tackling issues for medicaid high-utilizers
DESCRIPTION
Tackling Issues for Medicaid High-Utilizers. Essential Hospitals Engagement Network. October 22, 2013. Our new Name. We’ve rebranded! The National Association of Public Hospitals and Health Systems is now America’s Essential Hospitals . - PowerPoint PPT PresentationTRANSCRIPT
Tackling Issues for Medicaid High-Utilizers
Essential Hospitals Engagement Network
October 22, 2013
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OUR NEW NAME
We’ve rebranded! The National Association of Public Hospitals and Health Systems is now America’s Essential Hospitals. Although we’ve changed our name, our mission is the same: to champion hospitals and health systems that provide the highest quality of service to all by achieving the best health outcomes for every patient, especially those in greatest need. The new name underscores our members’ continuing public commitment and the essential nature of our work to care for the most vulnerable and provide vital community services, such as trauma care and disaster response.
This is an exciting time for us and our members, as we lean forward into new care models, opportunities and challenges of reform, and quality and safety innovations that often take root in our member systems. Our new website address: www.EssentialHospitals.org
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CHAT FEATURE
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RAISE YOUR HAND
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AGENDA
• Introduction – Vickie Sears, RN, MS
• Medicaid High Utilizers in the ED / San Francisco Health Plan CareSupport Program - Dr. Maria Raven and Courtney Gray, MSW
• Q & A
• Wrap-up and announcements
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SPEAKER INFORMATION
Dr. Maria RavenAssistant Professor,
Department of Emergency Medicine
UCSF School of Medicine
Courtney Gray, MSWManager, San Francisco
Health Plan Care Support Program
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PROGRESS TOWARDS THE GOAL
Q1-'11 Q2-'11 Q3-'11 Q4-'11 Q1-'12 Q2-'12 Q3-'12 Q4-'12 Q1-'13 Q2-'13
Rate
11.6% 12.0% 12.0% 11.8% 11.4% 11.3% 11.1% 11.9% 11.6% 11.4%
Hospitals Reporting
15 15 15 15 15 15 15 15 15 15
2010 Baseline
0.120260659945776
0.120260659945776
0.120260659945776
0.120260659945776
0.120260659945776
0.120260659945776
0.120260659945776
0.120260659945776
0.120260659945776
0.120260659945776
Goal of ↓20%
0.0962085279566208
0.0962085279566208
0.0962085279566208
0.0962085279566208
0.0962085279566208
0.0962085279566208
0.0962085279566208
0.0962085279566208
0.0962085279566208
0.0962085279566208
9%
10%
11%
12%
13% 11.6% 12.0% 12.0% 11.8%11.4% 11.3% 11.1%
11.9% 11.6% 11.4%
EHEN 30-Day, All-Cause Readmissions (UHC)R
ea
dm
issio
ns %
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PAYER SOURCES
Medicare25%
Medicaid36%
Uninsured18%
Commercial19%
Other3%
America's Essential HospitalsDischarges by Payer, FY 2010 (n=95)
Medicare15%
Medicaid44%
Uninsured29%
Commercial8%
Other4%
EHEN Discharges by Payer, FY 2010 (n=21)
Notes: Other = Workers‘ comp + Prisoner care + etc; Uninsured = Self pay + Charity care + Indigent care programsSource: America's Essential Hospitals FY 2010 Characteristics Survey
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America’s Essential Hospitals WebinarTackling Issues for Medicaid High Utilizers
October 22, 2013
Maria Raven, MD, MPH, MScAssistant Professor of Emergency Medicine
University of California, San Francisco
Courtney Gray, MSWCare Support Manager
San Francisco Health Plan
The Issue
• Small percentage of patients account for disproportionate share of health care use and costs
• Heterogeneous population: wide range of medical, behavioral, and social issues contribute– No “one size fits all” solution
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Approach
• Intervention is intervention• Payer may alter the way it’s carried out• 2 experiences:
– New York State Medicaid funded program within public hospital system: NYC Health and Hospitals Corporation (HHC)
– San Francisco Health Plan: MediCal Health Plan that administers Medicaid coverage for majority of SF safety net including SF General Hospital
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Program 1: Public Hospital SystemHospital to Home (H2H)
• SDOH-sponsored Chronic Illness Demonstration Project
– One of six NY State Department of Health contracts
• Intensive care management and coordination for fee-for-service Medicaid patients at high risk for frequent hospitalization
• August of 2009-March 2012- 540 patients enrolled cumulatively across 3 NYC public hospitals
• Now codified as part of federal Health Homes initiative12
H2H Financial Incentive
• State Medicaid incentivized to finance demonstration projects that could contain costs for very high cost Medicaid enrollees not yet enrolled in managed care
• State supported staff hired by HHC• Bear in mind
– Under fee-for service payment model, fewer admissions=lower revenue for hospital system
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H2H’s Mission• Find and enroll SDOH identified high-risk,
high-cost fee-for-service Medicaid recipients– Predictive modeling
• Goals– Reduce Medicaid expenditures (read: hospital
admissions) – Improve health and social outcomes
• All for $291.50 per patient, per month• “Supportive housing without the housing”*
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*John Billings, Professor of Health Policy and Public Service, Director of Health Policy and Management Program, NYU Wagner
H2H Team Composition/locus
• Staffing Structure:• Social Workers supervise Community Based Care
Managers (1:25 patient ratio), full-time housing coordinator, some dedicated primary care
• Care Managers required to have high school degree and relevant experience
• Offices (available for patient drop-ins) within 3 HHC hospitals, LOTS of field work, support groups
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Frequency of Contact
• State required minimum of 2 contacts per month, one face-to-face per quarter
• In reality, teams had extensive patient contact, much more than required unless unable to find
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Coordinating with Other Providers
• Extensive in-reach (within HHC) and outreach to community organizations
• MOUs in place for data sharing• Consents included multiple organizations• 24 hour on call system• For some, embedded primary care
