Tackling Issues for Medicaid High-Utilizers
Essential Hospitals Engagement Network
October 22, 2013
OUR NEW NAME
We’ve rebranded! The National Association of Public Hospitals and Health
Systems is now America’s Essential Hospitals.
Although we’ve changed our name, our mission is the same: to champion
hospitals and health systems that provide the highest quality of service to all
by achieving the best health outcomes for every patient, especially those in
greatest need. The new name underscores our members’ continuing public
commitment and the essential nature of our work to care for the most
vulnerable and provide vital community services, such as trauma care and
disaster response.
This is an exciting time for us and our members, as we lean forward into new
care models, opportunities and challenges of reform, and quality and safety
innovations that often take root in our member systems.
Our new website address:
www.EssentialHospitals.org
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CHAT FEATURE
The chat tool is available
to ask questions or
comments at anytime
during this event.
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RAISE YOUR HAND
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please “raise your hand.”
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when your phone line is
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AGENDA
• Introduction – Vickie Sears, RN, MS
• Medicaid High Utilizers in the ED / San Francisco Health Plan
CareSupport Program - Dr. Maria Raven and Courtney Gray,
MSW
• Q&A
• Wrap-up and announcements
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SPEAKER INFORMATION
Dr. Maria Raven
Assistant Professor, Department
of Emergency Medicine
UCSF School of Medicine
Courtney Gray, MSW
Manager, San Francisco
Health Plan Care Support
Program
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PROGRESS TOWARDS THE
GOAL
EHEN 30-Day, All-Cause Readmissions (UHC)
13%
Readmissions %
12.0%
12%
12.0%
11.9%
11.8%
11.6%
11.4%
11.6%
11.3%
11.4%
11.1%
11%
10%
9%
8%
Rate
Hospitals Reporting
Q1-'11
Q2-'11
Q3-'11
Q4-'11
Q1-'12
Q2-'12
Q3-'12
Q4-'12
Q1-'13
Q2-'13
11.6%
12.0%
12.0%
11.8%
11.4%
11.3%
11.1%
11.9%
11.6%
11.4%
15
15
15
15
15
15
15
15
15
15
2010 Baseline
12.0%
12.0%
12.0%
12.0%
12.0%
12.0%
12.0%
12.0%
12.0%
12.0%
Goal of ↓20%
9.6%
9.6%
9.6%
9.6%
9.6%
9.6%
9.6%
9.6%
9.6%
9.6%
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PAYER SOURCES
America's Essential Hospitals
Discharges by Payer, FY 2010 (n=95)
Other
Commercial 4%
8%
Other
3%
Commercial
19%
Uninsured
18%
EHEN Discharges by Payer,
FY 2010 (n=21)
Medicare
15%
Medicare
25%
Uninsured
29%
Medicaid
35%
Medicaid
44%
Notes: Other = Workers‘ comp + Prisoner care + etc;
Uninsured = Self pay + Charity care + Indigent care programs
Source: America's Essential Hospitals FY 2010 Characteristics Survey
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America’s Essential Hospitals Webinar
Tackling Issues for Medicaid High Utilizers
October 22, 2013
Maria Raven, MD, MPH, MSc
Assistant Professor of Emergency Medicine
University of California, San Francisco
Courtney Gray, MSW
Care Support Manager
San Francisco Health Plan
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The Issue
• Small percentage of patients account for
disproportionate share of health care use and
costs
• Heterogeneous population: wide range of
medical, behavioral, and social issues
contribute
– No “one size fits all” solution
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Approach
• Intervention is intervention
• Payer may alter the way it’s carried out
• 2 experiences:
– New York State Medicaid funded program within
public hospital system: NYC Health and Hospitals
Corporation (HHC)
– San Francisco Health Plan: MediCal Health Plan
that administers Medicaid coverage for majority of
SF safety net including SF General Hospital
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Program 1: Public Hospital System
Hospital to Home (H2H)
• SDOH-sponsored Chronic Illness Demonstration Project
– One of six NY State Department of Health contracts
• Intensive care management and coordination for fee-forservice Medicaid patients at high risk for frequent
hospitalization
• August of 2009-March 2012
- 540 patients enrolled cumulatively across 3 NYC public hospitals
• Now codified as part of federal Health Homes initiative
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H2H Financial Incentive
• State Medicaid incentivized to finance
demonstration projects that could contain
costs for very high cost Medicaid enrollees not
yet enrolled in managed care
• State supported staff hired by HHC
• Bear in mind
– Under fee-for service payment model, fewer
