The Engelberg Center for Health Care Reform at Brookings | The Dartmouth Institute

June 6–8, 2012

Third Annual National ACO Summit

Follow us on Twitter at @ACO_LN

and use #ACOsummit.  

Integrated Dual Eligible &Medicaid Reforms-Keynote

June 8, 2012

Martin Serota, MD; Vice President & Chief Medical Officer

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OVERVIEW

• The Duals in California• The Duals in Los Angeles and

Orange Counties• AltaMed Strategy• Accountable Care Network Strategy

PROBLEM STATEMENT

• System Fragmentation

• Results in:• Beneficiary Confusion• Delayed care• Inappropriate utilization &higher cost

Provide:• Integration and Coordination of

services• Minimize Patient & Provider

confusion• Improve access to care• Provide higher value services• Improve quality and outcomes• Reduce disparities• Cost containment

AltaMed Opportunity and Value Proposition:

Current Scenario: The duals access services through a complex system of disconnected programs (doctor visit, DME fulfillment, formulary access).

STATE ISSUESCalifornia Dual Eligibles Demonstration

• State DHCS and CMS are partnering to launch a three year demonstration in 2013 that promotes coordinated care to seniors and persons with disabilities who are dually eligible for Medi-Cal and Medicare

• Aims to create a seamless service delivery experience for dual eligible beneficiaries with ultimate goals of improved care quality, better health and a more efficient delivery system, but will be allowed to opt out of managed Medicare

• California has 1.1 million dual eligibles; 7 out of 10 are 65+; most are women; 50% live on less than $10,000 a year

• Dual eligibles tend to have multiple chronic conditions and social care needs• Will start in four counties: Los Angeles, Orange, San Diego and San Mateo;

pending state and federal approval will expand to six additional counties: Alameda, Contra Costa, Riverside, Sacramento, San Bernardino and Santa Clara

• Single integrated health plan will be responsible for delivering all Medicare and Medi-Cal benefits and services, including, medical care, long-term care, behavioral health care and social supports

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THE DUALS IN CALIFORNIADHCS provides the savings methodology for both Medicare and Medi-Cal in its dual demonstration proposal.

Medicare Key Assumptions:a. Hospital utilization will drop by 15% in FY12-13b. SNF utilization will drop 5% in FY12-13c. Physician utilization will increase by 4% in FY12-13d. Pharmacy utilization will increase 2% in FY 12-13e. Overall Medicare savings 4% FY 12-13

Medi-Cal Funded Long Term Services and Supportsa. Home and Community based services will increase 6.1%b. Institutional long-term care will decrease 11.7%c. Overall savings of 3.2%

Other costs/savings?a. Organization – ACO, ACN, etc.b. Medical managementc. State savings for claims processing

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MEDICARE & MEDI-CAL: DIVISION OF RESPONSIBILITY

Medicare is the primary payer for dual eligibles and covers medically necessary services such as: acute care services, physician services, hospital services, SNF services, prescription and home health care services.

Medi-Cal is the secondary payer and generally covers:• Services not covered by Medicare. This may include services such

as transportation, dental, vision, some mental health services, and until 2006, most outpatient prescription drugs

• Services such as cost-sharing and deductibles for Medicare as well as acute care and skilled nursing facility services that are delivered after the Medicare benefit is exhausted or specific criteria has not been met.

• Long-term care, including custodial nursing facility care, home and community-based services, and personal care services.

• Medicare Part A and B premiums for some dual eligible populations.

Medi-Cal Dual Eligible By Age and Gender

Medi-Cal Dual Eligible EnrollmentBy Aid Category & Plan Type

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Medi-Cal Dual Eligible Fee-for-ServiceExpenditures by Aid Category

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FINALLY A USE FOR CALCULUS

d Institutionalizedd Time

If the historic institutionalized rate is 6% and the annual mortality rate is x, and if the new institutionalized rate is y while the annual mortality rate is unchanged, then…

Clinical Conditions Driving Cost& Utilization - Disabled Dual Eligibles

Clinical Conditions Driving Cost& Utilization - Disabled Dual Eligibles

The Most Expensive Clinical Conditions

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DUALS IN ALTAMED COUNTIES

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ALTAMED STRATEGY FOR THE DUALSa. Internal

a. Add and expand services for Dualsb. PCMHc. PACE for the most fraild. Medical Managemente. Technologyf. Build Capacity Through Entire Enterpriseg. Team Up with Community Partners (ACN)

b. Externali. Build strong ACNii. HIEiii. Riskiv. Develop LTSS Network

TRANSFORMATION THROUGH INTEGRATION AND THE PCMH

Standard Work/ LEAN

Patient Portal

Medical ManagementDisease ManagementCare Management

IPA/Regional PODs

Operational-Clinics-Med Refill-Advanced Access-Pre Visit/ Post Visit-Cycle time

Operational-Enterprise-Call Management-Auth/Referral-Patient Outreach -Integrate Medical Mngt

