Robert J. Master, MD

1. Commonwealth Care AllianceA Non-Profit Prepaid Comprehensive Care System: Defining what a Real “ACO” is for Medicaid and Dual Eligible Beneficiaries with Complex Care Needs Robert J. Master, MD

2. Case Vignettes • Mattie H. - A fiercely independent 77 y.o. woman living alone with longstanding Diabetes and Hypertension. Three recent strokes caused left side weakness and requirements for significant personal assistance to maintain independence. Mobility limitations impeded access of medical care during the 9 months before enrollment. Increasing depression, withdrawal and erratic nutritional intake ensued. There were frequent falls and multiple hospitalizations for poorly controlled Diabetes, dehydration, urinary tract infections and pressure sores Nursing home placement, was recommended. • Anna C. - A 55-year-old woman with long standing Multiple Sclerosis with secondary partial paralysis in all extremities and urinary retention requiring frequent daily self catheterizations. There was a long standing history of depression, one prior major suicide attempt, and a history of alcohol abuse and heavy cigarette use as well. During the past few years there has been multiple hospitalizations for urinary tract infections, respiratory infections and asthma exacerbations. No consistent primary care or behavioral health relationship has ever been established.

3. In CY2010 CCA managed about $175M in risk adjusted Medicare and Medicaid premiums to provide the totality of benefits to the following populations

4. Primary Care Redesign 25 Primary care practices including FQHC’s in 8 fully contracted hospital systems  primary care financial investment – ($130 - $400 PMPM) Integrated multidisciplinary clinical teams, stratified to need; nearly 100 clinicians integrating in practices with IT, management, and infrastructure support

5. Multidisciplinary Clinical Teams with “Shared Decision Making”: Primary Care Redesign Elements Enhanced Primary Care •  comprehensiveness of intake assessments (multiple dimensions not just medical). • Individualized Care Plans (well beyond “problem lists”). • Same day, episodic care response capabilities (particularly in home settings). • 24/7 with EMR support. • Integrated palliative care and behavioral health clinicians. • Continuity clinical management in all settings and through all “transitions”. Care Coordination • Ability to order, authorize and connect to all medical, BH, DME, therapy and LTC services (“The teams own the checkbook”). • Resource allocations with contracted network via decision support tools.

6. RESULTS Senior Care Options Utilization • Homebound elders 17,061 PC visits/K/Yr.* mostly in home; Ambulatory elders 11,263 visits/K/Yr. (Medicare FFS Ave, 7200 visits/1000 Yr.) – MedPac • Hospital use, 1995 days/K/Yr. (Ave RS 1.98), 55% Medicare risk adjusted FFS Ave. • “NHC” nursing facility placements 36% of FFS Medicaid benchmarks (Mass. JEN Study) Quality • HEDIS 90+ percentile, comprehensive Diabetes care, monitoring patients on persistent medication, access to preventive health services. • 50%  in CHF hospital admissions (40.3 Adm/K/Yr. – 23% CHF prevalence) vs. MA Statewide Medicare FFS benchmark. Cost • 2004-2010 average annual medical expenditures increase 2.2% • Average MER 2004-2010 - 84% Disability Care Program • Exceedingly high member satisfaction – external survey. • Hospital admissions, expenditures, reduced 70% compared to Medicaid FFS experience. • 50% reduction in hospitalizations for pressure sores (prior studies) • Total medical expense 80% of risk adjusted premiums.

7. Summary