ronald j. shumacher, md facp cmd chief medical officer, optum complex population management ©aahcm
TRANSCRIPT
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Evidence for the value of home care medicine:
Medicare AdvantageRonald J. Shumacher, MD FACP CMD
Chief Medical Officer, Optum Complex Population Management
Ronald J Shumacher MD has the following financial relationship to disclose:
Employee of: Optum Services, Inc.
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Disclosures
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An average of 8+ conditions
An average of 10+ medications
Most members have both functional impairment plus chronic medical conditions
Frequent ambulatory visits, emergency room visits (3 plus/ year)
Require an extremely high level of care, attention and time
Do not regularly engage with doctor or look to payer for health support/ management
Disproportionate health care costs within MA patient populations
5% of the population drives50% of the medical
spend
Stanton MW. The High Concentration of U.S. Health Care Expenditures. Research in Action, Issue 19. AHRQ Publication No. 06-0060, June 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/factsheets/costs/expriach/index.html
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Medically complex members frequently present with multiple chronic conditions, associated cognitive issues and psychosocial complications that render them high-risk
Multiple providers and medications produce disjointed, confusing and sometimes contraindicated care plans
Traditional in-office medical care delivery is insufficient — in time and quality — to establish the patient insight and relationship depth that medically complex members uniquely require
Under the current care delivery model, primary provider and specialist practices are not structured or equipped to provide the urgent, 24/7 response proven to be critical in preventing chronic illness escalation and exacerbation
The accompanying gaps in care — along with a common lack of patient adherence — leave members vulnerable to frequent escalations and exacerbation; these, in turn, devolve into excessive medical crises requiring ER visits, acute hospitalizations, readmissions and unnecessary medications
Underperformance of traditional managed care approach
Need precision-targeted solution
• Bridges gaps in care after discharge from hospital
• Readmission rates typically >17% for Medicare Advantage
• Readmissions often result from poor communication, non-compliance, etc.
• Transition program can reduce avoidable hospital readmissions by 30 – 45%
Post-Acute Transitions
• Use predictive modeling to identify highest risk patients
• Longitudinal care and care management improves self-care and better manages triggers
• Care is coordinated with PCP
• Prevents avoidable ER visits and hospitalizations by 50 – 65%
Chronic Care Management
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Reduces overall health costs, including reduced hospitalization/re-hospitalization rates, emergency department (ED) visits and costs associated with end of life
Supports accurate diagnosis resulting in appropriate coding risk adjusted payments and MA plan revenue
Supports quality metrics, including Star ratings and HEDIS
Guides patients into right care at right time
Improves quality of life and satisfaction
Decreases caregiver burden while retaining involvement
Enables home situation and safety assessment
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The promise of home care medicine
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A house call program with 91 clients in a Nevada Social HMO produced a 62% reduction in hospital days and savings of $439,825 per year in acute, skilled and sub-acute days, with net savings of $261,2251
A randomized controlled trial explored in-home, post-discharge care for the elderly showed 65% reduction in hospital days and 50% cost savings2
One study of post-hospital care for high-risk CHF patients produced 50% reduction in rehospitalization when in-home, multidisciplinary program implemented3
Literature review: evidence for home care medicine
1 Phillips SL, et al. Chronic home care: a health plan’s experience. Annals LTC. 2004. 2 Naylor MD, et al. Comprehensive discharge planning and home follow-up of hospitalized elders.
