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MediCaring – Enabling Frail Elders to Live Meaningfully and

Comfortably at a Sustainable Cost

June 25, 2014Joanne Lynn, MD, MA, MS

Director, Center for Elder Care and Advanced IllnessJoanne.Lynn@Altarum.org

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By permission of Johnny Hart and Creators Syndicate, Inc.

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Single Classic “Terminal” Disease

Onset incurable disease Often a few years, but decline usually over a few months

Func

tion

Time

Death

Mostly cancer

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Begin to use hospital often, self-care becomes difficult

Func

tion

Time

Death

Long term limitations with intermittent serious episodes

Mostly heart and lung failure

2-5 years, but death often seems “sudden

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Onset could be deficits in ADL, speech, ambulation

Func

tion

Time

Death

Prolonged dwindling

Mostly frailty and dementia

Quite variable, up to 6-8 years

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1. Customize services for frail elderly 2. Generate care plans3. Geriatricize medical care4. Include long-term services and supports5. Develop local monitoring and management6. Fund added services and management from medical

efficiency

Channel the public’s fear and frustration into the will to change

MediCaring™! Key Components of Reform

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Identification of Frail Elders in Need of MediCaring™

AND one of the following:>1 ADL deficit or

Requires constant supervision OR Expected to meet criteria in 1-2Y

Unless Opt Out

Frail ElderlyWant a sensible care system

Age >65

Age >80

With Opt In

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Discuss

Useful category? Not setting, specific diagnosis, payment mode? Tolerable category? Better language?

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PERSON-CENTEREDCARE PLAN

COMPREHENSIVEEVALUATION

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What’s essential in developing a good care plan?

Thorough understanding of the person/family situation Reasonable prognostication Availability and acceptability of services Effective communication, sensitive but honest Person (and family) priorities, fears and hopes Involvement of all key service providers Discussion/negotiation/compromise/accord Time and event triggers for re-evaluating Document

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What about an "Advance Care Plan?"

Lifespan and dying are naturally part of the care plan

Include emergency plans like POLST

Designate surrogate decision-maker(s)

Document along with care plan

Update and feedback as for other plan elements

For frail elders, no advance care plan = serious error

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Discuss…

Process for adequate understanding and negotiation of care plan – and revisions, and feedback?

Why so strongly resisted, or inadequate versions accepted? Why no demand?

How can care plans be used in system management?

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Geriatricize Medical Care

Continuity Reliability, 24/7 to the end of life Enable self-management around disabilities Respect and include family and other caregivers Reduce the burden of medical care Move services to the home Prevent falls, wrong actions Enhance relationships, activities, meaningfulness Be steadfast with dementia

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2009 Health and Social Expenditures as Percentages of GDP

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Ratio of Social to Health Service Expenditures Using 2009 Data

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Disaster for the Frail Elderly: A Root Cause

Social Services• Funded as safety net• Under-measured• Many programs, many

gaps

Medical Services• Open-ended funding• Inappropriate

“standard” goals• Dysfx quality measures

Inappropriate

Unreliable

Unmanaged

Wasteful “care”

No Integrator

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Discuss…

How to scale up good practices? How to see services integrated across supports, medical

treatments, housing, etc.? Does overspending on health care provide an

opportunity?

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Local level– not just state/federal (and provider)

Frail elders are tied to where they live Local leadership responds to geography, history,

leadership Localities can engender and use off-budget or less

expensive services Localities can address employer issues for caregivers Local management is politically plausible now

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What will a local manager need?

Tools for monitoring – data, metrics

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Cincinnati Area Readmissions Over Time

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Patient- Reported Pursuit of GoalsUneven interval, multiple reporting strategies

Date Score7/1/2012 28/3/2012 48/8/2012 310/12/2012 12/28/2013 43/2/2013 35/23/2013 06/1/2013 36/30/2013 4

7/1/1

2

7/25/1

2

8/18/1

2

9/11/1

2

10/5/1

2

10/29/1

2

11/22/1

2

12/16/1

2

1/9/1

3

2/2/1

3

2/26/1

3

3/22/1

3

4/15/1

3

5/9/1

3

6/2/1

3

6/26/1

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0.5

1

1.5

2

2.5

3

3.5

4

4.5score ideal scoreIdeal Score = 4

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What will a local manager need?

Tools for monitoring – data, metrics Skills in coalition-building and governance Visibility, value to local residents Funding – perhaps shared savings Some authority to speak out, cajole, create incentives

and costs of various sorts A commitment to efficiency as well as quality

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Discuss…

Is service delivery for frail elders best done with a strong component of local, geographic management?

What existing entities could grow into this function? What are the political and other practical

considerations? Could willing communities be allowed to learn?

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Frail Elderly People Need Some New Spending…

$ Housing$ Nutrition$ Personal Care$ Caregiver training, respite, income$ New drugs and other treatments

Where will it come from?

$$$

$$$$$$

$$$

$$$

$$$

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My Mother’s Broken Back

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“The Cost of a Collapsed Vertebra in Medicare”

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A Winning Possibility: MediCaring ACOs…

Four geographic communities - 15,000 frail elders as steady caseload

Conservative estimates of potential savings from published literature on better care models for frail elders

Yields $23 million ROI in first 3 years

Net Savings for CMS Beneficiaries Yr 1 Yr 2 Yr 3 3-Yr Before Deducting In-Kind Costs -$2,449,889 $10,245,353 $19,567,328 $27,362,791 After Deducting In-Kind Costs -$3,478,025 $8,463,101 $17,629,209 $22,614,284

For more on financial estimates, see http://medicaring.org/2013/08/20/medicaring4life/

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Average LTAC, SNF, IRF costs per member per month (PMPM)

$122$99

$67$53

$42

Top quartile National average Medicare Advantage average

naviHealth average naviHealth Best

naviHealth Post-Acute Value PropositionVariation and overutilization of post-acute services offer significant opportunity to create better and more efficient outcomes

~50% less than FFS national average

(Fee-for-service Medicare)

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Post-acute utilization, in the fee-for-service Medicare population, is substantially higher than other managed models

BPCI opportunity can introduce coordinated data driven care to an otherwise fragmented andmisaligned area of healthcare

So – ~ half of expenditures saved – of 23% - if it costs half, 5% of Medicare is non-service profits

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Some options… Some ways to capture savings to invest in under-

supplied supportive services – ACO, bundled payment, managed care, Pay4Success

Create medical savings – Much more advance care planning and arrangements that let

more very sick, or very old people live the end of life on-island Reduce medical transport Reduce low value tests and consultations and “rehab” Move some services to the home

Monitor and manage services – supportive and medical Consider local social insurance for long-term care costs

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Discuss…

Can we put it all together? Can we have reliable services to support comfort and

meaningful lives in the period of frailty, at an affordable cost, in another way?

What is appealing and what is appalling (or at least, implausible or underdeveloped!) in the MediCaring approach?

What people and organizations might be supportive or hostile?

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1. Customize services for frail elderly 2. Generate care plans3. Geriatricize medical care4. Include long-term services and supports5. Develop local monitoring and management6. Fund added services and management from medical

efficiency

Channel the public’s fear and frustration into the will to change

MediCaring™! Key Components of Reform

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We can have what we want and needWhen we are old and frail

But only if we deliberately build that future!