nยบ5 - Summer Quarter 2019
SDoH SUCCESS STORIES
RISE takes a deep dive into two models that will inspire you and change lives for the better Click to see other articles
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NEWS THE LATEST Artificial intelligence and the power of deep learning in health care Inovalon
Kaiser Family Foundation report: Individual insurance market remains profitable
Addressing peripheral artery disease through enhanced clinical services Signify Health
Medicare Advantage likely to reach 70 percent penetration within 20 years
America is losing ground on dire diabetes complications: Let’s turn it around Advanced Plan for Health How artificial intelligence is transforming risk adjustment Cognizant Preheat marketing: The easy way to generate measurable results during Medicare’s AEP DMW 3 proven strategies to prevent disenrollment Welltok The crusade for value-based care: Rising risk and return models Pulse8 Attracting age-ins: A persistent issue Deft Research
3 takeaways from Deft Research’s 2019 Age-In Study
Only 32% of Medicare Advantage members are familiar with star ratings
Avalere report: Medicare Advantage outperforms fee-for-service Medicare plans on cost of care and quality
Medicare Marketing & Sales Summit: 3 health plan leaders offer insight into the Medicare Advantage market
4 insights into individual and family plan shopping and switching during the 2019 OEP
Lab data: The missing piece of your member profiles Prognos The science behind value-based care modernization SS&C Health 2
RISE Newsletter
WAN T T O KN OW M OR E ?
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Ilene MacDonald Editor, RISE
Letter From the Editor:
RISE, LIKE THE HEALTH CARE INDUSTRY, TURNS ITS FOCUS ON SOCIAL DETERMINANTS
The health care industry was slow to recognize that a person’s lifestyle, living conditions, and employment have a far greater impact on overall health and outcomes than the medical care he or she receives. Despite this, health plans, health care providers, government agencies, and community-based organizations are quickly gaining ground in this area, working together to develop programs that tackle social determinants of health. In the summer issue of our quarterly newsletter, we feature two examples of these efforts, programs that we hope will make you feel good about working in the health care industry and inspire you to continue to find ways to connect members to resources that can help them overcome barriers to good health. You’ll learn about the work of the Southwest Texas Crisis Collaboration, which was formed to respond to the large number of people in the San Antonio area who were chronically ill, homeless, or had a mental illness and frequently sought care in local emergency rooms and inpatient units (see P.12). Collaboration is in the name of the organization for a reason: members had to cooperate with one another and reach a consensus to create a regional emergency response system that navigates patients to the right care, at the right time, and at the right place. Partnerships are also an important component of UnitedHealthcare’s housing and integrated wraparound care model for superusers of the health care system who are currently homeless (see P.9). Unlike most health care models, which are built around body parts, the health plan’s model is built around people, Kathleen Stillo explains. Once these superusers have a home to call their own and no longer need to worry where they will sleep that night, they can finally focus on their health. Is your organization working on a program that addresses social determinants of health? We want to hear from you. Please email me at IMacDonald@risehealth.org to tell me about your efforts. Your program may be featured in an upcoming issue of our quarterly newsletter.
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Note from the Director:
DESIGNING THE FUTURE STATE OF U.S. HEALTH CARE
S
ummer greetings to all! I
The administrative knowhow and capabilities of our industry are indispensable. Our drive toward constant improvement, value-driven performance, transparency, and public accountability is what characterizes our brand of health care financing and delivery.
For those of us in the business of government health care programs, it is evident that population health needs to be incorporated into whatever the design may be for the future state of U.S. health care. With the social determinants of health (SDoH) as an emerging theme, for example, we are aware that perhaps 80 percent of the spend on health care is affected by SDoH factors. If we are ever going to bend the curve of spending in this country, we must come up with successful ways to incorporate strategies that get at the root causes that drive spending and impact population cohorts within our membership.
As an example of this, a recent study comparing the quality of care of dually eligible populations under a Dual Eligible Special Needs Plan (SNP) versus a traditional fee-forservice setting demonstrate that the SNP programs available to these populations deliver better quality care. The data used to better understand their needs translates into better care quality delivery.
hope you are having a great start to your summer, which is finally upon us. We also have the early stages of the 2020 elections emerging. Issues like “Medicare for All” loom in the public imaginations.
