The SCAN Foundation Defining the Business Case for Targeted Care Coordination

1. The SCAN FoundationDefining the Business Case for Targeted Care Coordination Congratulations, you have logged in successfully! Audio: Audio for the entire webinar can be heard through the speakers associated with your computer (built in or plugged in).If you are unable to use your computer’s speakers or an accompanying headset, you may dial into the conference at 1-888-858-6021 and enter PIN code 1575317364 followed by the # sign. Music will play until the webinar begins. • How the Webinar Works: Let the presentation run; you do not need to interact with your computer. All attendees are placed on listen only mode. If you have a question during the meeting click the Q&A menu at the top of the screen to submit your question. Technical Assistance: Communiqué Conferencing technical assistance is available by: • Press 00 on your telephone or • Calling 1-877-283-7062 or (973) 796-5047

2. January 22, 2015 Defining the Business Case for Targeted Care Coordination Featuring: Gretchen Alkema, Ph.D. VP Policy & Communications, The SCAN Foundation Dianne Munevar Director of Data Analytics, AvalereHealth Sally Rodriguez Director of Business Intelligence for Healthcare Providers, AvalereHealth

3. Agenda • Introduction • Effective Management of High-Risk Medicare Populations • Q&A

4. Effective Management of High-Risk Medicare Populations January 2015 avalere.com

5. Avalere Team Presenting Today

6. Overview The goals of the collaborative work between the scan foundation and avalere were to: 2 Evaluate the state of patient care surveys and health risk assessments (HRAs) used by Medicare Advantage (MA) plans and recommend improvements 1 Promote a greater understanding of “high-risk” Medicare beneficiaries and the characteristics that are predictive of high Medicare service use and spending 3 • Illustrate the quantifiable range for the return-on-investment (ROI) for selected care coordination programs

7. Webinar Agenda The Opportunity to Take a More Proactive Stance on Managing Risk Identifying High-Risk Beneficiaries The Opportunity to Enhance the Use of Patient Care Surveys Estimating the ROI from Effective Care Transition and Coordination Interventions Key Takeaways Discussion

8. The Opportunity to Take a More Proactive Stance on Managing Risk

9. The Health Care Delivery System Is Evolving to Reward Value Over Volume FEE-FOR-SERVICE (FFS) - THE TRADITIONAL APPROACH TO PAYMENT - VIEWED AS INSUFFICIENT AT CONTAINING COSTS FFS: Fee-for-service

10. Proactively identify high-risk beneficiaries To Succeed In the Evolving Environment, Providers and Health Plans Need Strategies To Mitigate Risk Understand the patient-level characteristics that correlate with being high-risk Manage the care of high-risk beneficiaries through effective care coordination programs Effective Population Health and Risk Management Strategies

11. However, Most MA Plans and Providers Rely Only On Administrative Claims Data To Identify High-Risk Members When an underlying chronic condition accompanies an inability to care for oneself independently, per capita health care spending can double.

12. Non-Medical Characteristics Are Critical to Care Coordination and Can Increase Utilization and Spending Medicare spends almost four times as much for beneficiaries with cognitive impairment, such as Alzheimer’s or dementia, than for those who do not have a cognitive impairment.

13. Identifying High-Risk Beneficiaries

14. Medical Characteristics Associated with Being At Risk For High Healthcare Utilization and Spending MEDICAL ISSUES RELATED TO HIGH-RISK BENEFICIARIES ARE EXPECTED 1. Average percentage point increase for patients having the factor based on a logistic regression model using the validation sample (2009 and 2010 data); and are rounded to the nearest tenth decimal 2. Defined as being in the top 10 or 20 percent of Medicare spending, respectively, based on a Per Member Per Month estimate

15. Looking Beyond Medical Information HOWEVER, AND POTENTIALLY MORE IMPORTANTLY, SOME NON-MEDICAL CHARACTERISTICS INCREASE THE PROBABILITY OF BEING HIGH-RISK THAT CANNOT BE DEFINITIVELY IDENTIFIED USING ADMINISTRATIVE CLAIMS Average percentage point increase for patients having the factor based on a logistic regression model using the validation sample (2009 and 2010 data); and are rounded to the nearest tenth decimal “High” utilization is defined as being in the top 75th percentile of the number of stays (inpatient services) or visits (ambulatory care) in the prior year Estimates are consistent from one year to another but there is relatively low precision of predictive power

16. The Opportunity to Enhance the Use of Patient Care Surveys

17. Patient Care Surveys Can Strengthen Risk Stratification and Care Management Activities Avalere conducted a literature review and interviewed industry experts to evaluate the state of patient care surveys used by payers AWV: Annual wellness visit; CMS: Centers for Medicare & Medicaid Services • Patient Care Surveys • Health-related questionnaires that are conducted telephonically, in-person, online, or through mailed questionnaires • Can strengthen risk stratification and care management activities by capturing key information about members’ health (e.g., family history, lifestyle, and functional status) that are not stored in claims data • Health Risk Assessments • One example of a patient care survey used by health plans is the HRA • MA plans must administer HRAs as part of AWVs; however, CMS provided limited guidance, and therefore significant flexibility, in how plans administer HRAs

