Organizational Infrastructure

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Organizational Infrastructure

• LTC Quality Summit
• February 20, 2006

John R. Mach, Jr. M.D.
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Multiple Chronic ConditionsDrive Cost and
Opportunity
2 chronic conditions drive 96 Medicare costs
Our data confirm predictability of utilization
Preventable admissions rise steeply with number
of chronic conditions
Quality matters and is measurable
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Multiple Chronic Conditionsand Miscellaneous
Costs
Other medical expenses
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0.3 Other psychoses
Patients Chronic Diseases, in Four Body
Systems 1 Mental Disorders 2 Nervous System 3
Musculoskeletal System 4 Endocrine,
Nutritional, and Metabolic diseases
1.5 Spondylosis, intervertebral disc
2.0 Epilepsy, convulsions
Expenses related to chronic conditions
4.1 Other connective tissue disease
5.3 Hereditary degenerative nervous system
conditions
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Diabetes
Early Retiree, Patient A
Source Uniprise Data
Individualized and comprehensive care plans are
necessary
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Special Needs Individuals
Special Needs Individuals

• 50 of people die in hospital outside of Hospice
• Poor palliation services

• 5 chronic conditions 2/3 of all Medicare costs
• Greatest suffering ineffective resource
  utilization

• Single condition but very high impact, e.g.
  quadriplegia, advanced Alzheimers Disease

• Maybe functioning well, but no reserve secondary
  to age
• Sudden event is catastrophic

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Special Needs People
Care Management Model
For Special Needs People
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Clinical Model EffectivenessWhat is Attainable
Today

• Enrollee satisfaction 97
• Physician satisfaction 90
• ER and hospital utilization for dual eligible
  community-based population reduced 30
• Arizona saved 111 million compared to FFS LTC
  Medicaid
• Texas saved 70 million in one county
• Florida saved 10K-15K per nursing home
  eligible enrollee per year

Unmatched clinical results
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Clinical Model Evolution
Frail, Elderly in Nursing Homes

• Hospice/palliative care
• Retirement Community
• ESRD
• AARP Medicare Supplement

Community-Based Long-Term Care Medicaid
Care One Clinical Platform
Medicare Advantage
Ovations Data Mart
Galaxy
Community-Based Medicare via Special Needs
Plans (dual eligibles)
Reaching people regardless of living setting or
payer
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Necessary Infrastructure

• 1. Nurse Care Coordinators
• NPs/RNs
• Extended Team
• Geriatrics Training
• Management Support
• 2. Engaged LTC Staff
• Training support
• 3. Engaged MDs
• Enabling reimbursement
• Outcomes data Transparency feedback
• Geriatrics support
• Accountability
• 4. Evidence-based Care Process

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Necessary Infrastructure (contd)

• 5. Clinical Infrastructure System
• Early Access
• Portability
• Bridge sites of care
• ePrescribing
• 6. Enabling Financing Environment
• Special Needs Plans
• CMS Demos
• 7. Data Infrastructure, Analytics Reporting
• Appropriate measures
• Transparency
• 8. Effective Outreach Leadership
• Role of Special Needs Plans
• AAHSA, etc.
• Care Provider Leadership Gap