If we need these sophisticated tools for population health management, then a simplistic health policy that implements an old-style indemnity model insurance coverage is a 1960s cure that will fail the 21st century realities. Just having insurance is no guarantee that highquality care will be provided nor that the underlying causes of disease and health care spending will be addressed.
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RISE Newsletter
It is not going to be easy, as you already know. That is because it is already our job to figure out how to do it better, based upon our experiences already in risk adjustment, HEDIS ®, stars, and population health management. In a recent RISE risk adjustment policy committee meeting, we had a long conversation about the challenges of data collection to drive our health care management programs, such as Medicare stars and population health, particularly given the emerging importance of SDoH. It is difficult enough now to collect comprehensive,
robust, and accurate diagnostic data to drive these programs that further improve our insights into population health status, enabling us to better stratify and manage cohorts of patient populations without placing additional administrative burdens on the physician practices. We must envision better methods of gathering information to help inform us about SDoH issues without further abrasion at the physician and point-of-care level. The RISE Association is keenly interested in supporting the industry by identifying best practice ideas and disseminating the shared knowledge. We will conduct studies among our community stakeholders to discover ways in which better data collection techniques can be discovered and rapidly deployed as widely as possible. We invite you to submit suggestions about ways you think RISE could help. Please reach out to me directly: kmowll@risehealth.org. I look forward to hearing from you.
Kevin Mowll
Executive Director, The RISE Association
A SNEAK PEEK AT RISE WEST 2019
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ISE West 2019 is shaping up to be bigger than ever. Our annual event returns to San Diego on September 9-11 to bring together senior leaders from Medicare Advantage health plans, commercial marketplace sponsors, Part D health plans, providers groups, pharmacy benefit managers, and accountable care organizations to discuss strategies to improve payer-provider collaboration and the member experience and address social determinants of health. We talked to Kevin Mowll, executive director of the RISE Association, and Marina Adamsky, executive director of production for RISE, to learn what’s new and what attendees can expect at this year’s premier event.
Advanced workshops on risk adjustment, HCC coding, and member engagement This year RISE West will kick it up a notch by offering three high-level half-day workshops plus one all-day workshop on September 9 that focus on management and strategy on member engagement techniques and strategies, HCC coding management training, and risk adjustment management techniques in Medicare risk adjustment for nonactuaries, and management techniques in commercial risk adjustment for nonactuaries. In addition, RISE will host an invitation-only executive think tank that focuses on practical innovation in healthcare. These “201” workshops will drill down on what leaders need to know to do their jobs and put these programs together. “Instead of focusing on the individual contributor, these workshops concentrate on what they need to do to execute these programs as a leader or a manager,” said Mowll. The sessions will offer practical advice, so attendees will take back action items that they can implement at their organizations, Adamsky said. “We want to make sure that the innovation ideas are not pie in the sky. They need to be
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RISE Newsletter
We want to make sure that the innovation ideas are not pie in the sky. They need to be tangible and scalable” tangible and scalable,” she said.
Sessions that focus on providers and collaboration with health plans Mowll anticipates that because of this year’s location, the conference will attract large physician groups from California that take on capitated risk contracts. Health plans will have an opportunity to network with these providers to learn how they can work together and improve quality, revenue, star ratings, and how they can differentiate themselves from their competitors.
Planned sessions will feature: Amy Nguyen Howell, M.D., chief medical officer, America’s Physician Groups (APG), who will discuss from the provider’s perspective how providers and payers can better collaborate in a fragmented health care system to improve risk adjustment programs and the patient experience. A discussion on how health plans tackle provider training activities and avoid provider fatigue and push back. Speakers will include Shannon
I. Decker, Ph.D., executive director of risk, NAMM California, part of OptumCare, UnitedHealth Group; Donna Malone, CPC, CRC, director of enterprise risk adjustment, HCC coding and quality assurance, Tufts Health Plan; Stacy Garrett-Ray, M.D., vice president, medical director, population health services organization, president, quality care network, University of Maryland Medical System, and Cristina Lopez-Pollard, director of government programs, Hill Physicians Medical Group. A panel of experts will also provide tips on payer-provider collaboration techniques that impact quality and risk adjustment on day two of the main conference. Panelists include Molly T. Turco, managing director of legislative policy and regulation, Blue Cross Blue Shield Association; John M. Kirk, founding CEO of Pioneer Medical Group and the former vice-chair of APG’s Public Policy Committee; and Dave Meyer, vice president of stars, Cigna.