18. Plans Should Leverage Other Available Data Sources to Create a Comprehensive Patient Profile

19. HRAs Can Help MA Plans Identify LTSS Needs • By incorporating questions that target LTSS needs into HRAs and other types of patient care surveys, plans will be better equipped to understand, and therefore, manage their members. Interviewees noted that hras can assess LTSS needs by evaluating the following domains: LTSS: Long-term supports and services; ADL: Activities of daily living; IADL: Instrumental activities of daily living • ADLs and/or IADLs • Behavioral/mental health • Cognitive function • Family and caregiver support • Frailty and fall risk • Functional status • Living situation • Having a regular primary care physician • Nutrition and/or access to proper meals • Skin issues • Home safety • Transportation

20. Medical History Alone Cannot Explain High-Cost Utilization Likelihood of Being Top 20 High-Cost Total Payment High-Cost Utilization Patient Profile • Forgetful • No family in the area • Smoker (1 pack/ day) • Widowed/ lives alone • No exercise • High blood pressure • High glucose levels • High sodium levels • Bone loss • Diabetes • Age 91 • High Medicare spending prior year ? $128k 35% Emergency department visit Readmission Index hospitalization

21. Using Comprehensive Patient Data Helps Prevent High-Cost Surprises Patient Profile Likelihood of Being Top 20 High-Cost Total Payment High-Cost Utilization Case Management Input • Forgetful, sometimes agitated • No family in the area • Bored during the day HRA • Smoker (1 pack/ day) • Widowed/ lives alone • No exercise • Improper nutrition Medical Record • High blood pressure • High glucose levels • Bone loss • History of falls Claims Data • Diabetes • Age 91 • High Medicare spending prior year 80% 75% $128k 45% 35% Emergency department visit Readmission Index hospitalization

22. Plans Should Use Targeted Questions in Patient Care Surveys to Support and Inform Care Coordination Efforts • Plans that use enhanced patient care surveys to support risk stratification care management efforts will have a competitive edge in an evolving Medicare paradigm that rewards population management and spending efficiency. Although Enhanced patient care surveys may require more financial investment, the ability to meaningfully assess risk can allow plans to: Improve patient satisfaction scores Better coordinate the care of their members Help keep members in the community Increase member retention rates Support patient education and engagement efforts

23. Estimating the ROI from Effective Care Transition and Coordination Interventions

24. Plans Should Support Risk Identification Efforts with Care Management Programs To Reduce High-cost Utilization

25. Effective Care Transition and Coordination Models Can Reduce Healthcare Utilization SNF: Skilled nursing facility; NH: Nursing home; NP: Nurse Practitioner; APRN: Advanced practice registered nurse; PCP: Primary care physician Project BOOST was reviewed as part of the ROI analysis, but the result is not included in the next slide because of the limitations of the evidence.

26. Employing Care Transition and Coordination Models Can Lead to Positive ROI for Health Plans • Care transitions programs that integrate care transition and long-term care management are cost-effective in reducing high-cost utilization. Also, higher program investments are not necessarily associated with higher financial return—narrower targeting aimed at the highest-risk members may improve ROI.

27. Establishing, incentivizing, or working with providers to implement care transition models such as those discussed MA Plans and Providers Can Strengthen Their Programming to Realize an ROI Offer services outside the scope of typical MA plan offerings, such as home modifications, fall prevention services, and fully coordinated care models Referring and coordinating care for beneficiaries with LTSS needs to community-based or other services Cost-Effective Care Management Yielding Positive ROI

28. Matching Appropriate Services to the Patient Has Potential to Reduce High-Cost Utilization Total Payment High-Cost Utilization Care Management $128k Meals on Wheels -25% $96k Community-Based Adult Day Services Emergency department visit Readmission Index hospitalization

29. Putting It All Together Costs Benefits Reduced unnecessary utilization GRACE Team Care intervention Meals on Wheels Reduced spending by $48,000 – that’s a 40 percent reduction in a single year Adult Day Care Services Improved Ruth’s quality of life Allowed Ruth to live independently $32,000 300% $8,000

30. Key Takeaways

31. Key Takeaways To effectively manage high-risk populations, plans and providers must: 2 Improve Data Collection. By expanding the scope of plans’ patient care survey use, plans have an immediate opportunity to collect member information that will strengthen their ability to risk-stratify and enroll members in patient-centered care programs 1 Identify the Right Risk Factors. Non-medical factors, when coupled with medical risk factors, are powerful predictors of costly health care utilization 3 • Implement Targeted Care Coordination Programs. Effective management of key populations not only improves outcomes for plan members, but can yield a positive ROI

32. The SCAN FoundationDefining the Business Case for Targeted Care Coordination Q & A

33. The SCAN FoundationDefining the Business Case for Targeted Care Coordination • Asking questions during the presentation: • Click “Q&A” menu located at the top left of your screen to open the Question Panel. • Place your curser into the blank field at the top, type in your question and press the ‘Ask’ button. Ask a Question Retract Question

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