Category Archives: Dual Eligible

Case Management of Chronically Ill Elderly Dual Eligibles

With chronic illnesses like diabetes and heart disease being cured isn’t the goal; feeling better on average, not going to the hospital as much, living a longer and higher quality life is the goal. The existence of chronic illness is a somewhat ironic demonstration of modern medicine’s success. Three decades ago, many chronic conditions killed you at much younger ages. Today, many like heart failure can be fought off for years or indefinitely.

Kenneth Thorpe, chairman of the health policy and management school at Emory University, estimates that 95 percent of spending in Medicare goes to patients with one or more chronic conditions — with enrollees suffering five or more chronic conditions accounting for 78 percent of its spending. According to Mr. Thorpe, “This is the Willie Sutton rule; If 80 percent of the spending is going to patients with five or more conditions, that’s where our health-care system needs to go.”

This is the basic health profile of full Dual Eligible, a population in the United States of more than 7 million people and in Missouri more than 168,000 of our citizens.  As we’ve discussed in earlier blog posts, dual eligible individuals are using the full benefits available to them under both Medicare and Medicaid. 61% are over 65, 39% are younger than 65 and disabled. Half have dementia or another mental impairment and 55% have three or more chronic conditions. This is the highest cost group of consumers in the American medical system. They are 15% of the Medicaid population and account for 40% of total Medicaid spending. In Missouri we spend in excess of $2 billion annually on this group’s healthcare.

Individuals with chronic conditions, many dual eligible, represent perhaps the best group for home health and community based services (HCBS) generally to demonstrate their biggest benefit to the healthcare system overall.

Many traditional care-management systems rely on nurses sitting in call centers, checking up on patients over the phone. These centers are often housed within insurance companies or subcontracted providers to insurance companies who have capitated contracts with state governments to manage chronically ill Medicaid beneficiaries and, increasingly, the dual eligible population at large.  That model has mostly proven to be a failure where maximizing long term savings to state governments is concerned and, more importantly, where improving the long term quality of life for beneficiaries is concerned. Most savings driven by this model are attained via provider reimbursement cuts and minimization of services which produce early savings that then tend to marginally abate with time.

While many are familiar with the use of home health nurse visits in the days and weeks after a serious hospitalization or nursing home discharge; a much greater benefit to the system can be achieved by sending a nurse to regularly visit chronically ill patients at home. Using home health in this fashion basically redefines the health-care system’s role where the elderly and chronically ill are concerned. It acknowledges that being older and chronically ill is a condition that requires ongoing, professional medical management. In this acknowledgement there is tremendous improvement in quality of life at much lower public expense, especially where the dual eligible beneficiary is concerned.

Many chronically ill patients think of the hospital as a place people go to get better. What providers of Home and Community Based services (HCBS) realize is that, in reality, a hospital is a place where chronically ill seniors get worse. Being in the hospital for multiple days is often the point at which a chronically ill but basically stable senior’s health condition really begins to deteriorate. It’s when the individual ends up in a nursing home and in some cases never makes it back to their own home. It’s also the point at which public health cost absolutely skyrocket. Keeping seniors out of the hospital and out of the nursing home is the core focus of HCBS; they cut cost and save and preserve quality of life; and it saves money, lots of it.

At home is where chronically ill elderly patients spend the time they don’t lose to hospitalizations. It’s where they take their medicine or fail to properly, eat healthy meals or eat poorly, are engaged or become depressed, get around or fall down. This is the key to the power of home health and HCBS; in the home a trained medical professional can see trouble before it becomes too late. As well intended as they may be, clinicians in call centers in O’Fallon and Omaha can’t get the same level of understanding of a situation as can a clinician on-site. It’s just very difficult to build an effective relationship over the phone that makes a lasting difference.

Pyramid Home Health Services has been building these relationships with Missourians suffering from chronic illness since 1972.  We fundamentally believe that where chronically ill dual eligible are concerned, you can’t treat them when they’re sick and ignore them when they’re well. You need to know them well enough and see them frequently enough to catch if they are depressed, if their color is good or bad, if they understand their medications and are managing them appropriately. When you consider that a relatively high acuity dual eligible with multiple chronic illness can be effectively kept out of the hospital and nursing home for approximately $4,000 annually and a very high acuity individual for less than $8000 annually and compare the same to one, three day hospital stay at $5,800, and $125 per day for rehab in a skilled nursing facility afterward, which can often run up to 100 days, the economic benefits of using HCBS to case manage the health of chronically ill elderly become abundantly clear. Further add to that fact that home is where everyone would rather be unconditionally.

