Coordinated Care and Beyond: The Future of Integrated Care for Complex Chronic Conditions: What’s Working, What’s Not?

8:00 – 8:45 a.m. Registration and Light Breakfast

8:45 – 9:00 a.m. Welcome and Introductions

• Sarah Dash
  Alliance for Health Policy

9:00 – 10:00 a.m. Future Trends in Chronic Care

• Peter Fise
  Bipartisan Policy Center
• Clay Marsh
  West Virginia University
• Sue Nelson
  American Heart Association
• John Romley
  USC Schaeffer Center for Health Policy and Economics
• Sarah Dash, moderator
  Alliance for Health Policy

10:00 – 10:15 a.m. Break

10:15 – 11:15 a.m. Coverage and Chronic Care

• Mark Fendrick
  University of Michigan School of Public Health
• Rebecca Kirch
  National Patient Advocate Foundation
• Kathleen Nolan
  Health Management Associates
• Hon. Allyson Y. Schwartz
  Better Medicare Alliance
• Julie Appleby, moderator
  Kaiser Health News

11:15 a.m.-12:15 p.m. The Future of Integrated Care for Complex Chronic Conditions: What’s Working, What’s Not

• Bart Asner
  Monarch Healthcare
• Larry Atkins
  Long-Term Quality Alliance
• Sandra Wilkniss
  National Governors Association
• Susan Dentzer, moderator
  Network for Excellence in Health Innovation

