Real Incentives, Real People

Presented by Karen Milgate at the Executive Leadership Summit on March 24 - 26, 2015.

This presentation provides concrete examples of payment and other policies that are driving a broader and permanent trend in increasing demand for effective care management. Ms. Milgate also shares a case example of a population in great need of care management that provides a unique new opportunity for health plans, health systems, states and the federal government: dual eligible beneficiaries.

Transcript

1. Real Incentives, Real People Karen Milgate Health Policy Consultant 1
2. Overview • Care management: Why is it important, what is it, who does it • Why now? • Who can most benefit? 2
3. Why • Baby boomers retiring – 54 million today to 80 million in 2030 – Increasing prevalence of chronic conditions - more 45 – 65 year-olds with 2, 3 and over 4 – Baby boomer bubble in 2025 will make Medicare program older (higher proportion over 75) – Even if per bene increase less, the number retiring – 3 percent increase annually • Total spending for Medicare and Medicaid is 39 percent of all health spending and growing – Medicare total @$500 b today - will double to $1 trillion in ten years – Less ability to pay for – 1970 4.6 workers per bene - 2030 2.3 per bene – Medicaid – 80 million benes and $470 billion in care • Price X volume (services times people)= cost – Lots of action on price. Has its limits. – What about volume? Know variation. Know excess. Know quality issues. • Care Management addresses both—excess volume and quality. 3
4. What Is It? Care management programs apply systems, science, incentives, and information to improve medical practice and assist consumers and their support system to become engaged in a collaborative program designed to manage medical/social/mental health conditions more effectively. The goal of care management is to achieve an optimal level of wellness and improve coordination of care while providing cost effective, non- duplicative services. (Robert Mechanic) 4
5. What Is It? • Key components (CHCS) – Identification, stratification, prioritization • Health risk assessments, predictive models, surveys, case finding, referrals – Intervention • EBM, interactive care plan, multi-disciplinary team, ―go to person‖, physical/behavioral integration, patient engagement – Evaluation • Program evals, rapid cycle micro-experiments, quality metrics, cost metrics – Payment/Financing • PFP, shared savings, care mgmt./medical home payment 5
6. Who Does It? • Plans? – Advantages: Data across settings, access to members – Disadvantages: Data not as rich, no real-time connectivity with providers, historical animosity with members • Providers? – Advantages: Face to face contact with patients, access to records, trust – Disadvantages: Lack of communication across settings, no integrated systems across, highly fragmented – Only see patients, not all enrollees for pop mgmt. 6
7. What’s Changed in Medicare? One Word: Incentives • Managed care – capitation - almost 30 percent of Medicare now • FFS: – Shared savings, shared risk @10 percent of benes – Bundled payment - demonstration – Pay for performance - IP and ESRD @$120 b and physvbp soon – Patient-centered medical homes - demonstration 7
8. Center for Medicare and Medicaid Innovation (CMMI) • $10 billion from 2011 to 2019 and $10 billion every ten year period after that • Pioneer ACO/Next Generation ACO • Bundled payment for care improvement-BPCI • Comprehensive Primary Care • ESRD bundles, oncology bundles • Multi-payer Advanced Primary Care 8
9. Secretary/CMS Goals • Category 1 – FFS, no link to quality • Category 2 – FFS with link to quality • Category 3 – alternative payment models built on FFS • Category 4 – population-based payment • Goals – 50 percent of FFS in 3 and 4 by 2018 – 90 percent of FFS in 2 – 4 by 2018 9
10. One Population: Dual Eligibles • Medicare is primary payer and Medicaid fills in the premiums, deductibles, cost-sharing and additional benefits, for example, long- term care • 9.6 million beneficiaries in 2010 (3.9 under 65 and 5.7 over 65) and 10.7 million in 2014 • $284 billion spending in 2010 ($169.9 Medicare and $114.6 Medicaid) – 34 percent of Medicare spending – 34 percent of Medicaid spending 10
11. Who Are the Dual Eligibles? • More minorities (42 percent duals, 15 percent non-duals) • More ADL limitations, poorer health, live alone, low education (49 percent no high school) • More medical conditions, cognitive impairments (Alzheimer's/dementia), behavioral conditions 11
12. Opportunities for Care Management for Dual Eligibles • Twenty percent are in Medicare Advantage • Only nine percent of those using LTSS in managed care • Fragmented delivery generally • CMMI/Medicare Medicaid Coordination Office – Financial Alignment • Ten states with capitation model • Two states with Managed FFS • One, Minnesota, building on SNP integration model – State Innovation models – Hard, some states have pulled back • Large dollars, so any care management in Medicare/Medicaid will need to address the needs for the duals 12
13. Opportunities For Care Management For Duals • 25 percent of hospitalizations for duals potentially avoidable • Costs $7 to 8 billion in 2011 dollars • Largest proportion come from SNFs • Primary causes (81.6 percent of all): – CHF – COPD/Asthma – Dehydration – Pneumonia – UTIs 13
14. Which States Have the Most Dual-Eligibles? California 1,250,000 Florida 677,000 New York 796,000 Texas 654,000 Illinois 346,000 North Carolina 323,000 Ohio 332,000 Pennsylvania 349,000 Total for 8 states 4,727,000 (almost half of all dual eligibles) 14
15. Which States’ Dual-Eligible Population Is Growing the Fastest? From 2007-2010 Connecticut 11.4 percent Florida 6.8 Maine 5.3 Montana 10.6 New Hampshire 5.5 New Mexico 8.8 Oregon 5.5 Washington 5.4 15
16. How Would This Work? • Preventing hospitalizations and everything that goes along with them • Managing transitions from acute care, but also post-acute • Keeping beneficiaries with low functioning at home – – supports for decisions, eating, exercise and medications, ways to identify when help is needed, providing that help as soon as possible and with as low intensity as needed – A person paying attention with ability to make decisions/recommendations and technology to track patient and identify when need for intervention occurs 16
17. Summary • Need is great. Costs, quality, growing population of aged, disabled and older aged • Incentives exist more than ever. Provider level, provider system level, managed care, and state level • Dual eligible population hard, but represents an important sub-group that drives significant costs and quality 17
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