If Pyramid Home Health Services can assist you or your organization with case management and/or additional HCBS for a chronically ill loved one or a population for whom you’ve contracted to manage, please contact us at 888-880-6565 or visit us at www.pyramidhhs.com.

The Medical Home Model and Dual Eligible

Last week we discussed the two main types of Financial Alignment Demonstrations sponsored by CMS and for full dual Eligible. These are:

  • The Capitated Model. This is a model that pays private health plans that contract with the state a PMPM rate to provide all Medicare and Medicaid benefits to full dual eligible on behalf of the state.
  • Patient Centered Medical Home Model. This model allows states to design systems to coordinate care for full dual eligible while Medicare and Medicaid continue to pay providers directly for delivered services.

This week let’s take a deeper look at the Patient Centered Medical Home Model in Missouri. Like we discussed last week, Missouri submitted in its proposal on May 31st, 2012 for a Patient Centered Medical Home Financial Alignment Demonstration.

Missouri proposed to build their Patient Centered Medical Home demonstration around their existing Medicaid Health Home initiatives. You may know, the state of Missouri applied for and received approval from CMS for two Health Home programs under Section 2703 of the Affordable Care Act (ACA) in January 2012. We were actually the 1st in the United States to be approved. These health homes currently provide care coordination services state-wide to 11,996 dual eligible Missourians. The first of the two programs, the Community Mental Health Center (CMHC) Health Home program, targets individuals who have serious mental illness in combination with another chronic condition. The second approved program, the Primary Care (PC) Health Home, targets individuals who have multiple and chronic conditions. There are currently 29 Community Mental Health Center based health homes and 24 Primary Care Health Homes mostly located in Missouri’s FQHC.

Missouri’s Financial Alignment Demonstration requests to extend Missouri’s existing Health Home initiative for select, full- dual eligible within the state. So what are the hallmarks of the Patient Centered Medical Home Model?

1. Strategies to target high-need, high cost beneficiaries. Missouri identifies eligible not already enrolled in a health home and who have 2 or more chronic conditions and/ or serious mental health issues through analysis of healthcare claims data and via referral from providers.

2. Care team led by a Care Coordinator who is the patient’s Physician or Advanced Practice Nurse.

3. Coordination of Multidisciplinary care teams that integrate behavioral and physical health. The care coordinator unites the disparate pieces of the health care delivery system and makes them work collaboratively for each beneficiary. Additional physicians (specialist), Nurse Practitioners, Psychiatrists, Behavioral Health Consultants, Nurse Care Managers, Dietitians, Diabetes Educators, Pharmacist, labs and other ancillary care providers work as governed by the beneficiaries personal plan of care as coordinated by their health home care coordinator. The Patient Centered Health Home locates, conducts outreach to and manages the ongoing treatments of all the extended team members. In Missouri these health homes receive a per member, per month payment of approximately $60 for the Primary Care Health Home Program and $80 PMPM for the Community Mental Health Center Health Home.

4. Enhanced access. This is early identification of need for and connection to community services that can avoid higher cost and usually facility based services after an acute event.

5. Provider and Payer Alignment. This is accomplished through PMPM case management fees and in some cases additional provider participation in shared savings.

6. The ability to drive Medicare and Medicaid Savings. In Fiscal year 2012 alone the Missouri State Budget was benefited by $44 million in avoided healthcare expenditures from existing Patient Centered Health Home initiatives.

Home Health and HCBS services can greatly extend the inherent benefits of the Patient Centered Health Home model. By effecting an ongoing relationship with the patient and the their health home based practitioners, a home health partner can ensure the dual eligible patient’s physician has a more granular understanding of the daily challenges a patient faces where adherence to recommended behavior and compliance with physician orders is concerned. HCBS services can assist as well to educate and train the patient’s friends and family in providing the supports necessary to better their adherence to the plan of care.

Additionally, where more complex co-morbidities exist, for example, a diabetic with open wounds, a home care provider with an expertise in advanced wound healing can add exponentially to the effectiveness of the health home team by bringing specific expertise in the form of knowing how to deploy, at home, support surfaces, wound vacuums, advanced debridement techniques and alternative dressings. This reduces the need for inconvenient and more expensive out of home trips for follow-up care and minimizes the potential for infection which often results in avoidable hospitalization and SNF rehabilitation.

