Transcript Ideas for Care Coordination Presented to the Kentucky

Passport Advantage
A Special Needs Plan for Dual Eligibles
April 20, 2006
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Organizational Structure
CMS
University Health Care, Inc.
dba Passport Advantage
Larry N. Cook, M.D.
President &
Chairman of the Board
Region 3 Medicaid
Partnership Council
Bill Wagner- Chairman
Robert Slaton, Ed.D.
Executive Vice
President
AmeriHealth Mercy Health Plan
Joyce Hagen - President,
Passport Advantage
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Organization and Governance
University Health Care, HMO
Risk bearing entity
Section 501(c)(3) tax-exempt organization
• Original Funders
– University of Louisville Medical School Practice Association (51%)
– Jewish Hospital & St. Mary’s Healthcare (13%)
– Norton Healthcare (13%)
– University Medical Center, Inc. (13%)
– Louisville-Jefferson County Primary Care Association(10%)
• Family Health Center, Inc. (FQHC)
• Jefferson County Health Department
• Park DuValle Community Health Center, Inc. (FQHC)
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• University of Louisville Primary Care Center
Region 3 Partnership Council
Committee Structure
Commonwealth of Kentucky
University Health Care, Inc.
Board of Directors
Finance
Region 3
Partnership Council
Primary Care Physician Workgroup
Quality Medical Management
ER
Quality/Member Access
Credentials
Child and Adolescent Health
Appeals
Women's Health
Delegation Oversight
Quality of Service
Pharmacy
Organizational Provider
Lock-In
Rural Health Advisory Council
Behavioral Health
Health Outcomes Oversight
Internal Quality Review
Medical Criteria/Policy Review
Passport Advantage
Behavioral Health
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Why Develop a
Special Needs Plan?
• As a result of the Medicare Modernization Act, Passport
Health Plan applied to become a Medicare Advantage
Special Needs Plan for its aged, blind, and disabled
members who are also eligible for Medicare.
• Absent a CMS contract, Passport Health Plan would have
lost the ability to manage pharmacy benefits and ultimately,
quality and continuity of care, for these dual eligible
members.
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Why Develop a
Special Needs Plan?
• As a Medicare Advantage Special Needs Plan,
Passport Advantage is able to manage both Medicare
and Medicaid benefits, thereby providing better
coordinated care for this vulnerable population.
Passport Health Plan was influential in achieving passive enrollment process
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Members Eligible
to Participate
• Only dually eligible beneficiaries currently enrolled in
Passport Health Plan.
• All categories of beneficiaries (aged, disabled, and
ESRD).
• Approximately 10,500 members.
Passport Advantage provides Medicare Parts A, B & D
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Members Eligible
to Participate
60%
50%
40%
55%
45%
Disabled
Aged
30%
20%
10%
0%
Disabled v. Aged
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Dual Eligible Demographics
35%
30%
25%
32.80%
31.40%
24.30%
20%
Aged
Disabled
15%
10%
11.50%
5%
0%
Female
Male
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Implementation Challenges
• New product – organizational stress.
• CMS eligibility file delays.
– System set-up error.
– Original eligibility file received mid-January.
(ID card contingency plan, interim payment).
– Still resolving last of January 1 eligibility issues.
• Confusion over Part D eligibility (reconciliation).
Eligibility and Part D confusion at retail pharmacy caused
greatest operational issues during immediate go-live
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Part D Implementation
• Provided frequent written communications to
inform/educate pharmacists about Part D benefit.
• Plan staff visited high volume pharmacies to explain
Passport Advantage and Part D benefit.
• List of Passport Health Plan members sent to pharmacies
where duals routinely had prescriptions filled to facilitate
transition from Passport Health Plan to Passport
Advantage.
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Part D Implementation
• Decision made on January 1 to cover prescriptions for
Passport Health Plan duals when pharmacy could not
confirm enrollment in any Part D plan.
• Worked closely with PBM (PerformRX) to assure access
to prescriptions.
• Redirected some pharmacy calls from PBM to Plan due
to unexpected call volume during first several weeks.
Passport Health Plan and Passport Advantage recognized by local
pharmacies and legislators as plan with best Part D transition
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Continuity of Care –
Provider Network
• Non-contracted providers paid 100% of Medicare payment
amount.
• Contracted providers receive higher reimbursement.
Minimize member disruption and maintain continuity of care
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Shift in Approach
Medical Management
Traditional Reactive Approach
• Utilization Management
• Case Management
Care Coordination
Progressive Proactive Approach
• Health Assessment
• Member Education
• Member Empowerment
• Preventive Health Management
• Wellness Awareness
• Disease Management
• Member Advocacy
• Predictive Modeling
• Member Safety
Shift from reactive to proactive approach
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Health Management Solutions
Well Members
Low/Moderate
Risk Members
High Risk
Members
• healthy Now (member educational articles)
• Preventive health outreach letters, postcards, phone calls, website
• Health risk assessment at enrollment
• 24/7 nurse advice line and audio library
• Utilization management
• Member outreach via letters, postcards, phone calls
• Case management
• Specialized Case Management:
i.e., Palliative Care, HIV, Transplant
• Disease Management
• Diabetes
• Asthma
• COPD
• CAD
Targeted interventions based on member health risk
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Advocate Community Support
• Supported advocate education to address confusion
over pharmacy benefits transitioning to Part D.
• Participation on new Medicare Advantage committees.
Support of advocates critical for member recruitment and retention.
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Key Success Factors
• Provider sponsored.
• Partnership model.
• Extensive physician/clinician involvement in developing,
implementing and managing the plan.
• Collaboration with community agencies and health
departments.
• Extensive provider network and enhanced
reimbursement.
• Member satisfaction and involvement.
• Proactive care coordination model.
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Questions and Answers
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