Payers Tailor Products to Treat Chronic Conditions, Duals

Reprinted with AIS Health permission from the September 23, 2019, issue of Health Plan Weekly

The silver tsunami that’s facing Medicare is forcing payers to get creative in the benefits they offer Medicare Advantage members, according to speakers who presented on Sept. 10 at the Medicare Advantage Product Design Innovations conference, hosted by Strategic Solutions Network in Arlington, Va.

New plan designs are also a response to CMS’s June 2018 guidance allowing payers to develop and target plans with supplementary benefits to cater to the specific health-related needs of members. By 2020, 12 million Medicare Advantage beneficiaries will have chronic conditions, according to Aaron Laverick, director of product management and development for Medicare programs at Pittsburgh-based Gateway Health, a subsidiary of Highmark Health and Livonia, Mich.-based Trinity Health System. The expected increase in life expectancy is another driver that’s pushing payers to develop targeted plans to help Medicare and Medicaid beneficiaries manage their health, said Laverick during a presentation at the conference. The top conditions Gateway Health is focused on include diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Gateway Health has 280,000 members in its Medicaid business.

In addition to coverage for benefits such as dental, vision, over-the-counter medications, and medical appointment-related transportation, supplemental benefits can include pest control, subsidies for rent and utilities, and air quality equipment, he added.

Addressing the needs of dual-eligible beneficiaries is difficult, especially for those with special needs. Gateway tapped its data warehouse for a holistic view of its members and to assess the factors that hindered members’ access to appropriate care.

Laverick noted that members often suffer from many comorbidities, so Gateway developed products that focus on managing those conditions. While each new product started on a pilot basis, the goal was to solve a pressing problem that impacted many members.

Simplicity Is Key for Members

Educating members also is a priority. “When we’re putting together these benefits, we like to sometimes overcomplicate things,” said Laverick. “But keeping it simple and easy for these members to understand is…critical to the success of that health plan.”

Member-facing staff receive a deep dive on the benefit design from Gateway Health’s implementation team. Laverick noted that most physicians don’t read mailed flyers about new products, so deploying contracting and provider relations teams is key.

Maintaining documentation and reporting is also important, said Laverick. “Expect that CMS is going to come to you….Make sure that you have the mechanisms in place to capture the reporting that’s necessary.”

As with many payers, diabetes and CHF are major medical cost drivers for members of Health New England, a wholly owned subsidiary of Bay State Health, a large nonprofit health system in western Massachusetts. The payer has 160,000 members across all product lines; it has 9,200 members in its Medicare Advantage plans.

Health New England created a plan for members with diabetes and CHF where, in exchange for participating in a care management program and seeing their primary-care physician and a relevant specialist, the member was entitled to reimbursement for eight physician office co-pays.

Health New England Conducts Outreach

Amy Sepko, Medicare program manager at Health New England, said members were selected for outreach based on diabetes and CHF billing codes. Outreach included mailers to members and training staff at events to respond to members’ questions. Equally important were the provider relations team’s efforts to educate providers, she added.

Once a member has completed the care management program, their care manager initiates a reimbursement for their physician office copays, according to Sepko, who also presented at the conference. There are 50 members in the program, which is the uptake Health New England expected. The only issue the payer has to navigate is with members who say they don’t have diabetes or CHF, despite the fact that their physician says they do. Otherwise, Sepko said the payer has received one response from a member who had a positive experience with the program.

Visit mabenefitdesign.com for more about the conference.

by Aine Cryts

CCA, UCare Used Pop Health to Tailor Duals Interventions

Reprinted with AIS Health permission from the June 6, 2019, issue of RADAR on Medicare Advantage

Using population health to identify the various needs of member subgroups and deploy tailored interventions can help reduce health care disparities and lead to lower costs and improved outcomes for high need patients, especially those who are dually eligible for Medicare and Medicaid, suggested two case studies presented by managed care organizations at Strategic Solutions Network’s 4th Annual Population Health Payer Innovations for Medicaid, Medicare and Duals conference, held May 14 and 15 in Arlington, Va.
For Commonwealth Care Alliance (CCA), that has meant leveraging the payer-provider’s unique integrated care model to design specialized methods of engaging high-need duals who are often hard to find and maintain contact with, explained Lauren Easton, senior director of behavioral health with the not-for-profit, community-based health care organization dedicated to serving duals in Massachusetts.

CCA Patients Have High Psychiatric Needs

CCA serves more than 32,000 members either through its 4-star Medicare Advantage Special Needs Plan (SNP), Senior Care Options, or the CMS-backed One Care demonstration for duals between the ages of 21 and 64. Its duals population presents some of the most complex patients in terms of psychiatric and medical needs, Easton explained. Ten percent of CCA’s members are homeless, and 80% have a behavioral health diagnosis, she said.
Since it is responsible for the total cost of care for duals in the state and operates five primary care practices, CCA is focused on keeping members in the community and developing long-term relationships with patients who have developed a distrust of the health care system for one reason or another, Easton told attendees. And because these patients tend to seek out the emergency department for primary care, CCA is always looking for ways to engage them, divert them at the ED and ensure that they are “getting the best services in the community,” she said.
All CCA member services are coordinated by an “interprofessional care team” that is led by a care manager (usually a nurse practitioner or a physician assistant) and includes a primary care provider, social worker, housing specialist, behavioral health specialist and long-term services and supports coordinator. Upon enrollment, every member gets a full assessment and in-person meeting to determine their needs and per-member per-month revenue category.
Recognizing a critical gap in care for people with serious behavioral health conditions, CCA in 2015 established its first Crisis Stabilization Unit (CSU) to serve patients who do not necessitate an inpatient level of psychiatric care and can be managed with short-term, intensive behavioral health and medical services. The organization set up a single-floor unit at a hospital that has facilities for patients with physical disabilities or who require intensive monitoring, then renovated a three-story Victorian home
near a hospital that it opened as “Marie’s Place.” The latter is a 14-bed program featuring a therapy dog, group therapy sessions and access to the local community once patients are stabilized. Eighty-five percent of the individuals in those units were diverted from inpatient stays in 2018, which results in “huge cost savings as well as quality” and in many cases has allowed CCA to locate patients who have been unreachable and are still in need of the initial assessment, which can be done during the stay, explained Easton. And upon discharge, CCA is “handing them off to our practitioners in the community…so it’s really considered more of a continuum of care instead of an episode of care,” she added.

