Dual Integrated Financing and Its Opportunity to Fundamentally Improve Care and Reduce Costs: The Commonwealth Care Alliance, Primary Care Redesign and Enhancement Experience © 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information NHPRI/RIHCA Policymaker Breakfast November 16, 2011

Case Vignette Anna C. is a 65-year-old woman, SSI then Dually eligible for 10+ years. She has long standing Multiple Sclerosis with complete paralysis in both legs, impaired bladder function, weakness and increasing spasticity in her arms. Chronic depression, a prior major suicide attempt and a history of severe asthma exacerbated by heavy smoking, predated her MS. For many years, Anna was able to use a manual wheelchair and perform self catheterizations but with progression of upper extremity weakness, this became increasingly difficult. Anna has received 4 hours of Personal Care Assistant (PCA) care for the past five years without adjustment despite functional decline. In the two years prior to enrollment, there have been multiple hospitalizations for urinary tract infections, asthma exacerbations, pneumonias and two long sub acute hospital stays for pressure sore management caused by extended hours in bed and a poorly fitted manual wheelchair. Anna has never had a primary care or behavioral health relationship. At enrollment she was emotionally withdrawn, functionally bedbound, incontinent, with rapidly worsening decubitus ulcers. © 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 2

3 Why Does Anna C’s Experience Cry Out for a Fundamental Primary Care Redesign that is only Possible with Medicare and Medicaid Integration  Anna is an example of Medicaid and/or Dual Eligible beneficiaries whose care is totally inadequate and as a consequence unnecessarily costly.  Predictable and preventable secondary complications, such as, urinary tract infections, asthma exacerbations, pneumonias and decubitus ulcers drive recurrent hospital contacts, declining health, poor outcomes and most costs.  Primary care as resourced and organized in both FFS or MCO iterations is hopelessly ineffective. Payer based care coordination strategies also have very limited effectiveness, particularly for beneficiaries with complex needs.  Needed long term care, durable medical equipment and behavioral health services are allocated (or not) without any kind of an individualized care plan, monitoring or sensitive modulation over time.  Continuity clinical management through all settings at all times, is non-existent. © 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information

What Do We Know About the Costs and Service Use Patterns of Individuals with Complex Care Needs and Anna C.?  They represent about 15% of Dual beneficiaries accounting for about 65% total expenditures.  They are the reason that the “dual eligible” population representing 15% of Medicare beneficiaries account for about 36% of Medicare expenditures.  Primary care is grossly under resourced in both current FFS and managed care iterations.  30-50% of total medical expenditures are for recurrent hospital care, as a consequence of the missed opportunities to effectively intervene on predictable complications. With effective interventions, the percentage of total medical expenses going to hospital care should be closer to 12%. © 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 4

Primary Care Redesign Elements Primary care multidisciplinary teams with professional and non professional components with abilities to assess, manage and coordinate in multiple settings, REPLACES the 20 minute medically focused physician office visit. Individualized care plans, and resource allocations, for long term care, durable medical equipment, and behavioral health services, REPLACES the widespread “under resourcing” and “over resourcing” that characterizes “rule based” benefits management. Elastic nurse practitioner home response capability, to assess and manage new problems, REPLACES physician telephone management, the Ambulance and the ED. For those with physical disabilities– integrated durable medical equipment clinical assessment and management, REPLACES distant prior approval processes and months of delay. For those in need of behavioral health service, integrated behavioral health clinician assessment, individualized care plan development, implementation and management REPLACES inaccessible “BH carve out options”. 24/7 clinical availability and continuity management REPLACES “going it alone”. Web based EMR support REPLACES absence of clinical information transfer capabilities. © 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 5

Anna C. Primary Care Redesign Experience Comprehensive in-home nurse practitioner, behavioral health clinician, physical therapy and durable medical equipment assessment produced the development, implementation and monitoring of the following individualized care plan: 56 hours of personal care assistant support/week instituted for assistance with daily living activities, subsequently reduced to 40 hours/week over time. In-home wound care nurse specialist consultation provided with a clinical management plan instituted. Specialized air mattress delivered within 24 hours and motorized wheelchair with needed seating adaptations quickly arranged. In-home behavioral health assessment with individualized care plan created; includes medication and counseling. Transportation arranged for specialty appointments, dental care and other activities. Smoking cessation strategies instituted. Primary care physician identified with continuous support by a nurse practitioner provided as a first responder to, and clinical manager of, new problems via home visits. © 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 6

