Care Management for High-Cost Beneficiaries (CMHCB) Demonstration

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Lexus Hybrid
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• Long Term Care Integration Project
• San Diego
• Personal Visiting Physician Delivery System
• the
• Care Management
• for High Cost Beneficiaries Demonstration
• Presented by
• Joseph W. Spooner, MD, MBA
• SVP Outcomes, Academic Government Relations

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• Presentation
• Components of the Personal Visiting Physician
  Delivery System
• Discussion of the Care Management for High Cost
  Beneficiaries (CMHCB) CMS Demonstration

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• 2005 CBO Report
• High Cost Medicare Beneficiaries
• Top 25
• Top 5 43 total expenditures
• Av. annual group cost 64,000
  
• Av. annual cost 7,300
• High vs. Low Cost Beneficiary Profile
• MD visits 11 vs. 6 per year
• Hospital admit 75 vs. 2.5
• SNF admit 16 vs. 0.1
• ER visit 63 vs. 14
• High Cost Trend
• 14 die annually, 40 in 4 years
• 50 survivors were high cost for 4 years

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Care Level Management

• Patient Care Stratification

Single Disease
Healthy
Multi Disease End of Life Hospice
 
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Figure 5
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THE STEP DOWN PRINCIPLE
Care Level Management

• ICU
• M/S LEVEL OF CARE
• SNF
• HOME
• SPECIALIST
• CCRN MD LEVEL OF PROVIDER
• RN RN
• LVN NON SKILLED

 
Figure 6
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• Components of the Personal Visiting Physician
  Delivery System
• 24/7 coverage by board-certified internists,
  family physicians geriatricians
• Direct cell phone contact
• Routine maintenance and urgent home
  interventions by the PVP

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• Components of the Personal Visiting Physician
  Delivery System
• Intensive home pharmacy management
• Intensive on-going education in the home by the
  PVP and by phone by the PCAN
• Post-hospital follow-up
• Post-ER follow-up

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• Components of the Personal Visiting Physician
  Delivery System
• Home Hospitalization

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• Home Hospitalization
• In-home physician management of medically stable
  patients with community-acquired, uncomplicated
  pneumonias urinary tract infections cellulitis
  and/or dehydration
• Patient always given options

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Home Hospitalization

• CLM CLINICAL RESULTS
• 1407 AVOIDED ADMISSIONS
• 378 HOME HOSPITALIZATIONS
• FINANCIAL RESULTS
• ALOS FOR HOME HOSPITALIZATION 4 DAYS
• AVERAGE COST OF HOSPITAL ADMIT 6,000.00
• COST OF HOME HOSPITALIZATION 1,190.00
• NET SAVINGS PER CASE 4,810.00
• TOTAL SAVINGS FOR 378 HOME HOSPITALIZATIONS
  1,818,180.00

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Care Level Management

• PCP

PCP OFFICE
Stand By
Referral
SNFist Case Manager
ER MD Hospitalist Case Manager
Rapid Diagnosis Rapid Treatment
ER
HOME
SNF
Referral
 
Logistic issue or Uncontrollable
Referral
Out Patient Services
Referral
Unmanageable Event
HOSPITAL
Hospitalist / Case Manager
Figure 13
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Care Management for High-Cost Beneficiaries
(CMHCB) Demonstration
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CMHCB DemonstrationBackground

• Section 721 of the Medicare Modernization Act,
  2003 provided for the Chronic Care Initiative
  Program (CCIP) now known as Medicare Health
  Support (MHS).
• Became very clear that CCIP was not designed to
  demonstrate the value of physician-based methods
  of managing chronic illness in the elderly

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CMHCB DemonstrationBackground

• CCIP was designed specifically for Disease
  Management companies approaches to chronic
  illness
• The only option given CLM by the Centers for
  Medicare and Medicaid Services (CMS) was to
  contract with a DM company

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CMHCB DemonstrationBackground

• Robert Berenson, MD, internist, Urban Institute,
  testimony to the House, Health Subcommittee, May,
  2004 in my opinion it CCIP is insufficient
  for truly addressing chronic care needs in
  Medicare because it lacks a focused physician
  component our emphasis

