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

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 taken it to the level of measuring quality of life, functioning and depression measured in addition to all of the utilization, cost measures, and traditional sort of medical intervention measures, and found a 91% reduction in depression scores on those people who were depressed. I can tell you a lot more, but I will stop there.

SUSAN DENTZER: Great, well thanks to all three of you. We’ve heard a lot about what goes into the recipe for integrated care. And I guess, any of you who are cooks, this is a really complicated recipe. This is Julia Child, you know, exotic French cooking, versus take out the Velveeta and make a casserole out of it. Some of you probably grew up eating that, as did I.

So, let’s talk about what they said was in that recipe. Bart talked about the recipe has in it, first of all “seamless movement of information across the healthcare system, so that various providers on the team, whether they are primary care, behavioral, the nurse practitioners, others that on your team all understand what is going on with the patient in real time. And therefore, because they understand that, they are able to decide what is needed and coordinate that. Coordinate across the team to deliver that care. So, a fundamental piece of the recipe, and Bart, you talked about how Medicare Advantage, in particular, on the healthcare side, gives you those — the financial incentive to do that as well as the ability to do that, without having to have everything fit into fee-for-service payment silos. Very important additional piece of the recipe for you.

Larry talked about the part of the recipe that pertains to these 12 million individuals with substantial functional limitations — the so-called activities of daily living — ADL’s. And as you heard, many of them on Medicaid, a small percentage of the Medicaid population, 6%, but using lots of the long-term services and supports and accounting for 43% of overall spending. So, lots of opportunity there to redirect the dollars in ways that support those individuals. And he mentioned a number of the models, as you heard, that get to this integration, whether it’s PACE or SNPs or so forth. But what they have in common, and part of the recipe that he focused on, was combining finances across programs so that you are not driving things just because there are dollars that pay for particular services. Flexibility to match the money and the services with the actual needs of the people. A single pointed contact to coordinate for that individual and family with the various care needs are. Comprehensive assessment of those needs. Again, this interdisciplinary care team that can conduct this, and really, create essentially a match between what the individual in the family needs. The settings in which those services need to be delivered, the needs that have to be met, et cetera, et cetera. So, that is another very important part of the recipe.

Then we heard from Sandra, when we are talking particularly about this population — the younger population of the 12 million in effect, who essentially have, again, a number of medical conditions, and she mentioned some of them. Whether it’s cardiovascular disease, whether it’s mental health, substance use, et cetera. What did they need? What is part of the recipe for them? Again, it’s alignment across various initiatives in states, whether it’s Medicaid, whether it’s the state innovation models, et cetera. Essentially an active state role in looking at local models that work, and spreading them and scaling them up. Data driven approaches and again, this goes back to the information piece that you talked about, Bart. Partnering with various organizations that we know are out there to do this now. Medicaid managed care organizations, et cetera. Then putting all of these pieces together.

So, you get my point about the complexity of this recipe. But it doesn’t say that it can’t be done. Baked Alaska’s can be made, right? These things can be achieved, it just takes a lot of coordination, a lot of work. With that, when we get to these optimal levels of integration, as all of you have said, ideally, we will reduce unnecessary healthcare services, we will free up some dollars to invest for other reasons, and also along the way, we will improve the outcomes for individuals. So, just taking that piece of it, those objectives, Bart, talking about how what you described earlier has met those.

BART ASNER: Sure. Happy to. So, we are capitated. So, we get paid a fixed amount per patient to take care of a population of patients. We have 250,000 patients we take care of in Monarch Healthcare. How do you know who to focus on? Well, the first step is, we have the technology to stratify these patients and their risk profile to know who is most in need of intensive follow-up by us and our coordinators and our nurses, down to the people who you just want to make sure they stay healthy. And at different levels of risk, we put different levels of resources towards those patients. Remember, we have fixed resources. Our goal is really not to reduce the cost of care, it’s to reduce the cost trend by using services wisely, and you heard a lot about choosing wisely earlier.

SUSAN DENTZER: So when you say “cost trend”, you want to keep costs going up at the level of inflation or less?

