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Proactive Approaches in NICU ManagementMedicaid Health Plans of America Annual Conference
Today’s Presenters
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Dr. Ellen Stang
Founder and CEO
ProgenyHealth, LLC
Dr. Marketa Wills, MBA
Sr. Corporate Medical Director
WellCare Health Plans
Dr. Robert S. London
Chief Medical Officer, SC
WellCare Health Plans
All numbers are as of June 30, 2019
*Includes states where the company receives Medicaid and Medicare revenues associated with Dual Eligible
Special Needs Plans (D-SNPs)
14KASSOCIATES
6.3MMEMBERS
607KHEALTHCARE
PROVIDERS
68KPHARMACIES
Medicaid
Medicare Advantage
Medicaid & Medicare Advantage*
#155FORTUNE 500
Health Insurance Marketplace
Medicare Prescription Drug
Plans (50 U.S. states & D.C.)
WellCare – Who We Are
WellCare’s Presence
Medicaid (Pending) &
Medicare Advantage†
† Anticipated beginning Nov. 1, 2019, WellCare of North Carolina will administer the state’s Medicaid Prepaid
Health Plans (PHPs). 3
WellCare – Who We Are
4
Our Approach
At WellCare, we foster strong partnerships with providers; offer an integrated
care model; establish trusting partnerships with our state and federal
partners; and address barriers to care in our local communities.
WELLCARE’S APPROACH
WellCare’s Maternal & Child Health
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Population Snapshot
1.3MFemales of childbearing
age (12-44)
165,025Pregnant members
116,156Babies delivered
13,873 NICU admissions
2.5M Children and adolescents
ages 0-17
Members receiving support and services that fall into the Maternal and Child
Health category make up approximately 80% of WellCare’s membership.
2018 Medicaid – All Markets
WellCare’s Maternal & Child Health
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Overview of Clinical Programs
National maternity care management
program focused on improving mother and
newborn outcomes and care.
Utilization management program designed to
ensure the right care at the right NICU level
and provide care management to the NICU
graduate’s family for the first 15 months of life.
WellCare BabySteps
NICU Program
Neonatal Abstinence Program
The program is designed to address the
increased incidence of prenatal exposure to
opiates through care management of female
members at risk of or abusing opiates.
Maternal & Child Health Scope
• Female members of childbearing age with a focus on
family planning and reproductive health
• Female members throughout the continuum of
pregnancy and postpartum care with a focus on pregnant
adolescents and high risk pregnancies
• Children from birth until their 21st birthday including a
focus on children with special needs
WellCare’s Maternal & Child Health
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WellCare BabySteps Maternity Program
National maternity care management program targets timeliness of care, early
identification of risk factors and management of health conditions that complicate
pregnancy
• Improve birth outcomes
• Improve quality of maternity care
• Increase member engagement
• Reduce cost of care for mothers and
infants
WellCare’s Maternal & Child Health
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Neonatal Abstinence Syndrome (NAS) Program
National NAS Program that targets at-risk mother and NICU graduate through early
identification, intensive prenatal and postnatal care management services
• Timely treatment of exposed newborns
• Improve outcomes and reduce cost of
care for mothers and infants
• Prevent opioid exposure in
newborns
• Stabilize pregnant members who
are using opioids
WellCare’s Maternal & Child Health
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Neonatal Intensive Care Unit (NICU) Program
National NICU program aligns care to newborn and pediatric care guidelines through
care management and coordination of services. Targets appropriate best practices in
the hospital, engages caregivers and family during hospitalization and post discharge
through first year of life.
• Improve birth outcomes
• Improve the quality of maternity care
• Reduce cost of care for NICU newborns
• Increase member engagement
• Increase provider engagement
Improving Lives Together
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WellCare – ProgenyHealth Partnership
Plan Integrate
Coordinate Expertise
Program Requirements
Integration with community providers
Partnership with community partners
Seamless integration with WellCare’s care model
Measurable outcome and quality metrics that
target industry benchmarks for population
Average
Length of Stay
(ALOS)
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Missouri
20.019.0
16.0 16.3
0
5
10
15
20
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National Benchmark Pre - Progeny Baseline Year 1 All Claims Data Year 1 Baby Trax Data
ALO
S (
Days)
Plan Year One 8/1/16 – 7/31/17
*Baseline Cases Only; does not include NAS, Expired, ECMO, and Trach
NICU Program Impact
*Based on Progeny BabyTrax data PY 2017, PY 2018 results and 2019 YTD data (Jan-Aug).
NICU Program Impact
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Missouri
WellCare MO
ALOS
*Based on Progeny BabyTrax data PY 2017, PY 2018 results and 2019 YTD data (Jan-Aug).
WellCare SC
ALOS
Top Providers – Facility ALOS* – Pre and Post Progeny
*Baseline Cases Only; does not include NAS, Expired, ECMO, and Trach or applied transfer logic
NICU Program Impact
South Carolina
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*Based on Progeny BabyTrax data PY 2017, PY 2018 results and 2019 YTD data (Jan-Aug).
