Rwj super utilizers presentation

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  • BH integration: prevalence of alcohol, mood and anxiety related diagnoses for high utilizersAlso, among top 5%: almost ½ use MH servicesTop 4 diagnoses all MH-relatedSPMI die 25 yrs youngerPreventive care/ care management: COPD, diabetesFor all children, respiratory distress and ear infections top ED useAsthma and bronchitis top IP


  • 1. Transforming Service Delivery, Producing Quality, Cost-Effective Outcomes In Maine’s Medicaid Program Presented by Mary C. Mayhew, Commissioner Maine Department of Health and Human Services Robert Wood Johnson Foundation Super-Utilizer Project Year Two Summit July 31, 2013
  • 2. 2
  • 3. Camden Coalition’s Snapshot Of Maine’s High-Cost Users • 1 percent of all MaineCare patients accounted for over 30 percent of total hospital costs across the three counties • 20 percent accounted for 87 percent of costs. • Most prevalent diagnoses: – Alcohol-related disorders (over twice as likely as non-High Utilizers) – Mood disorders – Chronic obstructive pulmonary disease and bronchiectasis (almost twice as likely) • 1.8 times more likely to have an IP diagnosis of diabetes compared to non-High Utilizers • 72% of all IP High Utilizers were over age 34
  • 4. Camden Coalition Snapshot Of Maine’s High-Cost Users ED High Utilizers • Almost 1.5 times more likely to have an ED diagnosis of "anxiety disorders” • Almost 1.5 times more likely to have an ED diagnosis of "spondylosis; intervertebral disc disorders; other back problems” • 1.4 times more likely to have a diagnosis of "Headache; including migraine“ • 67% of all ED High Utilizers were under age 35
  • 5. • A relatively small number of MaineCare members are responsible for a large percentage of the costs • High utilizers cluster in “hot spots” across the state • Improved integration of behavioral and physical health is a necessity • Many high utilizers’ health may be improved through access to primary care, preventive care, and chronic disease management Our strategy must be: • Community-based • Address integration of behavioral and physical health • Strengthen access to and use of patient-centered primary care • Provide care management for high need members • Social service agencies must address social/environmental barriers What the Data Tells Us
  • 6. Emergency Department Care Management Collaborative • Began as a one-hospital pilot project in 2011 • Identified 30 frequent ED users • Managed care with delivery in most appropriate setting • Recognized more than $100,000 in savings
  • 7. Emergency Department Care Management Collaborative Expectations for participating hospitals: – Investment of available care management resources for monthly case conferences – Daily sharing of ED and inpatient census data The State’s responsibilities: – Bringing all resources together – Providing care management resources for hospitals/communities with insufficient capacity – Daily census analysis – Sharing of diagnosis, medical compliance, PCP provider visits, and other utilization data – Technical assistance
  • 8. Emergency Department Care Management Collaborative As of June 2013 – All hospitals in Maine have constructed their lists of high utilizers. – Now working with 1,700 members – State staff dedicated to the program. – We are working with the larger health systems to help standardize processes and facilitate clear communication – Savings of over $4 million annually.
  • 9. Liz’s Story 10 • Introduced to program after 13 inappropriate hospital visits • Took her case to upon referral of a local hospital • Type II Diabetes, anemia, chronic pain, COPD, tobacco use, drug abuse, epilepsy, incontinence, adult failure to thrive and anxiety; suicidal. • Recent right hip fracture and repair, neurogenic bladder, Bell’s palsy, opioid dependence, deficits in mobility, which have been helped by a wheelchair • -Discharged from nursing home about a year ago
  • 10. Liz’s Story 11
  • 11. So Far, So Good 12 • In-home supports have allowed Liz to remain independent. • Behavioral health services are provided in her home. • No longer has thoughts of suicide. • Has not visited the Emergency Department since February. • Credits this program with saving her life.
  • 12. 13 Maine’s High-Cost Utilizers Cost Per Member Cost PMPM Top 5 90 to 95% 80 To 90% Bottom 80% $5,713 $1,750 $766 $78 Annual Cost
  • 13. The Top Five Percent 14
  • 14. The High Five Team: 15 • Form a group with at least two representatives from each of the offices within DHHS • Empower this group to act and ensure a holistic approach is considered when services are made available • Focus on services delivered and needs present NOT cost • Benchmark is to bring the top 5 percent closer to the second 5 percent in service and cost by improving quality of care and services provided
  • 15. The High Five Team: An Example 16 • Two adult females • Both receiving rent subsidy and MaineCare • SSI disabled • Diagnosis: depression • Risk scores comparable • Medical costs 2011 – Member #1 : $12,530 – Member #2 : $47,254
  • 16. Maine Health Homes A Key to Long-Term Sustainability 17 Stage A (ongoing): •Health Home = Medical Home primary care practice + CCT •Currently have 150 enrolled practices and 10 CCTs •Payment weighted toward medical home •Eligible Members: • Two or more chronic conditions • One chronic condition and at risk for another Stage B (Fall Implementation): •Health Homes = CCT with behavioral health expertise + primary care practice •Payment weighted toward CCT •Eligible Members: • Adults with Serious Mental Illness • Children with Serious Emotional Disturbance
  • 17. Other Keys To Sustainability 18 • ROI; Quality Outcomes; Cost Effectiveness • Federal Medicaid Policies Reflective of Social/Medical Model; & Community-based services: Homemaker services/Peer Supports; Any Willing Provider • State Policy Reforms; Payment Reform • Standardized practices/systems • Commitment to Continual Process Improvement • State Investments in the Model • Integrated DHHS System • Robust Data Systems/Data Analytics/Predictive Analytics
  • 18. Thoughts from the Field: Sustainability 19