admissions=lower revenue for hospital system
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H2H’s Mission
• Find and enroll SDOH identified high-risk,
high-cost fee-for-service Medicaid recipients
– Predictive modeling
• Goals
– Reduce Medicaid expenditures (read: hospital
admissions)
– Improve health and social outcomes
• All for $291.50 per patient, per month
• “Supportive housing without the housing”*
*John Billings, Professor of Health Policy and Public Service, Director of Health
Policy and Management Program, NYU Wagner
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H2H Team Composition/locus
• Staffing Structure:
• Social Workers supervise Community Based Care
Managers (1:25 patient ratio), full-time housing
coordinator, some dedicated primary care
• Care Managers required to have high school
degree and relevant experience
• Offices (available for patient drop-ins) within 3
HHC hospitals, LOTS of field work, support
groups
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Frequency of Contact
• State required minimum of 2 contacts per
month, one face-to-face per quarter
• In reality, teams had extensive patient contact,
much more than required unless unable to
find
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Coordinating with Other Providers
• Extensive in-reach (within HHC) and outreach
to community organizations
• MOUs in place for data sharing
• Consents included multiple organizations
• 24 hour on call system
• For some, embedded primary care
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Use of Technology
• Predictive modeling in theory helped target
the “right” patients from the start
• Demo project: risk score adjustments due to
under-enrollment, programs blinded to scores
• Patient Alert system: automated email alerts
to Care Managers
• Provision of cell phones for patients in need
• Program built own database, separate from
the EHR: double data entry at times
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Complexity of very high cost patients:
Enrollee #1
90
80
70
60
50
ED visits
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Admissions
30
20
10
0
12 mos PRE
12 mos POST
24 mos POST
32 mos POST
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Complexity of very high cost patients:
Enrollee #1
$300,000.00
$250,000.00
$200,000.00
$150,000.00
Cost
$100,000.00
$50,000.00
$-
12 mos PRE 12 mos POST 24 mos POST 32 mos POST
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Average monthly Medicaid costs
(program costs included in post period)
$6,000.00
$5,000.00
$4,000.00
Not homeless
$3,000.00
Homeless, remained
homeless
Homeless, housed
$2,000.00
$1,000.00
$Prior 12
months
First 6
months
Second 6
months
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San Francisco Health Plan
• 84,000 covered lives
• Contracts with multiple medical groups and
the San Francisco safety net
– Multiple risk arrangements
– 75-80% of San Francisco MediCal population
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Program Adaption: CareSupport
• Absorbed 12,000 SPDs due to mandatory
enrollment FY 2011-2012
• Limited experience managing complex patient
population
• Feb 2012: program expansion and
restructuring
 Prior: time limited phone based management
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San Francisco Health Plan
• 84,000 covered lives
• Contracts with multiple medical groups and
the San Francisco safety net
– Multiple risk arrangements
– 75-80% of San Francisco MediCal population
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Program Adaption: CareSupport
• Absorbed 12,000 SPDs due to mandatory
enrollment FY 2011-2012
• Limited experience managing complex patient
population
• Feb 2012: program expansion and
restructuring
 Prior: time limited phone based management
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SFHP CareSupport
• Current Program
 SFHP members identified based on prior
utilization (some referrals from within SFHP)
• ED and inpatient
 2 Teams:
• Each comprised of 5 BA level Community Coordinators
led by Social Work Supervisor
• Each team manages 125-175 members at any given
time (25-35 per coordinator)
• Time in program (“dose”) can vary
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CareSupport Activities
• Eligible members “vetted” by coordinators
with oversight of social work supervisors
• Outreach via phone or in person
• In-depth holistic assessment, Care Plan
developed and shared
• Day to day management, including:
 Connecting with needed resources (appointments, food,
phones, clothing, ect)
 Ongoing management of chronic issues (unstable housing,
substance use, mental health, low-self efficacy, ect.)