Pyramid Home Health Services Wound Healing Program consists of the following:

  • WOCN, a credentialed specialist RN, who reviews each patient’s H&P, initial assessment/ wound etiology, electronic wound photos, and consults on a holistic POC recommendation with the treating physician. They are also available for patient, physician and family in-home and in-office consultations and case conferences.
  • Case Manager that tracks compliance with POC, monitors healing progress, coordinates the communications of treating clinicians, the patient’s physician(s) and Pyramid’s WOCN using electronic medical record updates and digital transmission of wound care photos and treatment notes.
  • Treating Clinicians that are trained in and receive continuing education on advanced wound treatments, dietary and behavioural management techniques and patient education.

If Pyramid Home Health Services can assist you Medical Home Model please contact us at 888-880-6565 or visit us at www.pyramidhhs.com

Managed Care and Dual Eligible

Last week we discussed dual eligible individuals; people using services under both Medicare and Medicaid and specifically “full” dual eligible. These are our friends and neighbors that use a large number of services under both programs. We noted there are 7.4 million full dual eligible citizens of the United States and that more than 168,000 of our fellow Missourians are considered full dual eligible.

Because of the cost and the need for better case management of the services provided dual eligible, the Affordable Care Act created the Medicare-Medicaid Coordination Office within (CMS). Their goal is to make the two programs work together more effectively. They are charged with testing new approaches to care coordination which permits states to keep any earned Medicaid savings but also share in the Medicare savings resulting from their management efforts. The biggest of these initiatives is the Financial Alignment Demonstration. In this demonstration CMS is testing predominantly two models to better integrate primary, acute, behavioral health, and long-term supportive services for full dual eligible.  The Medicare- Medicaid office wants 2 million of the 7.4 million full-dual eligible Americans enrolled in these demonstrations by the end of 2014.

The two models being tested by the Financial Alignment Demonstration are:

  • The Capitated Model. This is a model that pays private health plans that contract with the state a PMPM rate to provide all Medicare and Medicaid benefits to full dual eligible on behalf of the state.
  • Patient Centered Medical Home Model. This model allows states to design systems to coordinate care for full dual eligible while Medicare and Medicaid continue to pay providers directly for delivered services.

So what’s the difference? The Capitated model and the Patient Centered Medical Home model are both, equally, managed care models. Operationally, the capitated model, through capitation, transfers the risk of financial loss from the state and federal government to a private third party who administers the program to control cost and provider behavior. The Patient Centered Medical Home Model addresses cost and provider behavior by establishing a single point of coordination to design and manage care plans, case manage individuals, and coordinate all services. It then shares the total system savings with providers who meet its quality and cost benchmarks.

As of March 2013 26 states have submitted proposals and 5 have executed memorandum of understanding with CMS (California, Washington, Ohio, Illinois, Massachusetts). The other states remain in negotiations with CMS. Missouri submitted its proposal on May 31st, 2012. Missouri chose to submit a Patient Centered Medical Home Model. Of the currently approved five states, Washington State is operating a Patient Centered Medical Home Model. Iowa and New York like Missouri are expected to receive approval soon.

Home Healthcare, HCBS services and medication management services (MTM) provided through a community pharmacy can play a fundamental role in improving a dual eligible citizen’s health and reducing the cost of their care, regardless of the Financial Alignment Demonstration model chosen by a state.

To make a positive difference in an individual’s health you have to first have a relationship with the individual. To build a relationship you have meet the person where they are; and where full dual eligible are concerned that primarily consist of home or the hospital. It’s better and cheaper for everyone to meet at home.

Where the capitated model is concerned, effective use of Home and Community Based Services (HCBS), services like personal care and basic nursing, and MTM through community pharmacy reduces medical expenditures and can result in better beneficiary satisfaction and increased profit for the insurance company. There is no better return on investment for an insurance company than reducing costly hospitalizations and rehabilitation time spent in Skilled Nursing Facilities after acute events like falls or strokes.