BART ASNER: I would love to keep it going up at the level of inflation. I would like to keep it — realistically, it’s lower than it’s going up right now. The level of basic inflation, the level of medical inflation, kind of go like that. So, if we can just slow down the medical inflation trend, we’ve got a lot more money to spend. And then you redirect the money into things that bring more value. By us saving unnecessary admissions, saving unnecessary ER visits, we can hire pharmacists, and social workers. We can pay for transportation. We can do all of the things that patients really need in addition to the individual episodic care that they get from the doctors when they see those doctors. So, does this really work? Well, the outcomes really over, like I said, over 20 years, at Monarch are proven. We used to have doctor who would get a message from us saying, “Did you know that Mrs. Jones visited the ER 27 times last year?” And the doctor went, “I had no idea! Well, I didn’t see Mrs. Jones all year.” “Well, you didn’t see Mrs. Jones, because she was in the ER, and by the way, she got admitted almost every time she went to the ER.” For a senior, if they end up in the ER, about 50% of the time, they get admitted, because it’s just the easiest thing for the ER to do that doesn’t know that patient. Well, put them upstairs and we will figure out what’s wrong. Not a very cost-effective system. So, we then found out this Mrs. Jones was homebound and really couldn’t figure out how to get to her doctor for appointments. And so, we said, hmm, why don’t we send someone to the home and build a relationship with Mrs. Jones? And that nurse then would check in with Mrs. Jones and see how Mrs. Jones was doing. Then when Mrs. Jones didn’t feel so good, instead of running for the ER, she called the nurse and said, you know, I’m not quite feeling so good today. And we talked about what was wrong, and often they could solve it over the phone, but often she could direct that patient and provide transportation for the patient to get to the doctor. ER visits plummet. So, in general, we can reduce ER visits. Hospital admissions. In fee-for-service Medicare, hospital admissions typically are somewhere around 2400 per thousand patients per year. Ours are under a thousand admissions per that same number of patients per year. So, it’s more than 50% less than you see in fee-for-service Medicare. The most expensive place for a patient to be, is in the hospital. Particularly unnecessarily. Our goal is to keep people healthy, keep people in the ambulatory setting, and keep them out of the hospital. When they need to go to the hospital, that’s fine. And we have specific doctors called hospitalists that take care of the patients in the hospital. We have nurses in the hospital that work on those transitions of care that I talked about. But we could reduce the ER visits, reduce hospitalizations that aren’t necessary, there is a lot more money to put into what is really valuable services for that population. So, because we are capitated on a fixed budget, it’s our goal to keep people healthy. We are incentivized to do the right thing. We actually make sure that patients get the quality care that they need. So, are they getting their mammograms? Are they getting their PAP smears? Are they getting colonoscopies? We will provide that information to the individual primary care doctor and say, you may not know that your patient didn’t get their colonoscopy that they needed. “Oh, I didn’t realize that. The patient didn’t come in.” Well, we will call that patient, we will even arrange for the colonoscopy at Monarch. So, we are a total team, and our outcomes are better, our cost of care is lower because we are reducing the trend through providing the right services at the right time, in the right place.

One other quick example is the use of ambulatory surgery centers. So, we actually can get surgical procedures that 85% of the time can be done in an ambulatory setting, instead of an expensive hospital setting. Done in an ambulatory setting. By doing that, our doctors are happier, because frankly, it’s a better patient experience, it’s more efficient for the doctors, and the quality of care is excellent, and oh, by the way, it’s a lot less costly to do that in the ambulatory surgical center than it is under a hospital where nobody really is quite as happy and it costs a lot more. So just as an example, there are ways that you could really make a difference when you have all the information, when you provide it to the physicians and you have a team approach to the care of the patient population.

SUSAN DENTZER: Great, thank you, Bart. Larry, you talked about the financial alignment models, which is the set of experiments that came out of the Affordable Care Act, designed to do a better job at integrating the care of the dual eligibles and experiment on different ways to do that. What are we learning from those experiments that speak to the elements of the recipe that you described earlier?

