NHP/Brightwood Evaluation

If special programs work - clinically and financially - for small groups of members with complex but homogeneous disability and medical needs …..

Can these programs be adapted to work on a population basis with the broad range of SSI members?

Selection of Brightwood as Pilot Site

Large community health center in Springfield, MA Much higher SSI clinic population than other

community health centers Strong clinical leadership and vision Already operating a specialized program for NHP

members with HIV/AIDS Largely Spanish-speaking population, and poor access

to culturally and linguistically appropriate behavioral health care

Initial Model: Identification

Convert 800 SSI fee-for-service patients to NHP members

Convert 500 long-term unemployed fee-for-service patients to NHP members

Conduct health risk assessment Conduct chart review Identify individuals through ED, Inpatient

admissions

Model: Stratification

Who gets preventive care reminders? Who gets telephone care management? Who gets intensive care management? Who gets enhanced behavioral health

coordination or services? Who gets peer interventions?

Model: Intervention

Reminders for primary and preventive care visits

Integrated care management team:– RNPs, RNs– Behavioral health clinicians– Peer support team – Addictions Advocate, Clinical

Assistants Different levels of care management

intervention

Financing

Spend an additional $50 PMPM on primary care and care coordination

Take $14 PMPM out of the behavioral health carve-out to purchase on-site behavioral health care

Spread costs over approximately 1000 SSI and Long-term unemployed members

Plan vs Reality

Plan Reality

# of SSI enrollees 800 345

# of Long Term Unemployed enrollees

500 245

Staffing 5 RNPs 5 different professions

Enhanced primary care and coordination PMPM

$50 $85

Barriers and Improvement Cycles

Enrollment Negotiation over modelPolitics, politics, politics

Implications of Selection

DXCG risk adjustment, applied to 282 SSI members at Brightwood.

Predicted costs would be 17% higher than NHP SSI average costs.

Disproportionate number of Brightwood SSI members with HIV or chronic mental illness (reflected later in RX expenditures)

CY 2002 PMPM Expenditures - Annualized

Service Average PMPM

Facility $124

Physician $60

Other Medical $61

Pharmacy $299

Behavioral Health $65

Enhanced Care Coordination $101

TOTAL $710

Distribution of Capitation, 2002

Pharmacy43%

Enhanced PC&Care

Coordination14%

Behavioral Health

9%

Physician8%

Facility17%

Other Medical9%

Distribution of Expenditures PMPM per Quarter

$0

$50

$100

$150

$200

$250

$300

$350

Q1 Q2 Q3 Q4

Pharmacy

Inpatient

Care Coordination

Emergency Room

Physician

Ancillaries

Other (DME, Vision,Home care)

Brightwood Experience Compared to Other NHP SSI Members

NHP Average PMPM for SSI members $719

Risk-adjusted expectation for Brightwood SSI members

$841

Brightwood Actual PMPM (including enhanced primary care and care coordination)

$710

NHP/Brightwood Comparison

SSI @

NHP

SSI@

Brightwood

Pharmacy PMPM $200 $299

Inpatient Behavioral Health $27 $4

Outpatient Behavioral Health $46 $61+$15

BH Penetration Rate 31% 42%