NHP/Brightwood Evaluation If special programs work - clinically and financially - for small groups of members with complex but homogeneous disability and medical needs ….. Can these programs be adapted to work on a population basis with the broad range of SSI members?

Selection of Brightwood as Pilot Site Large community health center in Springfield, MA Much higher SSI clinic population than other community health centers Strong clinical leadership and vision Already operating a specialized program for NHP members with HIV/AIDS Largely Spanish-speaking population, and poor access to culturally and linguistically appropriate behavioral health care

Initial Model: Identification Convert 800 SSI fee-for-service patients to NHP members Convert 500 long-term unemployed fee-for- service patients to NHP members Conduct health risk assessment Conduct chart review Identify individuals through ED, Inpatient admissions

Model: Stratification Who gets preventive care reminders? Who gets telephone care management? Who gets intensive care management? Who gets enhanced behavioral health coordination or services? Who gets peer interventions?

Model: Intervention Reminders for primary and preventive care visits Integrated care management team: – RNPs, RNs – Behavioral health clinicians – Peer support team – Addictions Advocate, Clinical Assistants Different levels of care management intervention

Financing Spend an additional $50 PMPM on primary care and care coordination Take $14 PMPM out of the behavioral health carve-out to purchase on-site behavioral health care Spread costs over approximately 1000 SSI and Long-term unemployed members

Plan vs Reality PlanReality # of SSI enrollees # of Long Term Unemployed enrollees Staffing5 RNPs5 different professions Enhanced primary care and coordination PMPM $50$85

Barriers and Improvement Cycles Enrollment Negotiation over model Politics, politics, politics

Implications of Selection DXCG risk adjustment, applied to 282 SSI members at Brightwood. Predicted costs would be 17% higher than NHP SSI average costs. Disproportionate number of Brightwood SSI members with HIV or chronic mental illness (reflected later in RX expenditures)

CY 2002 PMPM Expenditures - Annualized ServiceAverage PMPM Facility$124 Physician$60 Other Medical$61 Pharmacy$299 Behavioral Health$65 Enhanced Care Coordination$101 TOTAL$710

Distribution of Capitation, 2002

Distribution of Expenditures PMPM per Quarter

Brightwood Experience Compared to Other NHP SSI Members NHP Average PMPM for SSI members$719 Risk-adjusted expectation for Brightwood SSI members $841 Brightwood Actual PMPM (including enhanced primary care and care coordination) $710

NHP/Brightwood Comparison NHP Brightwood Pharmacy PMPM$200$299 Inpatient Behavioral Health$27$4 Outpatient Behavioral Health$46$61+$15 BH Penetration Rate31%42%