Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

UPMC for YouCommunity Team/High Risk Care Management

UPMC for You members with high costs, multiple admissions, complex medical conditions related to behavioral health and psychosocial conditions receive intensive case management in the

home/community settings.

OBJECTIVES

Engage members and providers in creation of

comprehensive care and wellness plan

Improve member’s health status, decrease

readmissions and reduce gaps in care

APPROACH

Integrated team approach to best serve individual, based on their unique

needs

Federally funded evaluation underway,

which includes technology tools

Social Worker

Nurse

Pharmacist

PCP

Support individual health care choices and use of telehealth and web-based health tools

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

28

Exec. Level

Mgmt. Level

Tactical Level

Claims Detail

Horizon NJ Health (HNJH)-Medicaid Population Health Management

▪ Health System responsible for all claims for Medicaid members attributed to PCPs practicing in designated region.

Attributed

membership

▪ Target calculated by applying an MCR target to state premium for a specific member cohort.

▪ MCR target will reflect the historical underlying claims experience of the attributed population.Medical

cost target

▪ Upside-downside risk arrangement ensues after first year of contract. Health System receives payments for favorable cost containment performance and is at financial risk for lack of care/utilization coordination.

– Losses initially capped at % of total revenue.

Risk model

1

2

3

Insightful, functional and

transparent reporting

This Document is Proprietary and Confidential – Do Not Print or Distribute Without Permission

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

32 | DATE | PRESENTED BY:

Pharmacy Innovation: Pharmacy Care Management

Care Management

Pharmacists

Member Focusand Engagement

Multidisciplinary Team Approach

Pharmaceutical Care Coordination

Medication Optimization

• Leading efforts to impact the opioid epidemic, the team identified high-risk members and developed individualized opioid use reduction interventions with the following preliminary results in this member group:

• 49% decrease in inpatient admissions• 4% reduction in readmission rates• 67% increase in physical therapy utilization• 18% increase in behavioral health utilization

• The team also implemented a hepatitis C treatment protocol in 2018, leading to the following cost-avoidance and savings:

• $100K from four self-resolving members not requiring treatment per protocol

• Up to $200K in lifetime medical cost-avoidance per successful treatment

• General savings attributed to pharmacist care managed members in 2018 include:

• $139K in decreased medical costs (42.5% reduction in PMPM expense)

• $69K in decreased Inpatient costs• $12K in reduced Emergency Department costs• $58K in other medical claim costs

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Aetna: Trauma-Informed Transformation

O D

Step 1: Initiate collaborative partnership with the National Council for Behavioral Health Aetna’s Medicaid Division trauma-informed approach is

underscored by the 4 R’s: Realizes that trauma is universal, Recognizes how trauma affects individuals seeking care, Respondsby implementing trauma-informed care best practices, Resistscausing additional trauma

Step 2: Train corporate staff in the foundations of trauma-informed care

practice

Step 3: Assess gaps and develop workgroups

Step 5: Replicate corporate process in LA and WV health plans with addition of provider

rollout

Step 4: Collect data and metrics

Step 6: Expand efforts to all health plans, continue working towards transformation

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

391Effects of a pregnancy management program on birth outcomes in managed Medicaid. Mary V. Mason, Amy Poole-Yaeger, Brad Lucas, Cathie R. Krueger, Tamim Ahmed, Ian Duncan Manag Care. 2011 Apr; 20(4): 39–46.

31%20%

8%

<2500g <1500g <1000g

Data confirm that the award-winning

Start Smart for Your Baby® program has a large impact on decreasing the

number of low birth weight babies.1

Confidential and Proprietary Information

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Transitioning to Safe and

High-Quality Community Care

Caregiver Supports

and Benefits

Targeted benefit packages

for caregivers

▪ Counseling/therapy services

▪ Health and nutrition coaching

▪ Preventive vaccinations

▪ Respite: In-home and out-of-home

(vacation for caregiver)

▪ Burnout prevention

Workforce Development

Initiatives focused on increasing

the workforce

▪ Established scholarship program for

CNAs to expand available workforce

and address future availability of

qualified frontline healthcare workers

▪ In-person/online education with

incentive payments & certification

training for specialty providers to

enhance quality of care delivery

Across all plans, 94-100% of nursing

facility members transitioned to home and

community-based services (HCBS) and remain in

community for more than 90 days

100% of HCBS members assessed for fall risk

This is What Going

Beyond Health Care

Looks Like

satisfactionrate of service

coordination

program

loweroverall inpatient

admission rate

reductionin nursing

facility

utilization

98%

These metrics are gathered

from WellCare’s experience

from 2015-2017.

31%

25%

94% 100%

100%

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Source: Institute for Medicaid Innovation. 2019 Annual Medicaid MCO Survey

Housing + Health Delivers Improved Well-Being

56

myConnections Overview

• UnitedHealthcare is seeing promising results for a targeted subset of homeless individuals.

• Intensive, multi-disciplined engagement along with stable housing are positively impacting outcomes, including ER and Inpatient utilization.

• Outcomes to date:

• 55% decrease in inpatient admits

• 67% decreased in inpatient days

• 33-43% decrease in ER visits

Annual Medicaid MCO Survey Subcommittee

Chair: Sayanti Saha, PhD, MBAHorizon Blue Cross Blue Shield of New Jersey

Tracy Altman University of Utah Health PlansScott Brunner Aetna MedicaidPoppy Coleman UPMC for YouKatrina Parrish L.A. Care Health PlanMelissa Palmer CenteneNicole Truhe UnitedHealthcare Community & State