A focus on member engagement In addition to the advanced workshop, the main conference will feature sessions that address member engagement, including: Matt Wallaert, chief behavioral officer, Clover Health, will provide examples of programs that have proven to change behavior and motivate members to be active participants in the health care system. Kathleen Ellmore, managing director of Engagys, will moderate a panel discussion on insights into the Medicare and Medicare Advantage product. Attendees will hear directly from Medicare and Medicare Advantage members about their experience, access to care, and suggestions on how health plans can improve their product offerings.
It’s estimated that medical care only addresses 10 to 20 percent of a population’s health outcomes” Strategies to address social determinants of health It’s estimated that medical care only addresses 10 to 20 percent of a population’s health outcomes. The rest are due to social determinants of health or the conditions in the places where people live, learn, work, and play. RISE West will take a deep dive into programs that have successfully addressed these conditions and improved patient outcomes. Kathleen Stillo will discuss how the Medicaid insurance arm of UnitedHealthcare successfully implemented a program that addressed housing and wrap-around care for formerly homeless members. Stillo, who serves as the president and chief operations officer, clinical redesign community & state for UnitedHealthcare, will also discuss “hot spotting” for health care super users and how organizations can help put patients on the right track of care. Attendees will also walk away with strategies to calculate the ROI of interventions that address social determinants of health. Shannon Decker
will join Su Bajaj, vice president of product and payor solutions, Episource, in a session that connects revenuegeneration operations with social determinant projects, funding options, and how to align financial goals with medical management. David DiGiuseppe, vice president of health care economics, Community Health Plan of Washington, will present a case study on how to use data-driven decision-making to drive resource allocation for social determinants of health. He’ll describe the lessons learned from Community Health Plan’s work developing a predictive model to identify members for care management programs.
Allysceaeioun Britt, Ph.D., director of strategic initiatives and quality assurance for the Tennessee Department of Health, will offer a case study on how to create crosssectional partnerships to address social determinants of health issues. She will provide examples of government and non-profit partnerships across several states and learn how to implement them within your organization. RISE West 2019 will take place September 9-11 at the beautiful Loews Coronado Bay Resort in San Diego. Click here to see the entire online agenda, the list of speakers, and how to register for the program.
Related Articles: Regulatory roundup: Recap on the latest on risk adjustment, price transparency, health care costs New study cast doubts on how much MA plans lower Medicare spending, but is the methodology flawed?
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A CARE MODEL ‘BUILT AROUND PEOPLE,’ NOT BODY PARTS RISE West to take a deep dive into UnitedHealthcare’s housing, wraparound care model that tackles social determinants of health
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Speaker Kathleen Stillo, president and chief operating officer of the clinical redesign direct care delivery unit in UnitedHealthcare’s Community & State division, talks to RISE ahead of the September conference about the organization’s mission to provide its most medically and socially complex members with better care at lower cost. Stillo will present the strategy and impact of leading-edge care models that address the health-related social needs of UnitedHealthcare’s Medicaid members at RISE West, on Tuesday, Sept. 10, the first day of the main conference program for the annual event. One model, Housing + Health, focuses on providing housing and integrated wraparound care to members who are persistent and frequent users of the health care system and are currently homeless. Housing + Health is modeled after a similar program that Stillo and Jeffrey Brenner, M.D., chief executive officer of clinical redesign at UnitedHealthcare Community &
pictured above Kathleen Stillo
State, ran at the Camden Coalition of Healthcare Providers and the Urban Health Institute at Cooper Health System in Camden, N.J. “Most models are built around body parts, ours was built around people. The work is similar in many ways, but from the position of payer, the opportunity is significant. We’re impacting vulnerable patients nationwide,” Stillo said. Indeed, UnitedHealthcare has approximately seven million Medicaid members across 30 states within its
system. A small percentage of these members live with a variety of extreme complexities–chronic medical conditions, behavioral health issues, and social disparities, like homelessness, according to Stillo. “They’re utilizing the health care system in many ways–ERs, nursing facilities, and so on. While their cost of care accumulates, they’re not feeling better. They’ve yet to have the root cause of their situations addressed,” she said. UnitedHealthcare launched its first Housing + Health model in the Phoenix market in 2016. The organization learned that those members who experience homelessness visit the emergency room nine times more frequently than other members who are not homeless. They have six times the amount of inpatient stays and their medical spend is more than three times of those members who aren’t homeless. These insights informed the organization’s strategy in Phoenix and subsequent markets.
