1. Moving Home Care Medicine into the Mainstream: Medicare Advantage
Ronald J Shumacher, MD FACP CMD
Chief Medical Officer, Optum Complex Population Management
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2. Disclosures
Ronald J Shumacher MD has the following financial relationship to disclose:
Employee of: Optum Services, Inc.
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3. Total Medicare Private Health Plan Enrollment, 1999-2013
99% of Medicare beneficiaries nationally have access to one or more Medicare Advantage Plans in their county
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4. Distribution of Medicare Advantage Plans by Plan Type, 2007-2014
99% of Medicare beneficiaries nationally have access to one or more Medicare Advantage Plans in their county
NOTE: Excludes SNPs, employer-sponsored (i.e., group) plans, demonstrations, HCPPs, PACE plans, and plans for special populations (e.g., Mennonites). Other category includes cost plans and Medicare MSAs.
SOURCE: MPR/KFF analysis of CMS’s Landscape Files for 2007 – 2014.

5. Challenges facing health plans today
Clinical quality and STARs
Care coordination and management
Greater focus on quality performance and outcomes evaluation
HEDIS measures tied to revenue
Financial incentives and brand identity critical to business
Shifts from fee for service to pay for performance and accountability
Member outreach and engagement
Integrated clinical data at point of care
Improved coordination of services and accountability
Health Plan
Performance
MA Plans face margin pressures and revenue management needs
Convergence of closing gaps in care at point of service
Compliance: EDPS and RADV
Admission and Re-admission prevention
Post-acute and end-of life care
SNF LOS management
Network/Contracting
Post-acute care accounts for large component of spending and significant variation suggests obvious opportunity for savings
Risk adjustment
Medical expense management
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6. Payer challenges: managing high-risk member populations
The most expensive members offer the biggest opportunity for savings; however, these patients require a home-based care program.
%5%
of the population drives 50% of the medical spend
The MA health plan needs to have a house-call program to manage this population. Further describe the patient. This subset of MA population requires intensive in-person services to address their complex problems and to coordinate care for multiple chronic conditions. They are not well served by the traditional care system
These patients take more medications, see their provider more and utilize the ER three times per year on average
Members do not regularly engage with or look to payer for health support or management
The high cost 5% of the population are generally on an erratic course
Stanton MW. The High Concentration of U.S. Health Care Expenditures. Research in Action, Issue 19. AHRQ Publication No , June Agency for Healthcare Research and Quality, Rockville, MD.
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7. Risk stratification and identification of members
Consider the unique demographics of MA plan populations — 10% of the population averages at least one hospital visit per year and accounts for 30% of the spend
Risk Score
% of Population
Hospital
Visits/Yr ER
# Chronic Diseases
$PMPM
% of Cost
<0.70
50%
.164
.252
0.3
$330
21%
.71 to 1.45
30%
.373
.429
1.3
$710
33%
1.46 to 2.05
10%
.660
.632
2.3
$1,190
15%
2.06 to 2.75 5%
.915
.766
3.0
$1,640
11%
>2.75
1.477
.992
3.7
$2,740
20%
Hospital Admits
There is an identifiable population that clearly experiences high utilization/high cost
ER Visits
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Source: Nationwide Medicare 5% Sample

8. Health plans typically provide services to patients with chronic illnesses like nurse line, education, telephonic case management, advocacy, wellness, DM, etc.
Tompkins et. al. Population Health Management in Medicare Advantage; Health Affairs Blog, April 2013

9. Initiating a relationship with MA Plans
Needs Assessment
Identify the problem being solved
Determine how it is applicable to MA plans
Understand the environment in which you’ll provide care (geography, etc.)
Value Story
Develop a proven ROI (e.g., executive summary, affordability analysis, ROI & quality metrics)
Provide a MA Health Plan health care economics analysis
Determine if there is a need to take on risk
Have a willingness to contract and get credentialed with the health plan
Implementation Plan
Propose a clinical program/model
Review of contract by legal
Develop a road to deployment (e.g., staffing, certification, filing, delegation agreements, credentialing, etc.)
Identify/align on early indicators and analytics
Determine program monitoring
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10. Developing a successful home medicine care program
Identification of members and risk stratification
Member outreach and engagement
Demonstrate value / ROI
Managing most challenging patients
Non-compliant
Scheduling
?graduation/end point
Capture of quality and encounter data
Develop clinical care model (e.g., visit types, how to manage the most challenging patients)
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11. Creating a profitable home care medicine program
Case rate (PEMPM)
Capitated payment (PMPM)
Gain sharing with quality metric goal(s)
Full risk/percent of premium
Reimbursement Structure
Low health care utilization (e.g., admissions, readmission, emergency department, etc.)
Manage quality measures, including STARs, HEDIS
Accurate documentation/coding
Simple way to share data
Profitability Management
FFS reimbursement has been a major obstacle for home care medicine in the traditional Medicare space. But MA presents opportunity to credit providers with savings from treatments averted or ailments prevented. Now as the dominant FFS model is eroding and value based payment is taking over. Medicare Advantage pays for care of people not for procedures and maximizing treatment
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12. Challenges associated with home care medicine and MA Plans
Risk mitigation strategies
Identification and stratification
Algorithms that accurately reflect implications of regression of the mean
Member outreach and engagement
Specialized outreach teams to manage engagement
Member compliance with care plans
Partner home care medicine providers with telephonic case management support
Collaboration with MA Health Plan case management and other programs
Establish clear criteria, communication and handoffs
Navigating MA Health Plan networks
Emphasize communication with network providers and provide documentation
Managing operational metrics
Rigorous management oversight and tracking tools
Data capture and tracking
Robust EHR and reporting/analytics
Regression to mean
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13. Thank you. Ronald J Shumacher, MD FACP CMD
Chief Medical Officer, Optum Complex Population Management
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