Lexus Hybrid

Long Term Care Integration ProjectSan 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

Presentation:

1. Components of the Personal Visiting Physician™ Delivery System

2. Discussion of the Care Management for High Cost Beneficiaries (“CMHCB”) CMS Demonstration

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

Patient & Care Stratification

100%100%2%2%  Healthy

Care Level Management

Single Disease Multi DiseaseEnd of LifeHospice

Figure 5

THE STEP DOWN PRINCIPLE

• ICU• M/S LEVEL OF CARE• SNF• HOME• SPECIALIST

• CCRN MD LEVEL OF PROVIDER

• RN RN • LVN NON SKILLED

 

Care Level Management

Figure 6

Sym

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m S

eve

rity

Time

Hospitalization Threshold

Chronically Ill Level

Normal health J.W. Spooner, MD

=course of patient without

PVP intervention

Sit

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f Care

H

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Offi

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ase

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Cycle of recurrent admissions to ER and Hospitals in chronically ill

patients

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

: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

:Components of the Personal Visiting Physician Delivery System:

• Home Hospitalization

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

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

Sym

pto

m S

ever

ity

Time

Hospitalization Threshold

Chronically Ill Level

Normal health J.W. Spooner, MD

Bi-Directional Access in progress

=course of patient without

PVP intervention

= points of intervention by

PVP

= course of patient with PVP

intervention

Emergency Room Threshold

Sit

es o

f C

are

H

osp

ital

ER

PVPDS

PCPPCP

OFFICE

ER

HOSPITAL

SNF

SNFistCase Manager

ERMDHospitalistCase Manager

HOME

Hospitalist / Case Manager

Referral

Logistic issueorUncontrollable

Stand By

Referral

Rapid DiagnosisRapid Treatment

Referral

Out PatientServices

UnmanageableEvent

Referral

 

Care Level Management

Figure 13

Care Management for High-Cost Beneficiaries (“CMHCB”)

Demonstration

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

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

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]…

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………

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”

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.”….

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}

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….

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

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.

CMHCB DemonstrationImplementation

• Expanded Networks:– Physicians –17 to 91 (74 new hires)– Overall Staff Increase -- >350%– Geographic Footprint -- Increased area >

25 times

• Engaged Independent External Experts– Milliman, Inc—actuarial support– RAND---ACOVE measurement tool – Sullivan / Luallin: satisfaction survey

California Geographic Reach for Care Level’s CMS Demonstration

California Geographic Reach for Kaiser Permanente

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

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

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

Summary• We believe that CLM’s 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.

Thank you….