How the model works
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she said.
Those members who experience homelessness visit the emergency room nine times more frequently than other members who are not homeless” UnitedHealthcare uses three pipelines to identify members who spend a large amount of time in hospital emergency rooms or as inpatients and who meet the criteria for the housing service. The first approach is an internal health care hotspotting capability that UnitedHealthcare developed based on Brenner’s use of data to reallocate resources to the high-needs, high-cost patients in Camden, N.J. It also relies on staff who are embedded in hospitals as part of the discharge process to identify members who may benefit from the service. Finally, the insurer relies on its state health plans to refer members to the program. Housing + Health provides immediate housing and, in time, stabilization for members who are experiencing homelessness, so they can address their medical and social needs. “If you are a person with severe diabetes and you are also homeless, you don’t have the ability to take care of yourself properly. You can’t store insulin if you don’t have a refrigerator. Immediate housing is very effective for members like these who have tremendous medical complexity,”
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RISE Newsletter
Different housing options, depending on need The health plan partners with a housing vendor to offer collocated single-site apartments, scattered site apartments, or group housing that has varying levels of staffing and supportive programming. The multiple housing options help meet the needs of members who are in different stages of complexity. For example, one member who lives in Reno, Nev., and has stage 4 colon cancer, was originally in a single-site unit but then was moved to group housing, which provides a family feel and has given her tremendous support and comfort. “She has a best friend who has become in many ways a significant caregiver for her,” Stillo said. “It’s been rewarding to see supportive relationships forming in our housing units. There isn’t one solution that fits everyone, so we offer different housing options for members experiencing varying states of complexity.”
recovery process. These services include purpose-centered case management, patient-centered care coordination (medical and prescription drugs), advocacy for disability benefits, oneon-one weekly health coaching, nonemergent transportation, on-site support groups, and classes for chronic conditions.) The Housing + Health integrated care model is currently in six states, but Stillo said UnitedHealthcare intends to expand to 15 states by the end of this year. “We have seen a real reduction in medical spend when this type of wraparound care is available to patients who are in the most complex medical and social situations,” Stillo said. Editor’s note: Stillo will discuss UnitedHealthcare’s Housing + Health integrated care approach in-depth at RISE West, which will take place Sept. 9-11, at Loews Coronado Bay Resort, San Diego. Click here for the online agenda or to register.
Plans to expand by end of 2019
UnitedHealthcare pays a monthly charge per member for housing and most programs have wraparound care services to get them stabilized and in a
WHAT THE COUNTRY IS SAYING Related Articles: Half of middle-income seniors won’t be able to afford housing and health care by 2029, new study finds Social determinants of health: 68% of Americans surveyed have experienced at least one unmet social need in the past year
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COLLABORATION IS KEY The biggest takeaway from The National Summit on Social Determinants of Health
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WASHINGTON, D.C.—Don’t wait for lawmakers on Capitol Hill to solve problems related to health care. They aren’t going to do it, according to Rich McKeown, the keynote speaker at RISE’s National Summit on Social Determinants of Health. Instead of lawmakers, solutions will come from the 250 attendees of the conference who represent community-based agencies, health plan providers, service providers, and consultants who will drive necessary changes.
about quality, and care about patient engagement who are going to change the health care system.”