LARRY ATKINS: Well, the experiments have been challenging. I think all of these efforts to get full integration are challenging for a couple of reasons. One is that really getting alignment both financial and programmatic alignment between Medicare and Medicaid in this case, is difficult. And getting alignment between the medical sector and the non-medical sector. So, I think the duals program kind of comes with a degree of alignment that you don’t get anywhere else, because the enrollees enroll in one program. So, in that sense, it’s a lot further ahead than a lot of the other integration efforts where you often will have somebody — if you are a MLTSS plan, you will have somebody in your managed long-term services Medicaid plan, but they are in somebody else’s SNP or they are in fee-for-service on the healthcare side, and you don’t get the information exchange, you don’t get the — you don’t know what is going on with the patient. But at least here, you are getting full enrollment in. But the way that the enrollment has happened, and it’s a challenge of trying to figure out how to do this, because Medicare permits individuals in the Medicare program to always have choice, no matter what. So, you can’t constrain that. In the MMP program, what they did was they auto-enrolled people in the MMPs and so a lot of people found themselves — they were in a Medicaid plan already and the state Medicaid plans will enroll them in a managed care plan, without any difficulty. But you can’t do that in the Medicare side. So, what they did was they auto-enrolled into these MMP plans, but had an opt out for the individual. And a lot of individuals got in without a lot of information about what they were getting into, without support from the physician community for them to be in the MMPs. So, they were encouraged by often the long-term service and sport providers or the physicians to disenroll, to opt out. So, you’ve got about a 30% in some states, and it’s been a little higher in some other states, up to 50% enrollment of the eligible population in these models. So, that’s been a challenge, trying to figure out how to get that enrollment up higher. In the SKO program, which is essentially the grandfather of the duals demonstration, it’s the FIDA SNP in Massachusetts, senior care options. That is a voluntary enrollment, so people choose to be in that. They only get about 30% of the eligible population that chooses to enroll that. So, we have to get over that hump of people really understanding what the benefits are, what the value is of being in a plan like that, and then understanding — and getting the understanding from the physician community about the importance of it. That’s been difficult, that’s been difficult to engage, you know, the physicians in the process.

Then I think, you know, we are still in a situation where we don’t have quality metrics on the home and community based services side. So, it’s very — we have a system that is overly medicalized, all of the focus is on medical treatment and it’s all evaluated on the basis of medical outcomes. But the outcomes that really count for people, often things like quality of life and stuff, are difficult to measure and we are still developing the science along that. I think in terms of achieving care coordination and achieving satisfaction from people who got enrolled in the program and stayed in the program. The levels of satisfaction have been very high and I think a lot of people appreciate, once they get in the program, that there is a real increment in value of the benefits that they get from being in that kind of a model.

SUSAN DENTZER: Great. So, Sandra, you talked about those success stories in Alaska and Puerto Rico territory — not a state, but — and them starting with the whole activity of hot-spotting, which as many people know is essentially looking at the data. We are back to data now, and doing these heat maps to figure out where the high utilization is coming from. And you talked about in the case of Alaska, just this one particular neighborhood where the clinic had closed and the you-know-what hit the fan as a consequence of it, and the rest of the healthcare system was left to pick up the pieces. As more states do this and understand what are the cost drivers here, are they able to address some of these challenges that Larry just identified? Yes, you may identify the needs and what is going wrong, but you’ve got to pull together different payers, you have to work across different state initiatives, as you said, was really critical in terms of addressing these challenges. How are these states rising to meet those constraints or not?

SANDRA WILKNISS: Yeah, thank you. I would say a few primary ways, I’m sure there are many others, but one is that many states are in a managed care, so now I’m back just in the Medicaid only space and the managed care situation. Many states are working very actively with their managed care partners in crafting contracts that actually change the incentive structure to move towards care models to serve this population, so that – -and incorporate new outcome measures that might be more aligned with behavior health and linking social supports and so on in order to drive that process. So, one is through partnership with managed care entities to try to shift the delivery model structure and some of the incentive around that.

Some are taking advantage of health homes, is a really good example, under the Affordable Care Act, section 2703, trying to really think about bi-directional. Missouri is a really good example of this — bi-directional integration where they have health homes for multiple chronic conditions and also behavioral health homes throughout the state, and that’s driving all the care coordination and really alleviating some of that difficulty in the fragmented system that’s out there. So, that’s another avenue. And, as I said before, Wyoming is a good example of state that is thinking about moving towards a regional model and partnering with local providers and other entities. You know, if you are out in a rural or frontier area, it’s not always just the obvious — you don’t have a bunch of docs and behavioral health specialists out there. If you take all comers and they are actually figuring out how to support these local collaboratives to do the work of supporting this population. So, those are a few examples. I hope that answer the question.

SUSAN DENTZER: And when you say “regional”, regional within the state or —

SANDRA WILKNISS: Yeah. I’m sorry, yes, within the state.

SUSAN DENTZER: Okay, not regional one state.

SANDRA WILKNISS: Nope, just all state program, how do we partner with local entities to drive more success in the space.

SUSAN DENTZER: Back to the point that Larry made about decreasing institutionalization, because that is a big cost saver and also because we know being in institutions is not the greatest thing for human beings. We have a lot of evidence that supports that. One of the elements in this has been another experiment, independence at home. To what degree have states taken up that experiment and build on that to deal with this institutionalization?