Clinical Integration Engine (AltaMedNet)

PCMHJuly 2011

Clinics: PCP, HIVSenior Services: PACE, ADHC, IPA

1115 Waiver-SPD-Dual eligible

Health Care Reform Market Forces

Safety Net ACN

Patient Centered Care Improved Quality and Outcomes

Reduced Disparities

Health CoverageInitiative

Behavioral Health

Restricted Knox Keen Licensee

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Senior/High Risk Patient Care Options

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SUCCESS FACTORS

• Small panel size• IDT• Fully integrated care• More services at point of care• Medical Management• Transportation• Social Services• Extended Hours• Aligned incentives

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Governance structure

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SAMPLE PROVIDER-LED PROJECTS• Medical Management

-Standard Intake (HRA) workflow for high-risk patients-Standard Transitions workflow

• Disease Management-Advanced directives (POLST) standardization and accessibility

-Diabetes mellitus and CHF standardization inpatient and outpatient

• Credentialing-Quality standards-Hospital privileges for non-admitting providers

• HIT-EHR recommendations and rollout-ACN-wide HIE

Role of HIT in Transformation

We are here

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AltaMedNet

CLINICALINTEGRATION 

ENGINE

PATIENT- CENTERED

CARE

PATIENT PORTAL

PRIMARY CARE

PORTAL

SPECIALIST PORTAL

HOSPITAL PORTAL HOME

HEALTH PORTAL

MEDICAL MANAGEMENT

CALL CENTER/

IVR

MOBILE DEVICES

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CARE MANAGEMENT

HEALTH INFORMATION

EXCHANGE

PATIENT HEALTH

RECORDS

ANALYTICS

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Vision Realized

“Triple Aim”“Triple Aim”

“Transform into a clinically integrated healthcare delivery system prepared for reimbursement based upon value and quality, not volume”

Communication Collaboration

Anticipation

CoordinationCoordination

“Quadruple Quiver”“Quadruple Quiver”

‐Donald Berwick‐Donald Berwick‐

Martin Serota‐

Martin Serota

Improving the experience of careImproving the experience of care

Improving the health of populationsImproving the health of populations

Reducing per capita cost of healthcare

Reducing per capita cost of healthcare

Vision Realized

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CHALLENGES

• Meeting the demand, esp. for mental/behavioral health, social services

• Reducing cost of the chronically institutionalized• Changing provider and patient mentality from fee

for service to managed care• Financing risk• Duals may opt out of managed Medicare, but

retain capitated LTC benefits• Making the math work

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SUMMARY

• The Duals are generally poor, sick, expensive and used to choice; they are not used to being managed.

• The Duals should benefit from coordinated care with better outcomes at lower cost.

• “Improving the patient experience” is subjective, may be difficult and will take time.

• Caring for the Duals will take new systems and/or realignment of resources to meet their special needs.

• Coordinating care for the Duals is the right thing to do.

• Let’s do it right!

Track 6: Integrated Dual Eligible and Medicaid ReformsPanel 1: Integrating Care for Dual Eligibles

Martin Serota, MD Vice President and Chief Medical Officer, AltaMed, Los Angeles County Accountable Care Network

Monica Basu, MBA Senior Program Officer for Health Care and Higher Education Initiatives, George Kaiser Family Foundation

David C. Grabowski, PhD Professor, Health Care Policy, Department of Health Care Policy, Harvard Medical School

Judy Feder, PhD Professor of Public Policy, Georgetown Public Policy Institute at Georgetown University; Urban Institute Fellow, Urban Institute

Ellen Meara, PhD Associate Professor, The Dartmouth Institute for Health Policy and Clinical Practice and Adjunct Associate Professor of Public Policy, the Nelson A. Rockefeller Center, Dartmouth College (Moderator)

Pikes Peak Region of Colorado•690,000 population•6,750 square miles

Colorado Springs Metro area  •48th

largest city in US

•620,000 population•186 square miles

Community Health Partnership

“Improving the health of our community 

through collaboration”