McKeown, chairman of the Leavitt Partners Board of Directors and cofounder of Leavitt Partners, emphasized the need for key stakeholders to collaborate to reach a consensus. “It’s the people who care about cost, care
Collaboration hard at work
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Jamo Rubin, M.D., president of Signify Community for Signify Health and chair of the conference, agreed that it will require cross-sector collaboration and the forming of alliances to move the needle on addressing social determinants of health. “We don’t have experience with this and it requires 350 million of us to do this work,” he said.
Health care organizations have slowly come to the realization that social, economic, and environment factors have a greater influence on a person’s
health than medical care. Although many providers are in the early stages of establishing programs to tackle these challenges, one unique partnership that formed approximately four years ago shows that it is possible to work with multiple players in the community to improve the care of vulnerable populations. Eric Epley, executive director of the Southwest Texas Regional Advisory Council, told attendees about the work of the Southwest Texas Crisis Collaboration. The group was formed in response to the growing number of people in the San Antonio area who were chronically ill, homeless, or had a mental illness, and who were frequently seek care in the emergency department
The problem was the system we had wasn’t a system. It felt like a bunch of puzzle pieces in a Ziploc gallon bag..” and inpatient units. Indeed, 2015 studies revealed that there were 3,500 super users in the region who had more than 62,500 health care encounters in the health care system, equating to a cost of $175 million. Part of the problem was the unnecessary emergency detentions of patients held against their will because they were a danger to themselves or others. An analysis of emergency detention patients on San Antonio emergency departments found that there were more than 9,000 emergency detentions each year, but half only needed a medical screening prior to psychiatric care. Instead, all these potential patients were sent to ERs and they became part of the national “boarding” problem, sometimes waiting 100 hours for care. “The problem was the system we had wasn’t a system. It felt like a bunch of puzzle pieces in a Ziploc gallon bag, but we didn’t have the picture on the front of the box, and the front of the box is essential,” Epley said.
Competitors work together for the greater good The group’s mission was to develop well-planned and coordinated regional emergency response systems and connect people who seek emergency services with the right type of care. The collaboration includes all major public payers, health system and hospital providers, philanthropy, public safety, the local mental health authority, behavioral health providers, and nonprofit organizations. A steering committee guides the work of the collaboration to ensure that members
reach their overall goals: create a system of cross-sector providers, develop shared metrics, mobilize resources, and advance policy. The key, he said, was the ability to work with engaged providers from the biggest health systems in the region. “It was all about collaboration, consensus and cooperation,” Epley said. The collaboration created a 24/7 regional communication system that routes 500 trauma patients each month, coordinates air medical support, and has a computer aided dispatch system for all 911 calls related to mental health. All psychiatric facilities now actively use an online tool to notify the regional system of their diversion status and available beds are segmented by child, adolescent, adult, or geriatric. Patients are screened immediately so they can quickly get to the appropriate care setting. “Trauma patients go to the trauma center. Stroke patients go to the stroke center. If a patient is medically stable we will take psych patients to the psych center, so they start getting care early and they aren’t sitting in an emergency department for hours,” he said.
right care at the right time and place In 2018, the system dealt with 16,138 cases. Epley said that 9,310 or 58 percent of the cases were sent directly to a psychiatric facility and 28 percent were sent to emergency departments. The patients were navigated to the right care, at the right time, and right place, he said. The program is so effective that the collaboration is now working on additional projects, including the establishment of a 35-bed behavioral health diversion program. This program would provide 24-7 residential support with embedded outpatient treatment services, psychiatric emergency services to help facilitate transfers and care coordination to the most appropriate level of care, and the development of an intensive care coordination program to further reduce emergency detentions and the subsequent use of emergency and inpatient services.
The result: Patients receive the
Related Articles: Survey: SDoH tops list of most difficult information to share through HIEs Data collection key to efforts that address social determinants of health
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UPCOMING EVENTS
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RISE Newsletter
March 15-17, 2020
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