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Moving Home Care Medicine into the Mainstream: Medicare Advantage

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Presentation on theme: "Moving Home Care Medicine into the Mainstream: Medicare Advantage"— Presentation transcript:

1 Moving Home Care Medicine into the Mainstream: Medicare Advantage
Ronald J Shumacher, MD FACP CMD Chief Medical Officer, Optum Complex Population Management ©AAHCM

2 Disclosures Ronald J Shumacher MD has the following financial relationship to disclose: Employee of: Optum Services, Inc. ©AAHCM

3 Total Medicare Private Health Plan Enrollment, 1999-2013
99% of Medicare beneficiaries nationally have access to one or more Medicare Advantage Plans in their county ©AAHCM

4 Distribution of Medicare Advantage Plans by Plan Type, 2007-2014
99% of Medicare beneficiaries nationally have access to one or more Medicare Advantage Plans in their county NOTE: Excludes SNPs, employer-sponsored (i.e., group) plans, demonstrations, HCPPs, PACE plans, and plans for special populations (e.g., Mennonites). Other category includes cost plans and Medicare MSAs. SOURCE: MPR/KFF analysis of CMS’s Landscape Files for 2007 – 2014.

5 Challenges facing health plans today
Clinical quality and STARs Care coordination and management Greater focus on quality performance and outcomes evaluation HEDIS measures tied to revenue Financial incentives and brand identity critical to business Shifts from fee for service to pay for performance and accountability Member outreach and engagement Integrated clinical data at point of care Improved coordination of services and accountability Health Plan Performance MA Plans face margin pressures and revenue management needs Convergence of closing gaps in care at point of service Compliance: EDPS and RADV Admission and Re-admission prevention Post-acute and end-of life care SNF LOS management Network/Contracting Post-acute care accounts for large component of spending and significant variation suggests obvious opportunity for savings Risk adjustment Medical expense management ©AAHCM

6 Payer challenges: managing high-risk member populations
The most expensive members offer the biggest opportunity for savings; however, these patients require a home-based care program. %5% of the population drives 50% of the medical spend The MA health plan needs to have a house-call program to manage this population. Further describe the patient. This subset of MA population requires intensive in-person services to address their complex problems and to coordinate care for multiple chronic conditions. They are not well served by the traditional care system These patients take more medications, see their provider more and utilize the ER three times per year on average Members do not regularly engage with or look to payer for health support or management The high cost 5% of the population are generally on an erratic course Stanton MW. The High Concentration of U.S. Health Care Expenditures. Research in Action, Issue 19. AHRQ Publication No , June Agency for Healthcare Research and Quality, Rockville, MD. ©AAHCM

7 Risk stratification and identification of members
Consider the unique demographics of MA plan populations — 10% of the population averages at least one hospital visit per year and accounts for 30% of the spend Risk Score % of Population Hospital Visits/Yr ER # Chronic Diseases $PMPM % of Cost <0.70 50% .164 .252 0.3 $330 21% .71 to 1.45 30% .373 .429 1.3 $710 33% 1.46 to 2.05 10% .660 .632 2.3 $1,190 15% 2.06 to 2.75 5% .915 .766 3.0 $1,640 11% >2.75 1.477 .992 3.7 $2,740 20% Hospital Admits There is an identifiable population that clearly experiences high utilization/high cost ER Visits ©AAHCM Source: Nationwide Medicare 5% Sample

8 Health plans typically provide services to patients with chronic illnesses like nurse line, education, telephonic case management, advocacy, wellness, DM, etc. Tompkins et. al. Population Health Management in Medicare Advantage; Health Affairs Blog, April 2013

9 Initiating a relationship with MA Plans
Needs Assessment Identify the problem being solved Determine how it is applicable to MA plans Understand the environment in which you’ll provide care (geography, etc.) Value Story Develop a proven ROI (e.g., executive summary, affordability analysis, ROI & quality metrics) Provide a MA Health Plan health care economics analysis Determine if there is a need to take on risk Have a willingness to contract and get credentialed with the health plan Implementation Plan Propose a clinical program/model Review of contract by legal Develop a road to deployment (e.g., staffing, certification, filing, delegation agreements, credentialing, etc.) Identify/align on early indicators and analytics Determine program monitoring ©AAHCM

10 Developing a successful home medicine care program
Identification of members and risk stratification Member outreach and engagement Demonstrate value / ROI Managing most challenging patients Non-compliant Scheduling ?graduation/end point Capture of quality and encounter data Develop clinical care model (e.g., visit types, how to manage the most challenging patients) ©AAHCM

11 Creating a profitable home care medicine program
Case rate (PEMPM) Capitated payment (PMPM) Gain sharing with quality metric goal(s) Full risk/percent of premium Reimbursement Structure Low health care utilization (e.g., admissions, readmission, emergency department, etc.) Manage quality measures, including STARs, HEDIS Accurate documentation/coding Simple way to share data Profitability Management FFS reimbursement has been a major obstacle for home care medicine in the traditional Medicare space. But MA presents opportunity to credit providers with savings from treatments averted or ailments prevented. Now as the dominant FFS model is eroding and value based payment is taking over. Medicare Advantage pays for care of people not for procedures and maximizing treatment ©AAHCM

12 Challenges associated with home care medicine and MA Plans
Risk mitigation strategies Identification and stratification Algorithms that accurately reflect implications of regression of the mean Member outreach and engagement Specialized outreach teams to manage engagement Member compliance with care plans Partner home care medicine providers with telephonic case management support Collaboration with MA Health Plan case management and other programs Establish clear criteria, communication and handoffs Navigating MA Health Plan networks Emphasize communication with network providers and provide documentation Managing operational metrics Rigorous management oversight and tracking tools Data capture and tracking Robust EHR and reporting/analytics Regression to mean ©AAHCM

13 Thank you. Ronald J Shumacher, MD FACP CMD
Chief Medical Officer, Optum Complex Population Management ©AAHCM

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