AETNA MEDICAID Respondent Demonstration to the Oklahoma Health Care Authority Care Coordination for the Aged, Blind, and Disabled August 26, 2015 Copyright Administrators, LLC 2015
Presenters Pam Sedmak President and CEO Robert Atkins, M.D. Senior Medical Director, Denise Gallagher National Head of Duals Janet Grant Vice President Great Plains Region 2
Agenda Overview of The Proven Value of Managed Care Recommended Care Coordination Model Collaborating to Improve Outcomes Transforming Payment and Delivery Closing 3
Aetna Building a Healthier World 2015 Aetna at a Glance 50,000 employees 23.5 million medical members Members we serve $61 billion revenue 160 years of national and international experience 3 rd largest managed care organization in the U.S. Aetna in Oklahoma: Serving 201,000 members We put the members we serve at the center of everything we do 4
History of Over 30 years of experience managing the care of complex, high-risk populations Founded in 1986 as Schaller Anderson Acquired Coventry Health Care in May 2013 1986 1995-2003 2007 2013 2014 2015 Aetna Acquired Schaller Anderson in 2007 Schaller Anderson managed Heartland Health Plan of Oklahoma Aetna Announces Acquisition, July 2015 5
2015 Overview Leader in managing medically complex populations at the local, community-based level by integrating physical health, behavioral health and social economic status of members We provide services for nearly 3 million members across 17 states AZ NE TX IA MO LA IL MI KY OH WV PA VA NY NJ MD A dedicated implementation team Aetna: 15 successful implementations in last 2 years FL We uniquely bring 30 years of successful experience with all Medicaid populations 6
ABD, LTSS, and Duals Programs ABD Programs AZ FL IL KY LA MD MI NJ PA VA NE LTSS Programs Arizona Florida Illinois New Jersey New York Duals Programs Arizona Illinois Michigan New York Ohio We Bring Extensive Experience Serving High Acuity Medicaid Beneficiaries 7
At, we believe in improving every life we touch as good stewards to those we serve 8
The Proven Value of Managed Care 9
Benefits of Managed Care for ABD and LTSS Fully capitated managed care offers: Market-based approach Health outcomes Performance and accountability Coordination Long-Term Services and Support Savings and budget predictability Satisfaction 10
Illinois Experience Integrated Care Program Summary Managed care program for ABD/LTSS beneficiaries launched 5/2011 Program has saved costs for the State while increasing the quality of care for Seniors and People with Disabilities (SPD) Integrated Care Program Financial Impact Initially the State had assumed 12% managed care savings with a maximum admin/profit load of 8.1% for MCOs Program Year Assumed Savings Actual Savings Variance Year 1 12% 25% 13% Year 2 5% 5% 0% Total Savings 17% 30% 13% By Year 3 the State realized the savings had outpaced the investment substantially (13%) and therefore reduced rates across the program solidifying the positive budgetary impact to the State impact Quality Results: 17% reduction in ED visits and a 22% reduction in hospital admissions for super utilizers 11
Validated by other Independent Studies Louisiana Bayou Health program reported $135.9M in first year of implementation (2013) This represents a PMPM savings of $29.55 (or 12%) Texas Milliman study for the six year period SFY 2010 SFY 2015 shows that STAR and STAR+PLUS programs savings over fee-for-service were 5.0% to 10.7% Overall savings was $3.8B or 7.9% over six years Health outcomes improved dramatically: STAR program asthma hospitalization rate decreased 22% from 2009 to 2011; diabetes complications 26%, gastroenteritis 37%, urinary tract infections 20% STAR+PLUS program (same period) diabetes complications decreased 31%, bacterial pneumonia 19%, urinary tract infections 31% 12
Avalere Independent Study Managed care performs better than FFS across four key metrics: 1. Adults access to preventive/ambulatory health services 2. Inpatient utilization 3. Emergency Department (ED) utilization 4. All-cause readmissions As compared to national FFS dual-eligible members, and adjusted to match the risk of the FFS dual-eligible members, the Arizona plan population exhibited: 31% lower discharge rate (as a measure of inpatient utilization) 43% lower rate of days spent in the hospital (as a measure of inpatient utilization) 19% lower average length of stay (as a measure of inpatient utilization) 9% lower rate of ED visits 21% lower readmission rate 13
Recommended Care Coordination Model: Fully Integrated Managed Care 14
The RIGHT Answer: Physical, Behavioral and Social Integration We have leading edge medical management capabilities that focus on: Fully integrated care encompassing physical health, behavioral health and social and cultural concerns of members Strong provider partnerships and alliances with community based organizations Interdisciplinary care teams that include the member and family Leveraging technology to ensure care team has a view of the whole person Physical Health Behavioral Health Social and Cultural Issues Pioneered by Industry just catching up 15