SANDRA WILKNISS: Yeah, it’s a good question and it’s probably one I’m less equipped to answer that particular question, but I would say broadly speaking, there is a lot of movement to align incentives for care that is in the community and/or in the home, and outside of institutions. And a lot of that requires building capacity, quite frankly, and building capacity in terms of all of the other services that are needed in the behavioral health and social support service, and the linkages, and the evidence base, which we — there actually is a large evidence base in the behavioral health space. There is a decent evidence-base in the social services base. People don’t really know where these elements exist and how to build capacity, so a lot of it is bringing all fo that information together and trying to build from there.

LARRY ATKINS: Can I make a point on that? I mean, I think when you look at home and community based services in Medicaid, you have to start from the understanding that Medicaid mandates coverage in an institution, in a nursing facility. That coverage is provided by the states, they have to provide it. Home and community based services is a waivor. So, in order to have home and community based services, you are basically backing out of all of the commitments you have on the Medicaid side, to entitlement program, basically. You are getting a pot of money to serve alternative setting, which is fine, but I mean, to start with, we wouldn’t even have home community based services if it wasn’t for the disability community going to court and getting the Supreme Court decision in the Olmstead case, that entitled them to be integrated in the community. And it’s been driven by the disability community, so that the rates of involvement in home and community based services in Medicaid are fairly high, and there has been a very strong movement from institutional to a home and community based services over the last several years. More than 50% of the dollars now are going to home community based services, but that is really heavily weighted toward the younger disability population. For seniors, it’s still primarily an institutional model that we are dealing with. So, the states get a pot of money and it is a fixed amount of money and so it’s like a block grant. And if there is not sufficient funds there, then there are waiting lists and stuff. So, we are not fully in with both feet on home and community based services and we need to be, much more so. But we are still treating is as an optional alternative to being in a nursing home, instead of the preferred setting for most people. And we need to start from the understanding that people’s preferred setting is in the home and community, support that, maintain that as long as possible and see the institutional setting as a default. But the way we measure whether you get home and community based services or not in the Medicaid program is — do you meet the qualification for institutionalization? So, you have to be able to be admitted to a nursing facility in order to even get home and community services.

SUSAN DENTZER: You have to have the ability to be admitted before you get the ability to stay out.

LARRY ATKINS: That’s right. And all I will say is, if Medicare reform goes through as the way it’s been proposed, I think these home and community based services are very much at risk.

SUSAN DENTZER: Which was part of the push back to those proposed reforms. Okay, we have time for a couple of quick questions. Once again, the microphones are roving, let’s come over here.

AUDIENCE MEMBER: Hi, I’m Amy York, and I’m the executive director of the Elder Care Workforce Alliance. I know that we are going to spend a whole summit talking about workforce, but I couldn’t go without a question about workforce, because it’s so critical to coordinate a care. And my question really is focused on training and how we can translate training mostly in the acute care settings, to this coordinated care system. What are the ways that you are seeing this happen? Are there models out there that you’ve seen that are really useful?

SUSAN DENTZER: Okay. Let’s get Bart to take a swing at that and then Larry, if you have a comment.

BART ASNER: So, we have 700 primary care doctors, 1500 specialists and about 450 other people who are part of this team at Monarch to take care of patients. And many of these people have been doing it for a long time. One of my problems is my primary care doctor base — let me get the numbers right — about 30% of them are over age 60. Okay? That is a real problem. That is the case all over the country, by the way. Primary care aging and not being replaced. So, we have workforce challenges all over the place. So, we are working very hard with medical schools, with training programs, to help doctors choose primary care, and when they come out of a primary care program, not to go into a specialty, but to go into primary care. So, we are working on that. The clinician side and the non-clinician side within Monarch, we bring young people in to learn the business, because a lot of my people, even on the non-physician side, are aging. They have been doing it really well, but for a very long time. We need to bring the next generation. We bring people into the system to learn, to train, to get educated. And we have to focus on that, otherwise, we may not have the better solutions going forward. And actually, when you bring new people in, frankly they have new ideas. We didn’t have pharmacists at Monarch in 1994. We didn’t have social workers in 1994. We didn’t do some of the things that we do today. We didn’t have the technology. By the way, I have my own IT workforce at Monarch that helps our people develop the solutions that they need to practice better medicine.

LARRY ATKINS: I will just say that I think one of the biggest challenges in long-term services supports and particularly home and community based services, is the direct care workforce and the challenges of a workforce that is very, very undercompensated.

