Commonwealth Care Alliance
A Non-Profit Prepaid Comprehensive
Care System:
Defining what a Real “ACO” is for
Medicaid and Dual Eligible Beneficiaries
with Complex Care Needs
Robert J. Master, MD
Case Vignettes
•
Mattie H. - A fiercely independent 77 y.o. woman living alone with
longstanding Diabetes and Hypertension. Three recent strokes caused
left side weakness and requirements for significant personal assistance
to maintain independence. Mobility limitations impeded access of
medical care during the 9 months before enrollment. Increasing
depression, withdrawal and erratic nutritional intake ensued. There
were frequent falls and multiple hospitalizations for poorly controlled
Diabetes, dehydration, urinary tract infections and pressure sores
Nursing home placement, was recommended.
•
Anna C. - A 55-year-old woman with long standing Multiple Sclerosis
with secondary partial paralysis in all extremities and urinary
retention requiring frequent daily self catheterizations. There was a
long standing history of depression, one prior major suicide attempt,
and a history of alcohol abuse and heavy cigarette use as well. During
the past few years there has been multiple hospitalizations for urinary
tract infections, respiratory infections and asthma exacerbations. No
consistent primary care or behavioral health relationship has ever
been established.
In CY2010 CCA managed about $175M in risk adjusted
Medicare and Medicaid premiums to provide the totality
of benefits to the following populations
Population
# Enrollees
Characteristics
Dual Seniors
2961
68%
nursing home certifiable (functionally homebound)
Average Medicare RS=1.9
70% from communities experiencing disparities
56% Diabetes, 23% CHF
 6% annual mortality
Ave. risk adjusted Medicare/Medicaid premium $4100 PMPM
Medicaid Adults with
complex care needs
(CCN)
2410
Multiple
Adults with severe
physical disabilities
270
defined chronic illnesses
Concurrent active MH/SA issues
Medicaid’s “12/60” population
Coordination needs high, “engagement” low
Ave. risk adjusted Medicaid premium, $1800 PMPM
SCI,
Cerebral palsy, Spina Bifida, Advanced degenerative neurologic disease (e.g.
MD, MS)
Require 65+ hours of PCA services a week to live independently
Meaningful primary care, previously rare to non existent
Average risk adjusted premium $5200 PMPM (excludes PCA services)
Primary Care Redesign
25 Primary care practices including FQHC’s in 8 fully contracted hospital systems
 primary care financial investment – ($130 - $400 PMPM)
Integrated multidisciplinary clinical teams, stratified to need; nearly 100 clinicians integrating in practices with
IT, management, and infrastructure support
Population
Primary Care Redesign
Homebound Seniors
RNP’s, RN’s 1:45, Geriatric SW’s 1:80, integrated
BH, PH, Palliative care clinicians
Medicaid “CCN” population
RNP
1:80
MH professional (e.g. LICSW)
1:200
CHW’s
1:120
Tracking, coaching, surveillance, infrastructure
Adults with Severe Physical Disabilities
RNP
SW
MH professional
PT
DME Coordinator
1:40
1:100
1:200
1:80
1:100
Multidisciplinary Clinical Teams with “Shared
Decision Making”:
Primary Care Redesign Elements
Enhanced Primary Care
  comprehensiveness of intake assessments (multiple dimensions not
just medical).
 Individualized Care Plans (well beyond “problem lists”).
 Same day, episodic care response capabilities
(particularly in home settings).
 24/7 with EMR support.
 Integrated palliative care and behavioral health clinicians.
 Continuity clinical management in all settings and through all
“transitions”.
Care Coordination
 Ability to order, authorize and connect to all medical, BH, DME,
therapy and LTC services (“The teams own the checkbook”).
 Resource allocations with contracted network via decision support
tools.
RESULTS
Senior Care Options
Utilization
•Homebound elders 17,061 PC visits/K/Yr.* mostly in home; Ambulatory elders 11,263 visits/K/Yr.
(Medicare FFS Ave, 7200 visits/1000 Yr.) – MedPac
•Hospital use, 1995 days/K/Yr. (Ave RS 1.98), 55% Medicare risk adjusted FFS Ave.
•“NHC” nursing facility placements 36% of FFS Medicaid benchmarks (Mass. JEN Study)
Quality
•HEDIS 90+ percentile, comprehensive Diabetes care, monitoring patients on persistent medication, access to
preventive health services.
•50%  in CHF hospital admissions (40.3 Adm/K/Yr. – 23% CHF prevalence) vs. MA Statewide Medicare FFS
benchmark.
Cost
•2004-2010 average annual medical expenditures increase 2.2%
•Average MER 2004-2010 - 84%
Disability Care Program
•Exceedingly high member satisfaction – external survey.
•Hospital admissions, expenditures, reduced 70% compared to Medicaid FFS experience.
•50% reduction in hospitalizations for pressure sores (prior studies)
•Total medical expense 80% of risk adjusted premiums.
Summary
Problem
Opportunity
Inadequate, discontinuous, unengaged Primary Care
Team approach – RN/RNP/SW/BH/PCP
Horizontal rather than vertical MD relationship
Inappropriate dependence upon Emergency Rooms for sick/nonemergent issues
24/7 telephonic access to care team, supported by member’s
clinical record to inform clinical triage and decision making
Difficulty of getting to physician offices/clinics for care; Inability of
physician to assess home environment
Capacity for home visits and transfer of clinical decisions to the
home or other care settings as necessary; full “picture” of needs
Traditional “disempowered role” of member in the relationship with
busy physicians
Meaningful consumer involvement in care management and care
design
Fragmented relationships with specialists, hospital and institutional
providers
Coherent and fully organized hospital, institutional and specialist
network centered around the primary care physician and team
Insurance company “rules” regarding benefit requirements and
service authorization
Fully empowered Primary Care Team able to order/authorize all
needed services
Lack of continuity and shared information among medical,
behavioral health and long term care providers
Fully integrated network of all providers and the Primary Care
Team as the “hub” of the wheel to promote information sharing and
care transitions
Incoherent “picture” of totality of member’s medical, behavioral
health and support service needs
Fully integrated clinical record and state of the art data support
Medicaid’s inability to “individualize” community based support
care needs. “Costs without Benefit”
PCA’s and community based LTC services allocated clinically as
part of individualized care plan