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San Francisco Health Plan
• Advantage of health plan as program lead
– Comprehensive member data across
uncoordinated medical systems
– Access to limited behavioral health information
due to carveout; however, this is shifting in
January ‘14
– Flexibility to support administrative needs such as
hiring and innovative interventions, compared to
county health system
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CareSupport Population: Overview
• Since April 2012, 920 referrals have been open
• Currently, 159 members enrolled
• Demographics




Average Age: 51 years old
Gender: 50% Female and 50% Male
Housing: 5% homeless and 5% temporarily housed
Mental Health: 34% reported being treated for Mental
Health
 Substance Use: 24% reported being treated for substance
use
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CareSupport Population: Cohorts
• Initial data shows 3 distinct groups
 Long Term CareSupport: members who are
enrolled more than 6 months
 Short Term CareSupport: members who are
enrolled 6 months or less
 Unengaged: members who were never found and
engaged in the program
• Unengaged groups appear fundamentally
different than the two engaged cohorts
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CARE SUPPORT : INPATIENT ADMITS PMPM
0.35
0.318
0.310
0.309
0.3
0.268
INPATIENT ADMITS PMPM
0.25
0.2
0.15
CS Utilization Report: Long Term
Care Support
CS Utilization Report: Short Term
Care Support
0.140
0.129
0.120
0.1
0.087
0.05
0
00-06 Prior
00-06 Post
00-12 Prior
00-12 Post
COHORT
PMPM: Per member per month
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CARE SUPPORT : ER VISITS PMPM
0.6
0.565
0.559
0.535
0.5
0.459
0.471
0.388
0.4
ER VISITS PMPM
0.352
CS Utilization Report: Long Term Care
Support
0.3
0.251
CS Utilization Report: Short Term Care
Support
0.2
0.1
0
00-06 Prior
00-06 Post
00-12 Prior
00-12 Post
COHORT
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Critical Components for Tackling Issue
of Medicaid High Utilizers
• Accept that telephonic management has seen its day
• Hire (and train) the right people
– Team members act as champions for program, see
themselves as accountable for patient outcomes
• Obtain comprehensive, accurate data in advance
– Outreach and evaluation purposes
• Partner with community based organizations, get
consent for or agreement to share information
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Critical Components for Tackling Issue
of Medicaid High Utilizers
• Understand the financial arrangements and
potential ROI ahead of time
– Partner with others who have an incentive to
remain or become invested
• Experiment with technology
– Cell phones, patient alert system, unified EMRs
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Critical Components for Tackling Issue
of Medicaid High Utilizers
• Understand that we don’t know what works
– Healthy skepticism: very little data to support
successful program models
• Track outcomes that will inform sustainability
and spread
– Decide if breaking even with good QOL and clinical
outcomes is “enough”
• Especially if targeting a heavy user population,
consider identifying a comparison group
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Thank you
• Maria Raven:
maria.raven@emergency.ucsf.edu
• Courtney Gray:
cgray@sfhp.org
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Q&A
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THANK YOU FOR ATTENDING
• Upcoming webinars – see chat box for event information
• 2014 Webinars – Look out for an announcement from
ltiscornia@essentialhospitals.org
• Evaluation: When you close out of WebEx following the webinar a
yellow evaluation will open in your browser. Please take a moment
to complete. We greatly appreciate your feedback!
• Essential Hospitals Engagement Network website:
http://tc.nphhi.org/Collaborate
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