CSUs Are Cost-Effective Alternative

Results have been encouraging, from anecdotal reports of patients feeling safe and comfortable in the environment to 97% of patients indicating member satisfaction rates of good or excellent. The average cost for a CSU stay is about $640 per member, compared with $1,100 for a stay in a psychiatric inpatient unit, while the average length of stay there is 9.3 days, compared with 11.4 at an inpatient facility. Other efforts to steer patients away from emergency and inpatient services include Mobile Integrated Health, through which community paramedics are available to members every day from 6 p.m. to 2 a.m. either through nurse triage and member services or on a planned basis, and a brand-new ED to Home offering, which integrates CCA primary care doctors into the hospital. Easton said CCA has learned over the years that the hospital is “the worst place” for its patients, who have complex issues that aren’t easily understood by ED physicians and who frequently end up sicker than when they arrived. Through the program, CCA physicians spend the day in the hospital, and ED doctors can let them know if a CCA patient is there and have them perform an evaluation to determine if an inpatient stay is the best course of treatment.
These and other “innovations” have helped CCA achieve a 5% reduction in the total cost of care, a 29% decline in inpatient admissions and a 13% decline in ED utilization. “It sounds like a very expensive model but as we engage folks in using the appropriate disciplines, we’re really seeing the overall cost go down and of course, the quality has been outstanding,” said Easton.

UCare Efforts Focus on HEDIS Gaps

UCare, an independent, not-for-profit health plan serving more than 100,000 seniors in Minnesota, has observed large health care disparities among its 11,000-member Minnesota Senior Health Options (MSHO) SNP population. Compared to its 4.5-star UCare Medicare MA plan, the dual eligible SNP features an older population with a higher percentage of females, greater racial diversity, lower education, lower income, more chronic conditions and higher utilization of health care services, said Jessica Assefa, UCare’s Medicare Stars Program manager.
Aiming to close HEDIS performance gaps, UCare conducted a demographic analysis to determine which factors were impacting people in different subgroups and looked at the correlation between HEDIS compliance and attributes such as language, race/ethnicity, geography and health condition. For intervention purposes, the plan opted to focus on less compliant groups with large enough numbers to translate to an improvement in the overall HEDIS rate, explained Assefa.
One of those member groups is “new Americans,” who make up about 33% of UCare’s D-SNP population and face cultural and language barriers, tend to live in metropolitan areas, rely on family members for support and have culturally unique beliefs and traditions in health and wellbeing, said Assefa. Compared to other subgroups, these individuals have the highest average number of claims per year and the second-lowest average number of prescriptions per year. Many of them are also Hmong or Somali- speaking.

Members Have Unique Cultural Issues

To help bridge cultural and language gaps, the insurer has partnered with adult day centers and other community organizations that work closely with these members to provide health information, arrange group transportation to health events or appointments and explain the importance of taking UCare’s member satisfaction survey, which Assefa said can identify the need for additional interventions and improvements to its model. UCare also sends community health workers who speak the members’ languages to their homes to set up appointments, arrange transportation, etc.
In another effort to address health care disparities, the plan identified the top primary care clinics within each subgroup and developed “unique” provider partnerships that involve sharing gaps in care and best practice reports so that providers can see how they perform on select HEDIS measures compared to their peers, said Assefa. For example, UCare partnered with a community clinic that serves mostly Hmong patients to boost medication adherence by providing them with monthly gaps in care reports identifying members at or close to nonadherence, encouraging collaboration between the provider and nearby pharmacy serving the same subgroup, and tying incentive dollars to performance goals. For Rural Members, Local Pacts Are Key
Meanwhile, serving rural Minnesotans required a different set of interventions, like partnering with local pharmacies. UCare has observed that rural Minnesotans often have close relationships with their pharmacists, who may work with interpreters to reach and educate non-English subgroups, said Assefa. And with data from the health plan, pharmacists can address HEDIS gaps and medication adherence at the same time. Other efforts include working with county social service and public health entities to provide care coordination and partnering with local Federally Qualified Health Centers to sponsor cancer screenings and other health events.
Assefa explained that in working with providers, UCare doesn’t discuss star ratings goals but rather focuses on “spaces of joint opportunity” like national HEDIS benchmarks that are more meaningful to the providers. And this work has translated into improvements on Consumer Assessment of Healthcare Providers and Systems and other CMS star ratings measures that over the last three years has brought the MSHO plan closer to a 4th star. For more information, visit www.pophealthsummit.com.

by Lauren Flynn Kelly