Aetna Medicaid A member s story: Sarah 16
Sarah s Story: Digging Deeper than the Clinical Presentation Clinical Description 64-year-old female Medical history and present illness Diagnoses: Substance Abuse, Bipolar Disorder, Diabetes, COPD Recent hospital discharge But Sarah is Much More than a Chart Connecting Sarah to the Plan s Case Manager Learning Sarah s story Engaging Care Planning Respecting what Sarah wants Addressing Sarah s social needs 17
A Brighter Future for Sarah Sarah s Outcomes The Plan Case Manager makes regular, face-to-face follow-up visits Sarah has a subsidized apartment in her old neighborhood She socializes now with her old friends She now can care for herself and follows her care plan Sarah significantly reduced her use of ED and inpatient services Sarah is beginning to make a new life for herself 18
Initial Engagement: Member, Family, Community 19
Coordinating with Existing Experts on the Care Team 20
Transformation: Wraparound System of Care 21
Integrated Care Management: Physical, Behavioral and Social Integration experience: Behavioral health conditions drive physical health utilization and cost Individuals with three or more BH conditions cost 335% more than those without any BH conditions $479 PMPM Medical Cost by Number of Behavioral Health Conditions $982 $1,272 $1,606 0 1 2 3+ Number of BH Conditions Combination of BH and PH is associated with a 60% 70% increase in health care costs * * MACPAC June 2015 Report 22
Consolidated Outreach and Risk Evaluation (CORE): s predictive modeling tool Identifies people at risk of high cost or high utilization over the next 12 months Is Medicaid-specific, proprietary, and evidence-based using data from our Medicaid populations, as well as our clinical and informatics expertise Has excellent ability to predict utilization over the next 12 months Finds the highest-risk members marked by Biopsychosocial complexity CORE has a positive predictive value of up to 95.4% 23
Distribution of Risk and Costs: Focus on Complexity Distribution of Membership 99% 99% 98% Distribution of Costs (PMPM) $9,922 $8,800 $9,061 83% $8,303 69% 67% $4,367 $3,486 19.6% 0.4% 0.1% 0.2% 8.5% 11.9% $206 $90 $140 $333 $621 $1,052 Commercial CHIP TANF ABD Duals LTSS Commercial CHIP TANF ABD Duals LTSS Low Risk High Risk Low Risk High Risk 24
Model of Care: We Begin and End Where the Member Lives Condition-Driven (old model) Addresses general membership and special needs populations, including behavioral health, intellectual and developmental disabilities, traumatic brain injury, and others Problem solving: compliance/adherence Complexity-Driven (new model) Integrates physical and behavioral health using a Bio-Psycho-Social understanding of every person we serve: no BH vs. PH members Member engagement: Collaboration of experts resulting in self-directed care Culturally competency; identifies and addresses health care disparities Solution-focused Root cause-focused, based on member s values, beliefs and priorities Brief/Intermittent engagement Extended/Intensive relationship Telephonic/Remote Community-based/Face-to-Face Multidisciplinary staff with subject matter experts that reflect needs of the membership Interdisciplinary team with mix of licensed independent practitioners, including clinical social workers and other behavioral health clinicians even when BH is carved out
What is Whole Person Care? Integrated Biopsychosocial Approach 26
Collaborating to Improve Outcomes: Members, Providers, Advocacy Groups, and Community Organizations 27
Despite the efforts of many organizations, the system of care is still fragmented Member Engaging all key stakeholders with the member at the center Supporting relationships that are important to the member Enhancing current providers ability to meet the member s needs Completing the circle of care Connecting providers to each other 28
Member-Centric Managed Care Engaging all key stakeholders with the member at the center Supporting relationships that are important to the member Completing the circle of care Member Enhancing current providers ability to meet the member s needs Connecting providers to each other Improving outcomes and quality of life 29
Engaging and Supporting Face-to-face assessments in their home Feet on the street with community organizations Collaborate with organizations currently working with the member Using tools and methods to find and engage members Establishing trusting relationships with members by engaging with them in a culturally appropriate manner Honoring current relationships that the member values Building a broad network that includes traditional and non-traditional relationships Supporting quality through credentialing of traditional and non-traditional providers (e.g., home health, AAA, Meals on Wheels, home modification, tribal healers) 30