12:15 – 12:30 p.m. Closing Remarks

PLEASE NOTE: This is an unedited transcript. Please refer to the video of this event to confirm exact quotes. SARAH DASH: Thank you. So, we are going to go ahead and get started again, and we have — we will give people just another couple of seconds to take their seats. We have another really terrific panel here too. I think it really encapsulates and rounds out a lot of the themes that we’ve heard and we are going to be talking about care delivery now, and to do that, we are thrilled to have with us Susan Dentzer, who is President and CEO of the Network for Excellence in Healthcare Innovation. Did I say that right? NEHI. And Susan is going to go ahead and introduce her panel and we will take it from there. Thanks. SUSAN DENTZER: Thank you very much, Sarah, and good morning to all of you. Our job on this panel, as Sarah just said, to talk about care delivery and particularly around the topic of integrated care delivery for those with complex chronic conditions. So, let’s focus for a moment on the word “integrated” because in healthcare of course, we throw a lot of words around, assuming that everybody understands what we are talking about, and of course, ten minutes into the conversation, you often realize that people are not on the same page. What do we mean about “integrated” here? We mean integrated in one context, across the conventional focuses of medicine. So, primary care, specialty care, and also behavioral health. We mean integrated in that respect. Because of course, the people with complex chronic conditions have needs and all of those fears. Primary care, specialty care and of course, very importantly, behavioral health. We also mean integrated in the sense that, as you have been hearing about all morning, people just don’t have health care needs that affect their health and their health status, they have a lot of social needs that have to be addressed. They have housing needs, transportation needs, et cetera. And so, when we think about what we might conceive of this as state-of-the-art of a model that would really address the needs of people with complex chronic conditions. Whether they are suffering from terrible health conditions, whether there are dual eligible and have not only different conditions, but having their care paid for through different payment streams, when we think about what might be a state-of-the-art model, we really want to think about integration in all of these contexts. So, that is the job of this panel, to solve this entire problem in the next hour. Or, at least to give you a sense of the models that they are either engaged in, or that they see on the horizon that could be very helpful in this context. Let me introduce with great pleasure, first of all, Bart Asner, who is the Chief Executive Officer and a member of the board of directors of Monarch Healthcare, which is an independent practice association model medical group that he founded in 1994, now part of United Optim, particularly. So, Bart, thank you very much for being here, we look forward to you discussing Monarch’s approach to these issues. Larry Atkins is also with us, he’s Executive Director of Long-Term Quality Alliance; he will tell you a bit more about what that does. He is also a board member and the immediate past president of The National Academy of Social Insurance and was recently the Staff Director of the Federal Commission on Long-Term Care, which many of you who follow that issue, know it issued its final report back in 2013. Sandra Wilkniss is with us. She is Program Director for the National Governor’s Association Center for Best Practices Health Division, and therefore has her handle on a number of the important state models that are emerging in this category. She focuses on issues related to behavioral health and social determinants of health in particular and the integration — there is that “I” word again — of those into the health system. So, welcome to all of you. We’ve asked each of them to start off with just four or five minutes to kind of tell us what models they are either engaged in, or see on the horizon, as I said earlier. How we think we can achieve this integration, what success stories we have to tell so far, if any. We know that there are some. We need to scale them up and replicate them. What success stories and in particular, what challenges we face in this whole integration effort. So, Bart, over to you. BART ASNER: Thank you, Susan, and thank you for inviting me to speak today. So, Susan referenced Monarch Healthcare, which I have been CEO of since it was founded in 1994, so nearly 25 years of experience in what is called managed care, now coordinated care. Managed care was an evil word for a while, now it’s coming back into vogue. We’ve changed the words to coordinated care. It’s all the same. Monarch is an IPA — an independent practice association. The “I” refers to physicians who are literally in independent practice. These are the doctors all over the country who have been practicing by themselves for years and we brought them together into this organization so that they can work on behalf of patients in a coordinated care system. So, that’s what an IPA is. We heard on the last panel a lot about value based care and coordinated care. We are on the ground doing just that for patients. We actually assume risk from insurance companies and take the risk and responsibility to provide for quality care at an affordable price for patients. Accountable care organizations, which are now all the vogue, we were an accountable care organization starting in 1994, we just didn’t know it, because the words didn’t exist. We have been accountable for the cost and quality of healthcare for a very, very long time. And along the way, of course, we have learned a lot about how to do that, how to do that better. We have modified what we do. But this is a physician led program. The physicians are taking that responsibility, so it’s in the provider segment — very, very different. We talk a lot about integrated care and coordinated care. Integrated care, from my point of view, refers to the seamless movement of information across the healthcare system. Following a patient wherever he or she may be — from the primary care office, to the specialty office, to the hospital, to the home and back, so that everyone has the information they need about the patient and the patient situation. I’m sure many of you have gone to a specialist