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CMHCB DemonstrationSolicitation Components

• Finally, in October, 2004 CMS released a
  Solicitation for the Care Management for High
  Cost Beneficiaries (CMHCB) Demonstration
• Solicitation This voluntary demonstration is
  part of an effort to develop and test multiple
  strategies to improve the coordination of
  Medicare services for high-cost FFS
  beneficiaries

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CMHCB DemonstrationSolicitation Components

• However, one approach which remains to be
  studied is intensive medical management for
  high-cost beneficiaries with various medical
  conditions to reduce cost as well as improve
  quality of care and quality of life for those
  beneficiaries

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CMHCB DemonstrationSolicitation Components

• Eligible organizations 1) physician groups 2)
  hospitals 3) integrated delivery systems. Other
  organizations may apply but only as a part of a
  consortium that includes physician groups,
  hospitals, or integrated delivery systems..

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CMHCB DemonstrationSolicitation Components

• Population-based study, with Intervention Group
  and Control Group
• Risk-based Awardee has to produce at least 5
  net savings to CMS in 3 years or must return all
  administrative fees paid the awardee not fees
  paid for actual physician visits/services

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CMHCB DemonstrationAwardees, July 1, 2005

• ACCENT - Consortium of physician clinics in
  Oregon Washington, Health Hero Network (home
  monitoring technology company), and American
  Medical Group Association
• Care Level Management- 24/7 physician home
  visiting physician program.

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CMHCB DemonstrationAwardees, July 1, 2005

• Mass General Hospital/Mass General Physicians
  Organization
• Montefiore Medical Center, Bronx, NY
• RMS DM, LLC renal disease mgmt org., LI, NY
• Texas Senior Trails -Consortium of Texas Tech
  Univ. Health Sciences Center, Texas Tech
  Physician Associates

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CMHCB DemonstrationCLM Implementation

• Began enrolling beneficiaries October, 2005
• Intervention Group 15,000 high-cost benies in
  California, Texas, and Florida. Approx. 13,000 to
  be enrolled in CA.
• Approximately 6,000 in Control Group
• Established CLM Enrollment Center in Phoenix, AZ.

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CMHCB DemonstrationImplementation

• Expanded Networks
• Physicians 17 to 91 (74 new hires)
• Overall Staff Increase -- gt350
• Geographic Footprint -- Increased area gt 25
  times
• Engaged Independent External Experts
• Milliman, Incactuarial support
• RAND---ACOVE measurement tool
• Sullivan / Luallin satisfaction survey

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California Geographic Reach for Care Levels CMS
Demonstration
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California Geographic Reach for Kaiser Permanente
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CMHCB DemonstrationCLM Implementation

• Expanded Existing Services and Systems
• CLM University / Academic Programs / Residency
  Programs
• Enrollment Center
• Expanded Existing and Added New Offices
• Community Relations Managers
• Augmented Information Systems
• EMR Seibel system in Enrollment Center

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CMHCB DemonstrationChallenges

• Competing BIPA Congestive Heart Failure DM
  Demonstration in CA by PacifiCare/Allere
  eliminated thousands of CHF beneficiaries from
  initial Intervention Control Group
• February, 2006 PacifiCare terminated BIPA demo
  10 months early due to lack of interest by
  beneficiaries
• On refresh of population, we hope to gain access
  to these beneficiaries

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CMHCB DemonstrationChallenges

• Ultra fast build-up of systems and personnel
  infrastructure
• Overcoming some beneficiaries fear of fraud
  against elders were we the real deal?
• Developing effective ways to convince primary
  care physicians that we supplement, not supplant,
  their care

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Summary

• We believe that CLMs CMHCB 3-year Demonstration
  will be able to validate the effectiveness and
  efficiency of physicians regularly visiting the
  frail elderly in their homes, as well as other
  facilities as necessary.
• We also believe that this Demonstration, will
  make the public, media and political players more
  aware of the unique advantages of providing care
  in the home to chronically ill high cost patients.

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Thank you.