Strategies for Navigating the New MedicaidStrategies for Navigating the New Medicaid

The Third National Medicaid Congress

Sam Willcoxon

CEO

Fidelis SeniorCare

Challenge 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

Solution 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.

Outcomes Outcomes

The typical Fidelis Member reflects population of institutionalized Medicare beneficiaries

Median age 82– 9% < 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 ADL’s 33.3% impaired in more than 4 ADL’s

– Average Medicare risk score of 2.1

Fidelis Model at a GlanceFidelis 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 member’s home, the nursing facility, where clinically appropriate

– Frequently communicates with family members

Fidelis Care Model ComparisonFidelis Care Model Comparison

USUAL NF CARE MODEL1. Lack of early diagnosis and treatment

results in deterioration, eventual hospitalization

2. Delirium, confusion from transfer results in chemical or physical restraints

3. Inevitable second hospitalization exacerbates problems (high-tech medicine has poor risk/benefit ratio)

4. Accelerated deterioration to end-stage disease, death

FIDELIS CARE MODEL1. Condition deteriorates from baseline;

diagnosed immediately on-site2. Stable for several months; gets skilled

services on-site3. Aging/progressive deterioration over

time; BUT remains comfortable and cared for on-site

4. End-stage disease; receives comfort, care until death

Long Term Care Facility Resident with Multiple Chronic Conditions

Cli

nic

al

Sta

tus

Time

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

A Snapshot of Fidelis Quality IndicatorsA Snapshot of Fidelis Quality Indicators

# of Medications

Baseline: various, Medicare FFS data

Lessons & ImplicationsLessons & 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?

Fidelis Value to MedicaidFidelis 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

Medicaid and Fidelis Integration OpportunitiesMedicaid 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

Medicaid HMO’s and FidelisMedicaid HMO’s 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