Enhancing and Connecting Sharing data and information with the goal of making it real-time and actionable at the point of care Entering into aligned incentive, value-based provider contracts to move from pay-for-volume to pay-for-value Participating directly in the Interdisciplinary Care Team (theirs or ours) Closing HEDIS care gaps Combining people and technology to communicate, weaving together a fragmented system of care Employing Community Health Workers and Peer Support Specialists to help members navigate the health care system and communicate with their providers 31
Completing the Circle of Care Filling the gaps in the delivery system better outcomes at a lower cost Improving access to existing services Providing non-covered services as needed 32
Enhancing HCBS: People live where they want to live HCBS Rebalancing Trend in Arizona 100% 80% 60% 40% 20% 0% Institutional HCBS 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 Arizona realized $300M in savings since program start by transitioning LTSS care from institutional settings to the community Plan successfully improved the HCBS ratio by approximately 29% over two years # Members 2,000 1,800 1,600 1,400 1,200 1,000 42% Institutional HCBS Rebalancing Trend in Delaware HCBS 54% 33
The Result: Satisfied Members Delaware Medicaid/LTSS: CAHPS results from 2013 Rating of All Health Care 91.3% Florida Managed Long-Term Care: First year results (2014) 80% of members reported improved quality of life ⅔ of members rated their satisfaction with their Case Manager as 10 out 10 Our LTSS member satisfaction surveys show: Case Manager treated them with respect 93% Worked as a team 93% Trusted their Case Manager 93% Experienced positive results when working with their Case Manager 93% Satisfied with the services that their Case Manager provided 97% 34
Transforming Payment and Delivery through Value-Based Solutions (VBS) 35
s Value-Based Solutions Move providers from Pay-For-Volume to Pay-For-Value Fee-For-Service Full Risk P4P P4Q PCMH/ Health Home Episodes of Care Medicaid ACO Bridge to PCMH and pay-forquality Rewards steps towards practice transformation Rewards practice transformation along the continuum Integrated care, financing and engagement across continuum Shared Risk Progressive Risk Improving access, quality, and affordability 36
Key Factors Necessary to Drive Value-Based Solutions Adoption and Success Goal Alignment Aligned goals and incentives from the State, payors, and providers to reward quality and value Integrated Care Management Financial Alignment Member Engagement Variety of payment models: Pay-for-Quality (P4Q), Pay-for- Performance (P4P), Patient- Centered Medical Homes (PCMH), Shared Savings, Risk arrangements Coordinating the actions of PCMH and PCPs through our Care Management team to drive quality outcomes Analytics and Data Sharing Real time, actionable data allows providers to manage member health needs and gaps in care Healthcare Technology Empowerment and active participation that promotes self-management Innovative tools and apps to enhance provider capabilities and give critical information to members 37
Innovative Technology Solutions HIE Connectivity HIE agnostic platform that connects providers and supports delivery of actionable data at point-of-care Member Mobile App Robust digital tools for engagement, accessing care, and monitoring health Telehealth Increased access through delivery of health-related services and information via telecommunications Care Manager Mobile ipad App Mobile capabilities for our clinical care teams in the community Remote Monitoring For patients with chronic conditions, tracking of vital signs allows quick adjustments in care Data and Analytics Real time, actionable data allows providers to manage health needs and gaps in care 38
In Closing 39
Keys to Successful Medicaid Managed Care Design Benefit Fully-Capitated, Integrated Approach Carve-In All Services Include ABD & LTSS Multi-year contract with renewal options Mandatory Enrollment & Open Enrollment Period Contract w/ Experienced MCOs Provides budget predictability, aligned incentives, and promotes MCO accountability for access, quality and affordability of care Ensures beneficiaries are cared for in a holistic manner; reduces confusion among beneficiaries, providers, and stakeholders Facilitates rebalancing of services by helping members live in least restrictive setting, improves quality of life and saves taxpayer money Gives MCOs runway to achieve program stability/ sustainability, build member trust and improve quality, access to care and affordability Enables member continuity of care, MCO scale/efficiency and increases opportunity to achieve quality outcomes and improved HEDIS measures Provides confidence that the most vulnerable beneficiaries are served by MCOs that have proven experience Actuarially Sound Rates Set by the State Ensures rate development is transparent and timely with MCOs 40
The Difference 30 years of expertise in serving complex, highrisk populations Commitment to achieving quality outcome improvements Pioneer in the integrated, member centric care model Value-based provider payment alignment Local, community-based plan Oklahomans serving Oklahomans Commitment to health care transformation and technology Duty bound to solve for health disparities and engage with beneficiaries in a culturally competent manner 41
Thank you