Working Together 101

co a li tion1. an alliance or union between groups, 

factions or parties, especially for a  specific reason, 2. the union of a mass 

of separate bodies

Improving Health through Collaboration

• A twenty‐year‐old coalition• Built on a foundation of trust aligned 

with mutual values and goals

• All major health care providers are  members, with executive leadership 

actively engaged

Doing What’s Best for Our Community

• Connecting donated medical services  to more than 1,300 uninsured 

residents annually

• Providing access to medications for  more than 1,200 people each year

• Coordinating care for 19,000  Medicaid members currently

Keeping Health Care Local

• Health care reform drives  communities to take ownership of 

health care delivery and outcomes

A Perfect Storm

• By 2020, two thirds of the American  public will get their health care from a 

government‐sponsored program

• Fee‐for‐Service = Fee‐for‐Volume

Accountable Care Model• Pay for value, not volume• Higher quality at a lower cost• Proactive by design, not reactive by 

design• Marriage of payment reform and 

delivery reform• Improved health, lower cost, better 

patient experience

The RCCO ‐Regional Collaborative Care Cooperatives• Colorado divided into seven regions 

having equal Medicaid populations

• Different ACO models in different  regions

A local response to health care reform _______

A community‐based ACO for Medicaid 

How is an ACO like a Unicorn?

Everyone seems to know what it looks  like, but…

no one has actually seen one!

Founding Members• Memorial Health System (2 hospitals)

• Penrose‐St. Francis Health Services (2 hospitals)• Colorado Springs Health Partners (CO’s largest multispecialty group)

• Peak Vista Community Health Centers (federally qualified CHC)

• AspenPointe Behavioral Health (community mental health)

• El Paso County Public Health• El Paso County Medical Society

• Rocky Mountain Health Care Services (PACE program)

• Mountain View Medical Group (specialty & primary care group)

• Pikes Peak Hospice & Palliative Care

Pilot Roll Out• Initial Phase – July 2011‐June 2012

• 2 Primary Care Medical Providers• 6,300 Medicaid clients July 2011 (19,000 clients May 2012)• Colorado Springs focus community• 2/3 adults, 1/3 children• Maintain fee‐for‐service structure to providers; additional 

payments to primary care medical homes and RCCOs

• Expansion Phase – July 2012‐June 2016• 10‐30 Primary Care Medical Providers• 60,000 Medicaid clients maximum potential enrollment• El Paso, Teller, Park and Elbert Counties• Potential shared savings payments• Propose payment reform models

A Collaborative Approach• Chief Medical Officer provided by Peak Vista

• Contract Manager funded by Penrose‐St. Francis

• Financial Manager, Network Development, Service 

Center, IT Support provided by AspenPointe

• RCCO CEO provided by CHP• Care Management Plan funded by Kaiser Permanente 

and developed by task force of partners

• Governance Committee made up of founding partners

• Fiscal authority provided by CHP Board of Directors

Pilot Goals

• Reduce Emergency Room Visits• Reduce Hospital Re‐Admissions• Reduce Outpatient Services

• (MRI, CT Scans, X‐Rays) 

• Health improvement goals TBD

Model of Care

• Medical Home 

• Integrated Care Coordination• Patient‐Centered

It’s about relationships…

• Enhanced access to care• Communication between patient and 

primary care team

• Comprehensive, coordinated care

Looking at the Whole Person

• Health care plays a surprisingly small role  in life expectancy – only 10%.

• 4 in 5 physicians say unmet social needs  are directly leading to worse health.

Health Care’s Blind Side , Robert Wood Johnson Foundation,  2012

Coordinated Care

• Coordinated Care is the core of the  ACO model

Identifying Risk• Stratification of clients by risk 

(identified by predictive risk and  point‐of‐care assessments)

The One Question

How is your health?  

Poor

Fair

Good

Excellent

Targeted Interventions• Health Coaching/Health Literacy• Disease Management Tools

• Shared Decision‐Making

• Discharge Follow‐Up• Emergency Department On‐Site Program

• Intensive Medical/Psycho/Social Case  Management

Building a Network• Adoption of common standards and 

expectations for care coordination  within the medical neighborhood

Collaborative Care ManagementCollaborative Care ManagementMutual AgreementMutual Agreement

•• Define responsibilities between PCP, specialist and patient.Define responsibilities between PCP, specialist and patient.•• Clarify who is responsible for specific elements of care (drug Clarify who is responsible for specific elements of care (drug therapy, referral management, diagnostic therapy, referral management, diagnostic

testing, care teams, patient calls, patient education, monitorintesting, care teams, patient calls, patient education, monitoring, followg, follow--up).up).•• Maintain competency and skills within scope of work and standarMaintain competency and skills within scope of work and standard of care.d of care.•• Give and accept respectful feedback when expectations, guidelinGive and accept respectful feedback when expectations, guidelines or standard of care are not metes or standard of care are not met•• Agree on type of specialty care that best fits the patientAgree on type of specialty care that best fits the patient’’s needs.s needs.