The Patient Centered Medical Home Model likewise benefits greatly from a robust home care component. Where it’s difficult for many dual eligible patients in a Medical Home to get to their doctor’s office, a home health provider, like Pyramid Home Health Services, who provides fully interactive tele-health can bring their doctor into their home. In fact, at Pyramid Home Health Services we use Android tablets and multi-split screen technology to simultaneously case conference with a patient, our nurse in the home, the patient’s physician and the patient’s Pyramid pharmacist. If labs are necessary they can be attained on the spot. If medication regimen need to be changed home delivery can ensure those changes are made the same day. Most importantly everyone knows what’s going on real time and our patient does not end up in the hospital because they could not get to the physician’s office. Now that’s a health care home that can work for our dual eligible citizens.

Pyramid Home Health Services has been Missouri’s premium home care provider since 1972. We offer a full array of home health, HCBS, Hospice and Pharmacy services. We are also a leading provider of both tele-health and tele-monitoring services for individuals with chronic illness. If Pyramid Home Health Services can assist you, your family, patients or plan beneficiaries call us at 888-880-6565 or visit us at www.pyramidhhs.com.

Case Managing Dual Eligible

Medicare covers 46 million elderly and disabled Americans. 10.2 million Americans are also covered by Medicaid. They are in the parlance of public health, “Dual Eligible.” 7.4 million of these dual eligible, very often our poorest and sickest citizens, are considered “Full-Dual Eligible.” These individuals are using the full benefits available to them under both Medicare and Medicaid. 61% are over 65, 39% are younger than 65 and disabled. Half have dementia or another mental impairment and 55% have three or more chronic conditions. This is the highest cost group of consumers in the American medical system. They are 15% of the Medicaid population and account for 40% of total Medicaid spending. There are 168,229 full dual eligible in Missouri and Missouri Medicaid spends in excess of $2 billion annually on their healthcare.  

So who pays for what? Medicare pays for most acute care services like hospitals and physicians, but also prescription drugs and certain post- acute services like rehabilitation in a skilled nursing facility, home health, some outpatient therapy and some DME. Medicaid pays the individual’s Medicare premiums, cost-sharing for acute services, and for services not covered by Medicare, most notably long-term care but also medical transportation, case management, and in some states vision and dental services.

Because Medicare and Medicaid pay for different slices of a dual eligible’s care this group’s services have been largely uncoordinated. The cost of investments designed to lessen overall spending, if done, is often borne by the state and Medicaid with the benefits accruing to the Federal government and Medicare. For example, reducing avoidable hospitalizations is a direct benefit of better coordinated care. CMS says 45 percent of hospitalizations transferring from skilled nursing facilities last year we’re avoidable. To reduce those hospitalizations requires investment in programs like fall prevention and expanded HCBS services. The cost of expanding these programs is roughly 40% born by the state under Medicaid but the financial savings from those investments accrue to Medicare and the Federal government.

To address this inequality, The Affordable Care Act created the Medicare-Medicaid Coordination Office within (CMS). Their goal is to make the two programs work together more effectively. They are charged with testing new approaches to care coordination which permit states to keep any earned Medicaid savings but also share in the Medicare savings resulting from their management efforts. The biggest of these initiatives is the Financial Alignment Demonstration. In this demonstration CMS is testing predominantly two models to better integrate primary, acute, behavioral health, and long-term supportive services for full dual eligible.  The Medicare- Medicaid office wants 2 million of the 7.4 million full-dual eligible Americans enrolled in these demonstrations by the end of 2014.

Home Healthcare and especially Home and Community Based Services, those services that deliver long term care into the individual’s home, can play a very important role in helping the States better meet the care needs of their dual eligible citizens. These programs which include tele-monitoring, tele-health, personal care, homemaker chore and basic nursing services provide the single most affordable mechanism for early warning of impending health events that likely will result in a hospitalization. For example, if HCBS monitoring identifies an individual is experiencing increased restlessness at night and unusual weight gain in the short- term, with Doctor’s orders, a home health nurse can intervene with administration of a diuretic if necessary and increased teaching on diet. A personal care assistant can prepare in advance healthy meals and have them ready to go when it’s time for the individual to eat; making it easier to stay compliant with a lower sodium, lower sugar diet.

This is just one example of how home health and HCBS can, for the cost of a few hundred dollars under Medicaid, avoid many thousands of dollars of cost under Medicare relating to a a CHF hospitalization. When provided as a part of a broader Financial Alignment Demonstration this means increased revenue to the state by driving the Medicare savings associated with this dual eligible citizen’s care.

Pyramid Home Health Services provides Home Health, HCBS and Pharmacy services throughout Missouri. We’ve helped Missourians remain at home since 1972. Call us at 888-880-6565 if we can be of assistance to you.