2009 SNP Alliance Profile and Advanced Practice Report October 29, 2009

Background on SNP Alliance and Profile Report The National Health Policy Group founded the SNP Alliance SNP Alliance is the only national organization exclusively dedicated to improving policy and practice for SNPs 2008 SNP Profile & Advanced Practice Report – December 2008 The 2009 Update of the Profile Report Are the SNPs targeting the “right people”? Are the SNPs doing anything “special”? Are the SNPs making a positive difference for their enrollees?

Medicare Special Needs Plans: National Overview

Number of Operational SNPs Increased Rapidly Through 2008 but has Declined During 2009 Number of Medicare SNPs (based on contract numbers) The number of operating SNPs rose 60% in less than two years The Number of Chronic Care SNPs tripled SNP Type December 2007 December 2008 September 2009 Chronic 73 241 212 Duals 320 436 407 Institutional 84 85 83 All SNPs 477 762 702 Source: CMS SNP Comprehensive Report

Percent Change, Dec ’07 – Dec ‘08 Percent Change, Dec ’08 – Sep ‘09 National SNP Enrollment Grew 20% in 2008 -- But Has Increased Only Modestly During 2009 SNP Type Enrollment December 2007 Enrollment December 2008 Enrollment September 2009 Percent Change, Dec ’07 – Dec ‘08 Percent Change, Dec ’08 – Sep ‘09 Chronic 192,610 283,406 293,569 47.1% 3.6% Duals 760,561 911,950 951,590 19.9% 4.3% Institutional 145,583 127,776 115,500 -12.2% -9.6% All SNPs 1,098,754 1,323,132 1,360,659 20.4% 2.8% Source: CMS SNP Comprehensive Report

Most SNPs Have Well Below 1,000 Enrollees (when looking at the contract number level) Mean Enrollment by Plan Type SNP Type December 2007 December 2008 September 2009 Chronic 2,638 1,176 1,385 Duals 2,377 2,092 2,338 Institutional 1,733 1,503 1,392 All SNPs 2,303 1,736 1,938 Median Enrollment by Plan Type 614 324 322 502 605 695 97 269 275 431 475 525 Source: CMS SNP Comprehensive Report

SNP Alliance Statistics

Data Collection: SNP Alliance Health Plans Survey Instrument sought information the SNPs have already compiled from two sources: Enrollment and Average Risk Score from the December Monthly Membership Report (MMR) Average Number of HCCs from Model Ouptut Report (MOR) Distinguished between enrollees “New to Medicare” (RAF Type E) and “All Other” Enrollees Health Utilization Statistics for calendar years 2007 and 2008 (annual utilization per 1,000 covered persons) Inpatient Days Skilled Nursing Facility Days Total Physician Office Visits Number of Prescriptions Advanced Practice examples and case studies Lisa C speaking

SNP Alliance Plans Operate in 41 states (and DC); These Plans Hold 34% of Nationwide SNP Enrollment Six States do not offer SNPs in 2009: Alaska, Montana, New Hampshire, North Dakota, Vermont, Wyoming (source: Kaiser Family Foundation; statehealthfacts.org)

Share of Enrollees “New to Medicare” A Growing Proportion of SNP Alliance Enrollees are Newly Eligible for Medicare Share of Enrollees “New to Medicare” SNP Type Dec 2004 Dec 2005 Dec 2006 Dec 2007 Dec 2008 Chronic -- 5.9% 10.7% 12.3% Duals 7.3% 7.2% 2.0% 6.0% 5.7% Institutional 0.8% 0.3% 1.0% 0.6% SNP Alliance 2.7% 3.1% 1.6% 6.7% 7.9%

Weighted Average Risk Score Expected Per Capita Cost for SNP Alliance Enrollees is Far Above the Medicare Average (as of Dec ’08) Weighted Average Risk Score SNP Type Dec 2004 Dec 2005 Dec 2006 Dec 2007 Dec 2008 Chronic -- 1.38 1.24 1.16 Duals 1.69 1.59 1.43 1.35 Institutional 1.76 1.74 1.78 1.95 SNP Alliance Weighted Average 1.52 1.34 Medicare Fee-For-Service Comparison Statistics (CMS 5% Sample Benchmarks) Total Medicare Population 0.96 0.98 Chronic: Diabetes Chronic: Congestive Heart Failure 1.77 Dual Eligibles 1.23 Medicare Advantage Enrollees 0.97 SNP Alliance plans are targeting a high-need subgroup of Medicare beneficiaries.

