs
  • Enrollment Center
  • Expanded Existing and Added New Offices
  • Community Relations Managers
  • Augmented Information Systems
  • EMR Seibel system in Enrollment Center

30
CMHCB DemonstrationChallenges
  • Competing BIPA Congestive Heart Failure DM
    Demonstration in CA by PacifiCare/Allere
    eliminated thousands of CHF beneficiaries from
    initial Intervention Control Group
  • February, 2006 PacifiCare terminated BIPA demo
    10 months early due to lack of interest by
    beneficiaries
  • On refresh of population, we hope to gain access
    to these beneficiaries

31
CMHCB DemonstrationChallenges
  • Ultra fast build-up of systems and personnel
    infrastructure
  • Overcoming some beneficiaries fear of fraud
    against elders were we the real deal?
  • Developing effective ways to convince primary
    care physicians that we supplement, not supplant,
    their care

32
Summary
  • We believe that CLMs CMHCB 3-year Demonstration
    will be able to validate the effectiveness and
    efficiency of physicians regularly visiting the
    frail elderly in their homes, as well as other
    facilities as necessary.
  • We also believe that this Demonstration, will
    make the public, media and political players more
    aware of the unique advantages of providing care
    in the home to chronically ill high cost patients.

33
Thank you.
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