who has said, well, why are you here? What is wrong with you? What did your doctor say? And you go, I’m not quite sure what the doctor said, and I need to see you, Mr. Cardiologist, because I had some pains in my chest. That’s not really a good way for information to flow. And then coordinated care really is about physicians; primary care, specialty physicians, all working together on behalf of that patient as a team. Physicians were often trained as individuals to just take care of the problem in front of them and not really thinking of the patient in a totality and the patient’s care across that continuum of care. So, we are working as a team to make sure that we provide high quality care and we eliminate sub optimal care, redundancy, unnecessary care, in the system, so that patients are really getting the best care that can be given to them. Our focus frankly is on the chronically ill, just like we talked about in the last panel. Those are the patients who are most in need of what we do. We take care of Medicaid patients, we take care of commercial patients, we take care of seniors. Seniors in the Medicare Advantage program; and we are very bullish on Medicare Advantage, because that gives us the opportunity to take the best care of the chronically ill seniors who are most in need of what we do. Compared to fee-for-service, where the individual doctor sees the patient and then the patient goes home, and the doctor doesn’t really know what is going on in-between care. In the Medicare Advantage program, we manage the care all the time. So, we know what is going on with that patient every day. I shouldn’t say “every day”, but most days, because we are in touch with that patient. We have nurse care managers, we have pharmacists, we have social workers, all of whom keep in contact with the patient, so that in-between care, is so important to know and to make sure the patient got their medication, they are following through on the doctor’s instructions. Most doctors are pretty busy seeing patients day in and day out, and they don’t really have time to think about what is going on in-between. That diabetic that we always talk about — are they following up and getting their blood tested? Are they going to see the ophthalmologist? Are they going to see the podiatrist? These are the kinds of things that we make sure happen to prevent chronic illness from getting worse. And when someone is really sick and they spend time in the hospital, we make sure when they go home from the hospital, the transition of care to the outpatient setting, goes very, very well. Typically, a senior who is old and frail, in the hospital, goes for a bunch of procedures, they take new medications and now, they are sent home. And if any of you have had this experience — I have with my own mother — they get home and they go, well, let’s see, they told me to call my doctor to get an appointment in the next three to five days. Okay, let me call. And they call the doctor’s office and the doctor’s office may have no idea they were in the hospital. May not know they needed to be seen. So, my next appointment is in two weeks and the senior says, okay. The senior gets medications in the hospital, comes home and has a whole bunch of medications at home they used before. Which medicine should I take? The ones they gave me in the hospital? The ones I had at home? Maybe I will just take both. Or maybe neither, because I don’t know what to do. Then, they get readmitted to the hospital. Right? So, all of these things, we have to make sure the transition of care goes really, really well. We make the appointment for the senior with their primary care and their specialist. We have people call them at home to make sure they know what to do. And if they are really frail, we will send someone to the home to make sure that that transition to the home environment went well. And we find all kinds of things out when someone goes to their home. We see seniors with these little throw rugs on the floor. That’s a terrible tripping hazard. We get rid of things like that. So, this is what coordinated care is all about. This is what we do, this is what we focus on, to make sure that people who really are most in need of care, are taken care of in a physician centric organization. SUSAN DENTZER: Great, well, thanks Bart. You can tell us later what kinds of results you are producing on the financial and other side that underscores the success of that model. Larry, bring into this now, the area that we think of as long-term services and support, which is not the medical care, not the healthcare aspect, but everything else, and how we build that out into an integrated model. LARRY ATKINS: Thank you, Susan. Long-Term Quality Alliance is a multi-stakeholder organization of a lot of the different organizations, large organizations, that work in the LTSS space. It includes payers, it includes the providers of the long-term services providers and consumers. So, we focus on trying to advance person-centered high quality integrated care that integrates long-term services and supports. So, long-term services and supports are the things that you know, the services that you need when you have functional limitations and you can’t do some of the basic things you need to do, just on a daily basis. Bathing, eating, dressing, taking care of your finances, a variety of other kinds of things that people need; but they are going to need help with. A lot of times – we have 12 million people in this country who have substantial functional limitations and need LTSS. We typically think of those people as primarily seniors and we think of the problem in terms of the growing demographics and the challenge of serving this population that is going to have growing functional care needs in the future. But, in fact, about half of the population is under 65 and it’s a very diverse population with physical, intellectual, development and mental health needs, even substance abuse needs, and often very complex interaction of those. So, the question is, why is it important to really focus on that long-term services and supports needs? It’s a relatively small population compared to the total population. So, why do we want to do that? If you look at the Medicare program and I think it’s indicative of what the total picture would look like if you measured it across all healthcare in the country, about 5% of the beneficiaries — you have heard this before — generate about half