Treating the Uninsured: Provider Perspectives on Caring for Uninsured Patients Karen Michael, RN, MSN, MBA Vice President of Clinical Services AmeriHealth Mercy

Who We Are Mission-driven, provider-affiliated Largest Medicaid-only, multi-state plan with over 20 years of experience Four distinct product lines: Full risk health plans Management and administrative service contracts PerformRx pharmacy management PerforMED care management 2

AmeriHealth Mercy Family of Companies Current Markets Contra Costa 68,822 Touchstone 3,285 Neighborhood Health Plan of Rhode Island 73,362 MDwise Hoosier Alliance 140,999 MDwise 142,544 Passport TANF, SSI, CHIP 144,926 AmeriHealth Mercy Keystone Mercy TANF & SSI 365,067 Horizon NJ Health 322,544 Virginia Premier 110,074 CalOptima 36,972 Inland Empire 308,800 Select Health TANF & SSI 75,707 Optimum Health Plan 757 METCARE Health Plans 5,368 Pediatric Associates Health Plan 9,686 Membership numbers as of April 2007 Full Risk and PerformRx MSA and PerformRx ASA PerformRx – Medicare Part D only PerformRx – Medicaid only Total Membership Risk 581,773 MSA/ASA/TPA 477,156 Pharmacy-Medicaid 1,149,578 PDP/Medicare Advantage 94,811_ Total 2,303,318

The Question How can care for the uninsured be improved within today’s delivery systems? Appropriate distribution across care settings Improved management of chronic illnesses Better health outcomes Less costly

Similarities to Medicaid Demographics Geographic Distribution Pent-up Demand Language Barriers Inconsistent Eligibility Transportation Parallel population to Medicaid – in some ways more challenging Cluster in cities/scattered in rural areas On and off MA roles (30% of 17,000) Children in household may have MA coverage – Parental influence may hinder child’s access to coverage Children more likely to use health care if parents did/uninsured children twice as likely to see doctor if parent visited doctor/insured children three times as likely Uninsured adults more likely to have neg. experience – role model this orientation to their children

Service Utilization System Navigation/Care Coordination No Medical Home/PCP No access to advocate who knows the system Source: National Public Engagement Campaign on Chronic Illness – Physician Survey, conducted by Mathematica Policy Research Inc., 2001.

Service Utilization 40% of Emergency Room visits have Primary Care components and/or relate to chronic illness Two patterns: Use of ER for primary care – or unmanaged chronic care Visit to the ER results in admission Hospitalizations are emergent – These individuals will be admitted (complex medical problems, no treatment history) Source: Emergency Room Data – 17,000 Uninsured individuals; CY 2006

The Setting 2 urban community hospitals Demographically challenged Forecasted population decreases Primarily medical admissions 70-75% of patients from Government payors Diminishing physician availability M Fitz: 368-bed acute care, community teaching hospital serving Delaware County and Southwest Philadelphia (70 years) M Hosp: full-service 266-bed community hospital (88 years) -        -    Demographically challenged with forecasted population decreases     -    Primarily Medical Admissions, High Surgery out migration from the service area to Academic Medical Center Providers     -    High utilizers of Emergency services for all levels of care - primary, Urgent, emergent - 70 - 80% of admissions from ED     -    70-75% of patients from Government payors (Medicare & Medicaid)    -        -    Levels of medical and administrative non-compliance to regarding healthy lifestyles and potentially available health coverage (but I guess you already know this)     -    Little to no new physicians entering service area to practice     -    Specialty Physicians leaving service area and not available patients, for ER coverage or any other call     -    Lingering Malpractice issues/perceptions     -    Placement issues, readmissions, Care Management, integration/coordination with other level providers

Community Need Index Five Counties Communities of high Need - we call this the red zone based on the Solucient Community Need Index - See Map and the Claritas Health Status Index

Uninsured: Higher Levels of Chronic Conditions Especially High Blood Pressure and Diabetes Data is from Mercy Fitzgerald Analysis Source: Community Needs Assessment, National Research Corporation, 2006-07 Survey

The PerforMED Model Predictive Modeling Holistic Approach Barrier Resolution Advocacy Community Outreach Data Management Remembering Maslow – “DM” story Proactive outreach – aggressive P4P incentives – new member assessment Create medical record from hospital and clinic data Health literacy, language, transportation Access – providers, community services Rapid response team

The Marriage Coordinate care for uninsured patients using Inpatient and ER services Goals: Improve quality of care Move care from IP to OP settings

Challenges Network Confidentiality statutes Medications Facilities Primary Care Specialty Care Ancillary Services Confidentiality statutes Medications

Discussion