Median Risk Scores are Also Useful in Depicting SNP Alliance Membership Mix SNP Type Dec 2004 Dec 2005 Dec 2006 Dec 2007 Dec 2008 Chronic -- 1.34 1.18 1.14 Duals 1.93 1.76 1.62 1.60 1.51 Institutional 1.65 1.72 1.80 1.92 2.04 SNP Alliance 1.63 1.58 1.44

Every SNP Alliance plans has an average risk score above 1.00. Risk Score Ranges Are Wide Due To Differing Target Populations Served (and some small sample size issues) Range of Risk Scores by Year and SNP Type SNP Type Dec 2004 Dec 2005 Dec 2006 Dec 2007 Dec 2008 Chronic -- 1.03 – 1.66 1.06 – 1.38 1.03 – 1.38 Duals 1.20 – 2.41 1.28 – 2.64 1.17 – 2.64 1.05 – 2.65 1.05 – 2.37 Institutional 1.35 – 1.95 1.44 – 2.00 1.57 – 1.87 1.56 – 2.02 1.68 – 2.21 Every SNP Alliance plans has an average risk score above 1.00.

Risk Scores for SNP Alliance Enrollees “New to Medicare” are Roughly 55% of those for the SNPs’ Remaining Membership Risk Scores for Enrollees “New to Medicare” Compared to “All Other Enrollees” SNP Type Dec 2004 Dec 2005 Dec 2006 Dec 2007 Dec 2008 Chronic -- 51.3% 54.5% Duals 58.1% 57.2% 59.3% 63.2% 69.9% Institutional 54.0% 43.4% 47.1% 47.4% 46.5% SNP Alliance 66.2% 54.2% 56.9% 55.4%

Weighted Mean Number of HCCs per Enrollee SNP Alliance Enrollees Average Roughly Twice The Co-Morbidities as the Overall Medicare Population Weighted Mean Number of HCCs per Enrollee SNP Type Dec 2004 Dec 2005 Dec 2006 Dec 2007 Dec 2008 Chronic -- 3.62 3.83 3.20 Duals 2.12 2.30 2.27 2.34 2.43 Institutional 1.63 2.91 3.05 3.25 3.72 SNP Alliance Weighted Average 1.75 2.73 2.51 3.00 2.93 Medicare Fee-For-Service Comparison Statistics (Derived from CMS 5% Sample Data Files) Total Medicare Population 1.46 1.48 Chronic: Diabetes 2.95 Chronic: Congestive Heart Failure 4.24 4.31 Dual Eligibles 1.88 1.90 3.66 3.71

Range of HCCs per Enrollee Several SNP Alliance Plans Serve Members with Exceptionally High Numbers of Co-Morbidities Range of HCCs per Enrollee SNP Type Dec 2004 Dec 2005 Dec 2006 Dec 2007 Dec 2008 Chronic -- 1.39 – 5.29 1.76 – 4.27 1.88 – 4.32 Duals 1.39 – 3.57 1.24 – 4.18 1.34 – 3.95 1.22 – 4.21 1.54 – 3.95 Institutional 1.63 1.87 – 3.70 1.70 – 3.80 2.30 – 4.00 2.40 – 4.60

SNP Alliance: Health Care Utilization

There is Considerable Evidence that the SNPs Substantially Lower Inpatient and SNF Usage Compared to FFS Medicare SNP Alliance Medicare Fee-For- Service

SNP Alliance Plans Lower Inpatient Utilization Specific impact estimates are hard to quantify, but there is evidence that: Strong management of inpatient care occurred across the chronic care SNPs The inpatient usage rate for dual eligible SNPs is 25% below the FFS average for dual eligibles Institutional SNPs may well have achieved the largest inpatient usage reductions – possibly by more than 50%

Substantial Reductions in Skilled Nursing Facility Utilization Also Occurred Precise impact estimates cannot be made with the available data, but the evidence indicates that: Chronic care SNPs substantially lowered SNF usage – possibly by more than half Dual eligible SNPs likely achieved more than a 20% reduction in SNF use

Office Visit Usage Increased Substantially for SNP Alliance Members The number of office visits are considered to reflect to improved level of access to needed services for this high risk group of beneficiaries Chronic Care SNP enrollees averaged 16 office visits per person during 2008 Dual Eligible SNP enrollees had nearly twice as many office visits compared with FFS dual eligibles

SNP Alliance: Qualitative Assessment

Hallmarks of the SNP Model of Care Extensive education initiatives and strong efforts to establish a positive relationship with each individual member Identify individual needs Involvement of family and other caregivers as key stakeholders A tailored array of programs and interventions Ongoing care coordination for all SNP Alliance members Recruitment and retention of specialized staff Comprehensive Medication Management Commitment to treating the whole person

Assessment and Orientation Programs for New Enrollees Multi-disciplinary care teams complete assessment for new enrollees within a short period after enrollment “Our care plans start with listening to what is important to the member.” The assessments “identify what a person sees as most important for their quality of life” and the care team learns “which intervention most align with a member’s perspective.”

Integration of Care Care Coordination & The Primary Care Home Multi-Disciplinary Team Model Care Coordination & The Primary Care Home Hospitalization & Transition/Discharge Program Mental & Behavioral Health Social Services Medication Management Wellness Program and Other Proactive Outreach Initiatives Continuous Improvement Efforts

Questions & Feedback

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