ExpectationsExpectations

Primary CarePrimary Care Specialty CareSpecialty Care

Follows the principles of the Patient Centered Medical Home or Follows the principles of the Patient Centered Medical Home or Medical Home Index.Medical Home Index.Manages the medical problem to the extent of the PCPManages the medical problem to the extent of the PCP’’s scope of s scope of practice, abilities and skills.practice, abilities and skills.Follows standard practice guidelines or performs therapeutic trFollows standard practice guidelines or performs therapeutic trial ial of therapy prior to referral, when appropriate, following evidenof therapy prior to referral, when appropriate, following evidencece--based guidelines.based guidelines.Reviews and acts on care plan developed by specialist.Reviews and acts on care plan developed by specialist.Resumes care of patient when patient returns from specialist caResumes care of patient when patient returns from specialist care.re.Explains and clarifies results of consultation, as needed, withExplains and clarifies results of consultation, as needed, with the the patient. Makes agreement with patient on longpatient. Makes agreement with patient on long--term treatment plan term treatment plan and followand follow--up.up.

Reviews information sent by PCPReviews information sent by PCPAddresses referring provider and patient concerns.Addresses referring provider and patient concerns.Confers with PCP or establishes other protocol before orders Confers with PCP or establishes other protocol before orders additional services outside practice guidelines. Obtains proper additional services outside practice guidelines. Obtains proper prior authorization.prior authorization.Confers with PCP before refers to secondary/tertiary specialistConfers with PCP before refers to secondary/tertiary specialists s for problems within the PCP scope of care and uses a preferred for problems within the PCP scope of care and uses a preferred list to refer when problems are outside PCP scope of care. list to refer when problems are outside PCP scope of care. Obtains proper prior authorizationObtains proper prior authorization when needed.when needed.Sends timely reports to PCP to include a care plan, followSends timely reports to PCP to include a care plan, follow--up up and results of diagnostic studies or therapeutic interventions.and results of diagnostic studies or therapeutic interventions.Notifies the PCP office or designated personnel of major Notifies the PCP office or designated personnel of major interventions, emergency care or hospitalizations.interventions, emergency care or hospitalizations.Prescribes pharmaceutical therapy in line with insurance Prescribes pharmaceutical therapy in line with insurance formulary with preference to generics when available and if formulary with preference to generics when available and if appropriate to patient needs. appropriate to patient needs. Provides useful and necessary education/guidelines/protocols Provides useful and necessary education/guidelines/protocols to PCP, as neededto PCP, as needed

Measuring Progress• Consistent metrics across medical 

homes and the broader medical  neighborhood

• Dashboards

Data Sharing• Use of common HIPPA‐compliant 

electronic communication tool for  referrals

Key Challenges• Lack of Medicaid enrollment stability, i.e. 

“Churn”

• Integrating mental and dental care

• Access to specialists• Payment reform is critical

What’s Next?• Payment reform • Policy reform• Expansion to other populations• Prevention & wellness – moving 

upstream

Transformation Takes Time

“The price of doing the same old  thing is far higher than the price of 

change.”‐

Bill Clinton 

Track 6: Integrated Dual Eligible and Medicaid Reforms

Panel 2: Transitioning Medicaid Programs to Accountable Care

Carol Bruce-Fritz Executive Director, Community Health PartnershipsJaeson T. Fournier, DC, MPH Chief Executive Officer, West Side Community Health ServicesJeanene Smith, MD, MPH Administrator, Oregon Health Policy and ResearchJennifer DeCubellis, LPC Area Director, Hennepin County Human Services and Public Health DepartmentTricia McGinnis MPP, MPH Senior Program Officer, Center for Health Care Strategies (Moderator)

The Engelberg Center for Health Care Reform at Brookings | The Dartmouth Institute

June 6–8, 2012

Third Annual National ACO Summit

Follow us on Twitter at @ACO_LN

and use #ACOsummit.