of the costs in the Medicare program. You say, well, who are those people? Who is the 5%? And we know it’s very heavily associated with multiple chronic conditions. The number of chronic conditions you have drive up the costs that you are going incur in the Medicare program. So, I put a little chart in your packet, you can take a look at it while I’m talking about it. If you look at the number of chronic conditions that there are, and you can see that the costs of serving — the Medicare costs of that population go up with the number of chronic conditions. But you also see that if you have functional impairment and chronic conditions, compared to somebody who has multiple chronic conditions, but no functional impairment, that the costs in the Medicare program have about doubled. If you really took a look at who — what is the driver of a lot of this medical expense? You know, it’s not just medical need. In fact, the best predictor of who is going to be in that population is functional limitations. So, what’s interesting about it, of course, is Medicare does not pay for LTSS, so this cost is all medical costs, generated by these people. If you go in the Medicaid program, where we do provide payment for long-term service and supports, we know about 6% of the Medicaid population are using LTSS services, and that 6% is accounting for about 43% of Medicaid spending. So, it’s a very small population that had a very, very high medical spend. If you want to get at high medical spending, you really do have to address the functional needs of this population, and they are a pivotal population, a critical population in the overall effort to address medical costs. But at the end of the day, it’s really not about saving dollars by providing long-term services and supports, but it’s really more about — when we talked about this in the earlier panels, about redirecting the dollars. You know, being able to take the — to avoid some of the medical expense by really providing much more support and services in the community and home, and taking away some of the drivers right now that we have in the healthcare system, which is this incredible degree of institutionalization and specialization that we have. Now, in the Medicaid program, there are about four million people that are using LTSS, and about a third of those people now are in managed LTSS. In about 22 states. That number of states is growing and the size of that population is growing. We have a lot of programs out there that are trying to integrate care across the Medicaid program, and then for people who have dual eligibility in the Medicare program, which on the senior side is most of the seniors in Medicaid have dual eligibility. It’s not as much so with the younger disability population, but where we do want to integrate, we are talking about integrating across Medicare and Medicaid to provide a fully integrated package. There are very few really fully integrated plans out there, and they are programs like PACE, we have heard about SNPs before, the Special Needs Plans in the Medicare Advantage programs. The DSNPs, which specialize in dual eligibles, are obligated to have a relationship with the state on Medicaid services. There is really only one model of that that really has a high level of integrating, it’s called the FIDA SNP, which is a fully integrated dual eligible SNP. I know this is getting into alphabet soup. Then we have the financial alignment initiative, which has — is called the Duals Demo, in which people enroll in a fully integrated plan that has both Medicaid and Medicare components integrated, which is kid of the highest level of integration that we have. So, there are a lot more things going on that you can label as integration and Bart talked about a model that is really based on a physician based model for integration and there is a lot of that out there, but there is very little fully integration where we are really putting all the pieces together with the services. Where the money is on the table. And because we only pay for it in Medicaid, it really is right now, most of the full integration models are really aimed at duals population. What do we mean by integration? I won’t answer that question, I will just say that we did quite an extensive taxonomy on integrated long-term services and supports, what is it? What are the components that are involved in it? What are the levels at which you can have integratedness? So, that is on our website and you can have fun with that. And then we did ten case studies following up on that, and looked at a variety of different approaches to integrating that are out there in the country. Successful models. Some of which were for example, physician based Medicare Advantage plan that was taking responsibly outside of the typical array of Medicare Advantage services that are available. Then we had a continuing care retirement community that had a Medicare Advantage plan and its own embedded physician practice. So, you find a lot of different interesting models out there. But, you know, at the end of the day, all of these models come back — you know, people talk about the complexity and the alphabet soup out there, but all of it comes back to some simple ideas about what works in integration. What is it about integration that makes a big difference? I will just run through a few of those. One, obviously is combining the financial resources — Medicare and Medicaid. And then with some degree of flexibility in how you use those. So, the problem with Medicare, more than Medicaid, but the problem with both of those programs is that they cover specific benefits. So, they don’t cover outcomes, they don’t cover the needs that people have, they cover specific benefits, and they are quite limited in the way they do that. So, when you put the two programs together, you have this problem of having to report encounters on everything that you do. So, you break every interaction with a bunch of — with a person in their home, you have to break it back out into a series of encounters that you can report back for purposes of reporting, and assuring that you are providing the services that are specified. The intent of integration is to get beyond that and to be able to have more flexibility, and be able to match the services to the individual, and the problems that you see individually in a home. Another piece of the secret sauce is a single point of contact and accountability for the member. People