What’s Special About SNPs? Rich Bringewatt Chair, The SNP Alliance and President, National Health Policy Group 9th Annual Leadership Forum on Integration and Specialized Managed Care October 10-11, 2013

Six Case Studies AIDS Healthcare Foundation Brand New Day CareMore Commonwealth Care Alliance Family Choice of New York SCAN Health Plan

What’s Different About Them?

1. Pervasive Caring They care more than anyone else cares. Compassion is everywhere. The people they serve really are THE focus of ALL their work. They can’t stop thinking about doing what is right for those they serve.

Pervasive Caring Examples CareMore: “The name intended to imply a proactive model of care with a caring touch.” SCAN’s I-SNP: They “incorporate member education and coaching to enhance self-management skills.” Brand New Day: The program makes heavy use of “life coaches” that “delve into the life situation of the member.” They start with “building trust” with pervasive use of “Best Friend Service.” All Case Examples: Go beyond the label of “person-centered care,” with the substance of what they do embedded in a very “high-touch” and “personal” approach to care. When you talk with program leadership, the “feel” and depth of their “caring” is infectious.

2. Population Health Management They don’t focus on establishing a generic, high quality program for all Medicare and/or Medicaid beneficiaries, as many traditional MA and Medicaid MCOs do. Their sole reason for being is to address the unique need of defined population segments, e.g. frail elders, adults with physical disabilities, persons with SPMI or AIDS, etc.

Population-Based Examples Family Choice: “Anatomical and physiological changes that occur naturally as part of the aging process require specialized assessment, diagnostic techniques, and interventions.” Commonwealth Care Alliance: Offers two separate plans in the same service areas with one program (called SCO) tailored specifically to address the unique needs of people age 65 and older, and the other program (called One Care) designed differently to address the unique needs of adults with disability. All Case Examples: Look at every aspect of benefits and program design, and CHANGE what they do across the continuum to respond to the unique needs of defined population segments.

3. STRENGTHEN PRIMARY CARE Docs have expertise in needs of target subset. They function as teams. Support staff are empowered. They are concerned about every aspect of their patient’s life. They engage in every aspect of the system. EVERYONE (patients, caregivers, providers, etc.) is empowered to do what is right.

Primary Care Examples CareMore: “Teams of non-physician health care providers, based in a CareMore Care Center, supplement primary care medical practice with hands-on disease and frailty management. They employ “extensivists” to directly manage a member’s care” using “a fundamentally new method of delivering needed services” in hospitals and other settings. Commonwealth Care Alliance: “Enhanced primary care, care coordination/management, interdisciplinary care teams…deliver or arrange every type of care needed by the individual…with access “24-7”. Different primary care teams and protocols are used to manage the care of disabled adults vs. frail elders. Standard transitional primary care is seen as “simply inadequate.” All Case examples: Reorder primary care methods, with protocols tailored to the unique needs of defined population segments. They make heavy use of primary care NP/RN and non-physician professionals. The teams get involved in every aspect of the care process.

4. BUILD COMPLEMENTARY RELATIONSHIPS Docs, nurses and social workers. Hospitals and nursing homes. Homes and technology. Medical care and behavioral health. Medicare and Medicaid.

Relationship Examples SCAN’s I-SNP: “Employs an integrated medical/social approach to managing vulnerable individuals.” Brand New Day: Complements medical treatment with a “life coach” who may “enter into a behavioral contract with the member” that can include helping the beneficiary manage “housing and financial instability.” CareMore: “Uses NPs to provide care to members residing in nursing homes”… “remote monitoring to support people at home” that can trigger home visits within a few hours and “proactive, integrated health” in serving persons in the hospital and other healthcare environments. All Case Examples: Pay special attention to the interface between Medicare and Medicaid, bridge the boundaries between medical care and behavioral health, and provide complementary support to cover medical weaknesses traditionally found in nursing homes and psycho-social weaknesses traditionally found in acute care settings.

5. Invest in Right Stuff Focus is on where to invest rather than where to trim. Remove financial barriers for consumers to do what is most important. Spend money on what does the most good.

Investment Examples Commonwealth Care Alliance: Has made “significant investment into primary care infrastructure, care coordination, and home and community long-term care services…resulting in reducing hospitalization and nursing home placement.” CareMore: Has made significant investment in approaches “uniquely suited to the specialized needs of patients with chronic conditions,” CareMore Care Centers that “supplement primary care medical practices with hands-on disease and frailty management,” and benefit designs that “remove barriers that lead to patient non-compliance with care programs. All Case Examples: Focus more on where they invest their money in innovation to achieve better cost and quality outcomes overall than simply looking where to trim costs for cost savings.

The Pay Off Commonwealth Care Alliance: CMS Quality Star Ratings of 4.5 Stars for performance in 2011 and 2012 placed CCA in the 87th percentile of all Medicare Advantage Plans. Using 2008 Medicaid expenditures, their Disability Model cost $840 PMPM for primary care vs. $41 PMPM in FFS BUT it resulted in an overall cost reduction of $3,601 vs. $4210 PMPM in Medicaid FFS. CareMore: 42% fewer admissions than national average for ESRD patients. Their diabetic amputation rate is 60% below the national average. They also reduced hospital admissions by 56% in 3 months for CHF patients, with wireless scales alerting clinicians of excessive weight gain in 12-72 hour increments, triggering a same-day visit. Brand New Day: Extended life expectancy of their enrollees by 4.7 years. Psychiatric hospital bed days were reduced 49.9%; Medical/surgical stays were reduced 17.5%; and ER visits were reduced 42.4% over two years of continuous enrollment.