Anna C. - One Year Later Engagement with life, family, community and in self management; greatly improved. Withdrawal and despondency diminished. Decubitus ulcers entirely healed. Effective BH psychopharmacology and LICSW in-home counseling relationship established. Smoking cessation efforts partially effective, frequency of asthma exacerbations greatly diminished. Continuity relationship established with a PCP (though most primary care occurs via NP home visits) and with a neurology consultant. One year service use.  2 ED visits for asthma exacerbation management.  One three day hospitalization for urinary tract infection management. © 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 7

What is Commonwealth Care Alliance? Commonwealth Care Alliance is a Massachusetts, state-wide, not-for-profit, consumer governed prepaid care delivery system.  Fully Integrated Dual Eligible Medicare Advantage Special Needs Plan; began as a demonstration program in 2004 under a three way contract with CMS and MassHealth  Focuses exclusively on the care of Medicare and Medicaid’s most complex and expensive beneficiaries  Relies on Medicare and Medicaid risk adjusted premium to redesign care with a focus on investment in primary care  Care Model - enhanced primary care and care coordination capabilities through deployment of multi-disciplinary Primary Care Teams 8 © 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information

9 Commonwealth Care Alliance Programs Senior Care Options Program: Medicaid Only and Dual Eligible Elders  $170M Blended Medicare/Medicaid “Risk Adjusted Premiums”  Dual and Medicaid Only seniors (Avg. RS = 1.68) ■ 71% nursing home certifiable - Avg. RS 1.98 ■ 62% primary language other than English ■ 56% with diabetes, 23% with CHF  25 primary care sites with integrated multidisciplinary teams RN/NP/SW ■ $16.9M increase in primary care expenditures over FFS Medicare, in ■ 82 RN/NPs, 44 SW/BH/PTs in practices, not there in ■ 554 Full-time in home personal care assistants funded as per individualized care plans. Medicaid Program for Disabled Individuals with Complex Care Needs  600+ Medicaid and Dual individuals with Severe Physical Disabilities.  Plans in place for statewide expansion of this program – roll out in 2012  Program development underway to respond to anticipated state procurements to serve other individuals with complex care needs under the age of 65 © 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information

Time Risk Adjusted Hospital Admits per 1000/yr. Risk Adjusted Hospital Days 1000/yr. CCA: Nursing Home Certifiable (NHC) CCA: Ambulatory Medicare Dual Eligible FFS Experience Hospital Utilization is Markedly Lower Than Comparable Medicare FFS Experience 10 *Lewin Associates study commissioned by the SNP Alliance of member risk adjusted hospital utilization experience vs. Medicare benchmark © 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information

Fewer “At Risk” NHC Frail Elders Become Long Term Nursing Home Residents: 34% of Medicaid FFS Rate for Comparable NHC Frail Elders CCA NHC ( ) Medicaid FFS (2005) * % of Post hospital SNF Facility stays becoming Long Term Residents 10.7%31.2% © 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 11 * JEN Associates, 2009

Enhanced Primary Care: Central to the CCA Model of Care Nursing Home Certifiable Enrollees Ambulatory Enrollees Multidisciplinary physician/nurse practitioner/social worker team visits per enrollee per year (2010) 2012 Dual Eligible Other Medicare Beneficiaries FFS Avg. primary care visits/Medicare beneficiary/ per year ( ) 3.7*6.7** *Medicaid/SCO Procurement Document **MedPac Medicare Beneficiary file analysis 2006 © 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information

Bending of the “Cost Curve” Commonwealth Care Alliance Timeframe Nursing Home Certifiable (NHC) Enrollees Ambulatory Enrollees Average annual medical expense increase %2.6%* 13 * period due to insufficient enrollment in 2004 © 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information

Quality Metrics Commonwealth Care Alliance  Overall Plan Rating: (4.5 Stars)  Health Plan Rating (Part C): (4.5 Stars) Staying Healthy: Screenings, Tests & Vaccines Managing Chronic Conditions Rating of Health Plan Responsiveness & Care Health Plan Member Complaints & Appeals Health Plan’s Telephone Customer Service Risk adjusted 30 day hospital readmission rate = 4% vs 13%, the MA median, >95 th percentile Drug Plan Rating (P art D): (4.5 Stars) Drug Plan Customer Service Drug Plan Member Complaints, Members Who Choose to Leave, and Medicare Audit Findings Member Experience with Drug Plan Drug Pricing and Patient Safety Medicare Star Ratings - Over 80% of Medicare Advantage plans score 3.5 Stars or below © 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 14