who are wrestling with long-term services and supports needs in the fee-for-service world, have no idea where to go, most of the time. And when they do, it’s trial and error to figure out how you get services and how you put them all together. So, having a single point of accountability. Having a care manager or a care coordinator. With the reach and some authority cross medical and non-medical sectors, so that they have the ability to interact with the medical side to make things happen on that side as well. A comprehensive assessment, cross-sector, that really is person and family centered and I can’t emphasis the person centeredness enough, because at the end of the day, what you are trying to do, when you come into somebody’s home and you are trying to provide and help with services that are being provided, if the individual is not part of the team, if the individual is not driving with the care plan, you don’t get compliance. You know, if you really want to have things done, you don’t come in and tell them what it is they are going to have to do. And that’s really overcoming a professional training and the sense that you have after all these years of graduate school, that you know better than anybody what the right answer is. It’s coming in and starting from a completely different point. But if you don’t do that, you don’t get the trust, you don’t get the engagement with the individual. Then a comprehensive assessment that drives a person and family-centered care plan that is developed with the individual, interdisciplinary care team, because you want to be able to have that level of coordination and communication that is critical across sectors, among all of the various individuals that are going to encounter that person. Then the communication that is shared and information that comes with that. Risk stratification and targeting, because there is a level of intensity that comes with this that is appropriate where you have very complex needs that need that level of interaction, but you have to also have the ability to figure out where that has the most benefit and it is anticipatory. It is anticipatory of where the ER and hospital needs are going to develop. And then focusing on supporting individuals in home community settings and deferring and avoiding institutional care. That’s where the money is, in integrating care. It is in avoiding the unnecessary and inappropriate, accidental, you know, emergency room visits, ambulance rides, hospitalizations, re-hospitalizations, and ultimately institutionalizations. So, as everybody said before, you know, the default in our system is medical treatment. We look at everything that happens with people with complex care needs as something that is diagnosed and treated and it’s a medical event, but for these people we are talking about, very often there is so much more in their lives and medical events are so little a part of that, that we really miss the whole point a lot of times when we do that. I will end there. We can talk later on about what’s holding us back, why is this so — this kind of level of integration so rare in our system and how do we get to a system where we have much more prevalent access to integrated care. SUSAN DENTZER: Great. Thanks so much, Larry. So, Sandra, share with us some insights that some of the states have arrived at as they go down this quest for integrated models of care. SANDRA WILKNISS: Yeah, and thank you for letting me be here and to share that. So, to just let people know, I am part of the Center for Best Practices at NGA, which is the non-profit side of NGA. It serves as a hybrid think tank consultancy, and we really — our entire reason for being is to support governors and their policy advisors in identifying best practice solutions and implementing those solutions. So, I’m going to focus a lot on what we have been doing for the last three years with the complex care program states are trying to either establish or support through state levers. We’ve worked intensively with ten states and one territory over the last three years and have recently just finished what we are calling a road map for states to establish our advanced complex care programs, with lessons learned from those states and building off of lessons from pioneering states like Arizona, California, Missouri, Oregon and others who have really tackled this knitting together the healthcare, behavioral health and social services supports needs that this population has. We focus very much on just the Medicaid only population, so I’m going to talk a little bit less about the dually eligible, and focus more about the younger set. But the characterization, the population, is very similar — multiple chronic conditions, diabetes and cardiovascular disease. A lot of mental health issues, substance use disorders and a whole array of social support needs. Unstable housing, unemployment, food insecurity, transportation challenges, and — and — and. So, these are the populations that states are trying their best to support through these complex care programs. The lessons learned — I’m going to put them into four buckets, there is a whole lot of detail behind this, which I’m happy to share. But, let me give it to you in four buckets so you understand where states are going with this, and let me also take a step back and say, states are in a position of being very active in this space, and having to identify and implement solutions, because governors have to balance their budgets — it’s really that simple. And so, while we don’t want to focus just on cost effectiveness or cost savings, we actually encourage states to measure that, because once you can tell the story with some cost savings in your hand, you can engage stakeholders and governors can think about how to create sustainable programs and reinvest those savings. So, I agree with you, the reinvestment piece is really critical. Four lessons learned: One is alignment across health initiatives. So, we know that there are umpteen health initiatives going on, on the state level. There is Medicaid reforms, state innovation models, state health improvement plans, behavioral health reform, corrections reform, housing interventions. All of this is happening, and one of the key lessons here is that states that are successful are really proactively aligning across all of those initiatives. Moreover, there is this horizonal alignment, and then a vertical appreciation of what is happening with