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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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9

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 rshumacher@optum.com

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