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Facility A Facility B Facility C Facility D Facility E
Year 1 Cost per Discharge % savings from baseline
WellCare SC
Cost Reduction
per Discharge
*Baseline Cases Only; does not include NAS, Expired, ECMO, and Trach or applied transfer logic
-36%
-47%
-22%
-44%
-8%
NICU Program Impact
South Carolina
14*Based on Progeny BabyTrax data PY 2017, PY 2018 results and 2019 YTD data (Jan-Aug).
Levels of Care
Impact of Leveling by ProgenyHealth
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Missouri Care
43%
28%
36%
45%
21%
27%
Rev Code 172 Rev Code 173 Rev Code 174
Baseline
Claims
Provider
Billed-
Claims
$ $$ $$$
Shift to Less Costly Days
WellCare’s Maternal & Child Health
19.3
16.7
15.9
16.6
13
14
15
16
17
18
19
20
pre-PH 2017 2018 2019 YTD
NICU Average Length of Stay (ALOS) (Days/Admit)
6.0%
1.4%
2.5%2.8%
0%
1%
2%
3%
4%
5%
6%
7%
pre-PH 2017 2018 2019 YTD
NICU Readmit Rate (30 Days)
Reduce NICU ALOS (days/admit) from
WellCare baseline measure of 19.3 daysReduce 30-day emergent readmissions
from benchmark of <6%
Target CM enrollment goal of >65%
Enterprise Goals and ProgenyHealth Results
*Based on Progeny BabyTrax data
PY 2017, PY 2018 results and 2019 YTD data (Jan-Aug).
65%
84%87%
91%
60%
65%
70%
75%
80%
85%
90%
95%
100%
pre-PH 2017 2018 2019 YTD
Case Management Enrollment Rate (%)
Reduce NICU Average Length of Stay Reduce readmission rates Improve CM enrollment rates
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ProgenyHealth
Dr. Ellen Stang
Founder & CEO
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Progeny – Who We Are
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Progeny’s Approach
Purpose-built to help health plans and employer groups reduce costs and ensure quality in the care of
at-risk infants and their families. Our NICU trained teams have the expertise needed to keep a watchful
eye on the baby’s care plan; provide resources, education, and support to the families; and deliver
attentive oversight for each case.
Process Platform People
WellCare Partnership
ProgenyHealth’s Solution
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Live in 10 markets
Program
focus on…
• Seamless member experience
• Clinical integration
• Strong local provider partnership
• Improving health outcomes
Case Management
Key Performance
Indicators
• 6,801 cases managed
• 4,549 successfully
contacted members
• Average of 9 successful
calls per enrolled
member
• 5,100+ successful
SDOH interventions
(education, access,
community, financial)
WellCare Partnership
Market Launch
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NICU
week 1
week 1
week 2
week 2 - 4
week 3 week 4 week 5
week 5 month 8
1st BirthdayNICU
Discharge
Discharge Sick baby
UM team
CM team
Our process monitors the baby from birth to first birthday. On average, our NICU specialized UM team interacts
with the hospital care team 7 times more frequently than a typical UM team. Our NICU specialized CM team
connects with the family early in the hospital stay and continues to support them for the entire 1st year.
Integrated UM and CM that encompasses the social determinants of health
WellCare Partnership
ProgenyHealth Process: Proactive, Data Driven, Integrated Approach
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WellCare Partnership
Importance of extended case management
Familyeducation
Quality /
HEDIS
24/7
Support
Reduction of readmissions
Schedule
Baby Trax app
Family/CaregiverCM team
Social
determinants
1st BirthdayNICU
70% of readmissions happen after the first 30 days. Going above and beyond is our process for CM. The
families with the greatest need are often the most difficult to reach. We have the national expertise and
access to local community resources to provide needed support to the families.
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WellCare Clinical & Financial Results Delivered in 2018
Financial Impact
NAS ALOS*
ALOS
Return on Investment:
>3.45:1
19.3 days: average client baseline
17.1 Days**
13.8 Days***
*Discharged newborns with NAS diagnoses through 12/31/18.
**Tyler N.A. Winkelman, et al, Incidence and Costs of NAS Among Infants With Medicaid: 2004–2014, Pediatrics, March 2018.
***Baseline Cases Only; does not include Iatrogenic, Expired, ECMO, Transplant and Trach cases.
15.7 days: WellCare current
WellCare Partnership
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2.5% (30-day readmission rate)
7.6% (FYOL readmission rate)
Readmission Rates
Member Satisfaction
90% +
WellCare’s Maternal & Child Health
Achieving the Triple Aim
Achieving Triple Aim
Through an enterprise NICU management
program we are improving outcomes for
moms and babies, increasing member
satisfaction, and significantly reducing the
cost of care.
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THANK YOU!
Do you have any questions?Please feel free to contact us if you need additional
information.
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