Strategies for Navigating the New Medicaid

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Strategies for Navigating the New Medicaid
The Third National Medicaid Congress
Sam WillcoxonCEOFidelis SeniorCare
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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

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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.

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Outcomes
The typical Fidelis Member reflects population of
institutionalized Medicare beneficiaries

• Median age 82
• 9 lt 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
• 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
• Activity of Daily Living (ADL) Impairments
• 91.3 impaired in more than 2 ADLs
• 33.3 impaired in more than 4 ADLs
• Average Medicare risk score of 2.1

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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 members home,
  the nursing facility, where clinically
  appropriate
• Frequently communicates with family members

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Fidelis Care Model Comparison
The Fidelis Nursing Facility (NF) experience
demonstrates the results of superior clinical care

• 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

• 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

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A Snapshot of Fidelis Quality Indicators
of Medications
Baseline various, Medicare FFS data
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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?

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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

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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

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Medicaid HMOs 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