JAMA. 1999;281:613-620.3 Rich MW, et al. A multidisciplinary intervention to prevent the readmission of elderly patients
with congestive heart failure. N Engl J Med 1995;333:1190-1195.4 Costs and cost-effectiveness of home medical care. AAHCM. Accessed online: http://
go.nationalpartnership.org/site/DocServer/Costs_and_Cost_effectiveness_of_home_medical_care.pdf?docID=6850
At $1,500 per ED visit, the cost of 10 house calls can be offset by preventing one
ED visit. 4
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1 2 3 4 5 6 7 Seven month
average
Combined next 12 months
1,6231,690
1,4651,567
1,4031,529
1,975
1,608
633715
633 677
354
630502
593 563
Acute admits/1,000 comparison
Control Group Home-based Medicine Group
Months
Home care medicine reduces inpatient admissions
Optum CarePlus outcomes study on dual skilled nursing population’s inpatient admissions compared to actuarial equivalent matched cohort (n=15,000 members), Jan. 2008 – Jul. 2008. Arizona health plan. Data compiled by Optum Data Analytics.
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Different markets, same results
1 2 3 4 5 6 7 8 Combined
2,872
3,277
2,607 2,574 2,574
3,000
2,500
3,426
2,696
1,271 1,177
914
627771 858
580
1,242
973
Baseline Admits/1,000 Program Admits/1,000
Markets
Optum CarePlus outcomes study for high-risk Medicare Advantage health plan members (n=20,000 members), Jan. 2007– Dec. 2008. Florida Medicare Advantage health plan. Data compiled by Optum Data Analytics.
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Home care medicine implementation: results of first six months
Admits/1000 Skilled days/1000 ED/10000
500
1000
1500
2000
2500
3000
3500
1476
2865
1660
497
746
994
Baseline First 6 months post-implementation (Year 1)Optum CarePlus outcomes study: cost of high-risk Medicare Advantage members (2+ chronic conditions and 1+ hospital admission) during the first six months of the program inception compared to the previous six months (n=35,000 members), Jan. 2009 – Dec. 2010. Alabama Medicare Advantage health plan. Data compiled by Optum Data Analytics.
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PMPM Cost Admits/1000
2,792
2,442
1,694
1,141
Baseline Year one
One-year MA plan performance: reduction from baseline
Optum CarePlus outcomes study: cost of high-risk Medicaid members (2+ chronic conditions and 2+ inpatient admissions) claims during the CarePlus program (n=20,000 members), Jan. 2008 – Dec. 2009. Tennessee health plan. Data compiled by Optum Data Analytics.
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Reduction in medical costs approaching end of life
Month 1Month 2Month 3Month 4Month 5Month 6
$4,000
$–
$8,000
$12,000
$16,000
$20,000
$2,042
$2,662
$3,826$4,323
$2,491
$2,172
$5,316
$3,142
$2,691$3,400 $3,391
$5,412
$3,845
$7,449
$4,665
$11,037
$10,104
$17,559
All Medicare
Medicare High Risk
Home-care managed
Outcomes study: cost of members during the last six months of life measured against both an actuarial equivalent cohort and the average medicare advantage costs in the Michigan and Alabama Medicare Advantage health plans (n=70,000 members; 35,000 members), Jan. 2010 – Aug. 2010. Data compiled by Optum Data Analytics.
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In-home visits have huge impact downstream on HEDIS/Stars and quality outcomes
Screening, tests, vaccinations, management of chronic conditions can all be influenced by home-based provider
Robust outcome studies not performed but many MA plans leveraging home provider visits to augment Star strategy
HEDIS/Star improvement and home care medicine
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Patients highly satisfied with in-home medical care/perception of improved quality of life
High levels of provider satisfaction with home care delivery models
Enhances reputation for caring and compassion
Medicare Advantage Star ratings driven by CAHPS, HEDIS and HOS patient satisfaction survey measures
Satisfaction with home care medicine
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Address patients without visits
Must be based on face to face encounter with provider (physician, NP, or PA)
Must be documented in medical record
Requires monitor, evaluate, assess, or treat
At least annually
Highest level of specificity (training is critical)
Main reason for visit and coexisting conditions are documented
Much more effective than network based physician coding
Risk Adjustment/HCC and Home care Medicine
Thank youRonald J Shumacher, MD FACP CMD
Chief Medical Officer, Optum Complex Population Management [email protected]
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