successful local models, and determining what is the state role in scaling and spreading those successful local models for complex care programs? So, alignment is key, the typical — and this where a governor can really use his or her convening power to bring all of these people together. On the internal side of bringing folks together, it’s bringing all the agency decision makers together who have anything to do with complex care populations, and these are typically health and human services, secretaries, Medicaid Director, behavioral health leads, housing finance agencies — we can talk more about that if you want, a really important player in this space. Correction folks, depending upon the state goals. And so, the successful teams are actually bringing all of these people together to align initiatives. And then of course, partnering with really key local stakeholders who have some vested interest in shaping policy, and/or implementing programs. So, consumers, family members, providers, payers, are among the key players there. Another lesson learned is a data driven approach is absolutely essential to create and sustain these programs. Lots of challenges on the data side. I won’t go there, but I will just talk about the value of it for three specific reasons. One is targeting the population you want to serve in a complex care program. And states often do start these with high utilizers of emergency department and in-patient services, and really trying to characterize those people who are using those services because there is a lack of evidence based care in the community that would actually serve them better, but they are ending up in these sites of care, because they have nowhere else to go. So, that’s part of the targeting strategy, is characterizing who is using these services, what their needs really are, and what best practices have to be built in order to better serve them in the community. Data sharing, really critical, we already talked about how providers need to talk with each other. Doing that in real time to the extent possible, especially when there is a crisis event, is really key and states are working to try to develop those opportunities. Then, a robust evaluation stately — already talked a little bit about return on investment, but the key here is really the three-part aim for states are doing a lot to measure health improvement outcomes, and I’m happy to talk about specific outcomes states are looking at that are across the spectrum, also utilization and cost data are really important to states to figure out how to build sustainable programs. Then taking that information to stakeholders and moving forward. On the delivery and payment approach side, we have already talked a lot about it today. I would just highlight that states are taking three general approaches — for those of you who are interested: Partnering with managed care organizations, actually moving towards regional models, ala the Oregon CCOs and Colorado RICOs. There are states that are really interested in figuring out how to devolve both the financing and the responsibility to local and regional partners. That is the super interesting development and there is a lot of traction there. Also, provider initiated models. So, academic medical centers are those who are really trying to build their own model. States are trying to figure out, how do we partner with them to figure out that what they are doing can continue? Just a few highlights on where the focus is on delivery and payment. It’s on community based care coordination, multi-disciplinary teams that include behavioral health, the includes strong linkages to social support services, care transitions and integrating solutions like housing. I just brought this along as a little prop. We at NGA only respond to the requests that we get from governors for the kinds of policy solutions they are after, and we got a lot of requests for housing solutions. And so, we built a roadmap for housing is health approaches. Of course, this is based on evidenced-based housing first model, so FYI, there is tons of interest from governors on these kinds of strategies. And then of course moving toward value is really the key, and trying to figure out how to move towards shared savings, or work with provider and payer partners to take on more risk so that they can have more flexibility to do the kind of work that they know matters, and of course measure outcomes and align incentives to adopt evidence-based and social support services. Just one more second on two states that I want to highlight their work and there are a bunch more states I could talk about. One is Alaska. Alaska took sort of a three-phrase approach. They started with a Camden Coalition like hot-spotting approach, and they found that in Anchorage — actually, they found that 25% of emergency department costs were in one neighborhood in Anchorage and the entire reason was because the healthcare clinic closed, in short order local and state worked together to get the healthcare clinic back up and saw a massive connection to primary care and a massive reduction in emergency department costs. They further build that out with a boots-on-the-ground multi-disciplinary care team that does behavioral health social supports, and within 12 months that team has linked people up with all kinds of services and 50% further reduction in ED and 50% in-patient. So, there really is an opportunity to move that needle. I know other folks were a little skeptical earlier, but we are actually seeing those kinds of outcomes in the state programs. Finally, balance of state for Alaska is super, super hard. Try to wrap your head around boots-on-the-ground services across Alaska. They have actually engaged a remote care coordination service, which I was skeptical about originally. Also, really connecting with a lot of people around the state, also finding 26% reduction in avoidable emergency department use and linkage with services locally. The last state I will just mention really quickly, I can’t help myself, is Puerto Rico. Puerto Rico also engaged in a Camden Coalition-like approach. I don’t know, for the lack of a better term, I just try to use that, because I think people know what Camden Coalition has been doing to try to integrate all of these services. They took it across all the eight regions. I want to highlight just the outcomes that they are measuring. They have also found a lot of really good results, but they have