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Use of Technology
• Predictive modeling in theory helped target the “right” patients from the start• Demo project: risk score adjustments due to
under-enrollment, programs blinded to scores• Patient Alert system: automated email alerts
to Care Managers• Provision of cell phones for patients in need• Program built own database, separate from
the EHR: double data entry at times18
Complexity of very high cost patients:Enrollee #1
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12 mos PRE 12 mos POST 24 mos POST 32 mos POST0
10
20
30
40
50
60
70
80
90
ED visitsAdmissions
Complexity of very high cost patients:Enrollee #1
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12 mos PRE 12 mos POST 24 mos POST 32 mos POST $-
$50,000.00
$100,000.00
$150,000.00
$200,000.00
$250,000.00
$300,000.00
Cost
Average monthly Medicaid costs (program costs included in post period)
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Prior 12 months
First 6 months
Second 6 months
$-
$1,000.00
$2,000.00
$3,000.00
$4,000.00
$5,000.00
$6,000.00
Not homelessHomeless, remained homelessHomeless, housed
San Francisco Health Plan
• 84,000 covered lives• Contracts with multiple medical groups and
the San Francisco safety net– Multiple risk arrangements– 75-80% of San Francisco MediCal population
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Program Adaption: CareSupport
• Absorbed 12,000 SPDs due to mandatory enrollment FY 2011-2012
• Limited experience managing complex patient population
• Feb 2012: program expansion and restructuring Prior: time limited phone based management
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San Francisco Health Plan
• 84,000 covered lives• Contracts with multiple medical groups and
the San Francisco safety net– Multiple risk arrangements– 75-80% of San Francisco MediCal population
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Program Adaption: CareSupport
• Absorbed 12,000 SPDs due to mandatory enrollment FY 2011-2012
• Limited experience managing complex patient population
• Feb 2012: program expansion and restructuring Prior: time limited phone based management
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SFHP CareSupport
• Current Program SFHP members identified based on prior utilization
(some referrals from within SFHP)• ED and inpatient
2 Teams:• Each comprised of 5 BA level Community Coordinators
led by Social Work Supervisor• Each team manages 125-175 members at any given
time (25-35 per coordinator)• Time in program (“dose”) can vary
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CareSupport Activities• Eligible members “vetted” by coordinators
with oversight of social work supervisors• Outreach via phone or in person• In-depth holistic assessment, Care Plan
developed and shared• Day to day management, including:
Connecting with needed resources (appointments, food, phones, clothing, ect)
Ongoing management of chronic issues (unstable housing, substance use, mental health, low-self efficacy, ect.)
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San Francisco Health Plan• Advantage of health plan as program lead
– Comprehensive member data across uncoordinated medical systems
– Access to limited behavioral health information due to carveout; however, this is shifting in January ‘14
– Flexibility to support administrative needs such as hiring and innovative interventions, compared to county health system
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CareSupport Population: Overview
• Since April 2012, 920 referrals have been open • Currently, 159 members enrolled• Demographics
Average Age: 51 years old Gender: 50% Female and 50% Male Housing: 5% homeless and 5% temporarily housed Mental Health: 34% reported being treated for Mental
Health Substance Use: 24% reported being treated for substance
use
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CareSupport Population: Cohorts
• Initial data shows 3 distinct groups Long Term CareSupport: members who are
enrolled more than 6 months Short Term CareSupport: members who are
enrolled 6 months or less Unengaged: members who were never found and
engaged in the program • Unengaged groups appear fundamentally
different than the two engaged cohorts
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00-06 Prior 00-06 Post 00-12 Prior 00-12 Post0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.318
0.129
0.309
0.14
0.310
0.120
0.268
0.087
CARE SUPPORT : INPATIENT ADMITS PMPM
CS Utilization Report: Long Term Care SupportCS Utilization Report: Short Term Care Support
COHORT
INPA
TIEN
T AD
MIT
S PM
PM
PMPM: Per member per month
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00-06 Prior 00-06 Post 00-12 Prior 00-12 Post0
0.1
0.2
0.3
0.4
0.5
0.60.565
0.388
0.559
0.471
0.535
0.352
0.459
0.251
CARE SUPPORT : ER VISITS PMPM
CS Utilization Report: Long Term Care SupportCS Utilization Report: Short Term Care Support
COHORT
ER V
ISIT
S PM
PM
Critical Components for Tackling Issue of Medicaid High Utilizers
• Accept that telephonic management has seen its day• Hire (and train) the right people
– Team members act as champions for program, see themselves as accountable for patient outcomes
• Obtain comprehensive, accurate data in advance– Outreach and evaluation purposes
• Partner with community based organizations, get consent for or agreement to share information
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Critical Components for Tackling Issue of Medicaid High Utilizers
• Understand the financial arrangements and potential ROI ahead of time– Partner with others who have an incentive to
remain or become invested• Experiment with technology
– Cell phones, patient alert system, unified EMRs
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Critical Components for Tackling Issue of Medicaid High Utilizers
• Understand that we don’t know what works– Healthy skepticism: very little data to support
successful program models• Track outcomes that will inform sustainability
and spread– Decide if breaking even with good QOL and clinical
outcomes is “enough”• Especially if targeting a heavy user population,
consider identifying a comparison group35
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Q & A
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THANK YOU FOR ATTENDING
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