1. 2009 SNP Alliance Profile and Advanced Practice Report
October 29, 2009

2. 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?

3. Medicare Special Needs Plans: National Overview

4. 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

5. Percent Change, Dec ’07 – Dec ‘08 Percent Change, Dec ’08 – Sep ‘09
National SNP Enrollment Grew 20% in 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

6. 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

7. SNP Alliance Statistics

8. 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

9. 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)

10. 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%

11. 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.

12. 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

13. 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.

14. 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%

15. 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

16. 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

17. SNP Alliance: Health Care Utilization

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

19. 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%

20. 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

21. 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

22. SNP Alliance: Qualitative Assessment

23. 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

24. 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.”

25. 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

26. Questions & Feedback

27. Contact Info, Profile Report Authors
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