SUSAN DENTZER: By direct care, you are talking about the people that go into —

LARRY ATKINS: The people who are in the home and when you look at who — you know, I mean, people in the home are a wide array. I mean, you have a lot of family caregiving going on, that’s the primary source of care for people who are in the home. But after that, you get paid care workers and/or in many states you now pay the family to be a care provider in that case. But the direct care workforce is one of the fastest growing workforces in the country. Obviously, immigration issues will have an influence over that. But it is an undertrained, you know, in a non-professional — there are not career ladders. Compensation is very low. The challenge here is that – first of all, we really want to immigrate people who are in the home, into the care teams. We want that communication, they are the eyes and ears. They can be there to anticipate things that are happening and feed that into the medical side. But you need people who are trained to be able to do these kinds of things. When we talk about dementia care, which is increasingly a challenge, you need a much higher level of sophistication and how to deal with dementia. So, we need the training, we need the standards in the field, and we need better compensation to go with it. But we won’t get that if we continue to have direct care provided in the very expensive, hands-on, 24-hour presence kind of system that we currently have. So, we provide an extremely inefficient way. I will just say that I think in the context of managed care, I think there is an opportunity to do a number of things in revolutionizing the way we provide services and long-term services and supports. If we don’t change the way we do it, we can’t afford it long-term. What we need to do, is we need to look at the efficiency of the way we provide care. We need to bring technology into play, to be able to provide care more efficiently. We need to have a higher trained workforce that has the capacity to do things kind of in a more targeted way, when it’s necessary. We need career ladders to make these people interested in kind of advancing their career and stuff. So, these pieces need to come together with a complete transformation of the way we provide care. I think there is a lot of interesting things that are going on in this space, I don’t want to talk about them but —

SUSAN DENTZER: Let’s try to do a lightening round. Tell us what your question is and we will try to group them together and have the panel address them collectively.

AUDIENCE MEMBER: How does a Medicare benefit for concierge services?

SUSAN DENTZER: Okay, that’s one question. Yours?

AUDIENCE MEMBER: My question was related to the pharmacists’ incorporation as far as transitions of care go, and are there any other models that have been proven beneficial? That is a new thing with pharmacists, like pharm to pharm, meds to meds, these are programs that help with transitions of care. So, I wondered if there is anything else about the expansion of those services that would be beneficial.

SUSAN DENTZER: Okay, I guess we have two questions. One is Medicare and the benefit for concierge services and then integrating pharmacists into care provisions.

BART ASNER: I will take the integrating pharmacists really quick. We have pharmacists; they not only help patients manage their medications and understand how to take their medicines, but they actually run our disease management programs. We have programs for diabetics and originally, we had nurses managing their programs, but so much of the diabetic care was involving medications, we put pharmacists in charge of that. The outcomes have been much, much better. So, I will take that question.

SANDRA WILKNISS: Just to add on, the pharmacist program, Community Care of North Carolina has a pharmacy homes project, where the pharmacist is one of the key players who addresses complex care needs. I would refer you to them, happy to put you in touch with them.

SUSAN DENTZER: Okay. Anybody want to comment on Medicare concierge? Final question for all of you and we have to keep this kind of quick if you would. We talked about this very complicate recipe. We are at an interesting junction now, as we know with respect to national health policy making. Let us assume that one step could be taken over the next indefinite period of time by the Congress, by the administration or jointly, to move forward and actually push us down the road further to these kinds of integrated care delivery models that you all have discussed. What would be the single most important step to take? Bart?

BART ASNER: I would say that we need to accelerate the movement from fee-for-service to fee-for-value through support of coordinated care programs. Medicare Advantage being one that is quite important. Medicaid managed care being two, and we heard earlier today about the movement of duals and we heard a comment earlier about how difficult that is. The duals cost more than any other segment of the Medicare population. We need to move those patients into a coordinated care system. We will get better outcomes and lower cost.

SUSAN DENTZER: Not to put too fine a point on that, but basically the delivering payment reforms that were embedded in the Affordable Care Act and that have spread beyond the federal government into the commercial sector — that needs to move forward even faster.

BART ASNER: As fast as we can.

SUSAN DENTZER: Okay, Larry?

LARRY ATKINS: Well, I wanted to pick up on what Bart said, because I think that that last point, that we really need to move people who are duals, into integrated settings. I mean, it is such a better environment for people who have those kinds of complex care need and many of them do. And so, I think we have to address the question of whether we want to change the — give the states more flexibility with regard to Medicare money — and I know the governor of Massachusetts and his secretary of HHS has written a letter to the CMS, asking that the states be given more authority over Medicare, to be able to say to a dual, you need to be in an aligned Medicare/Medicaid plan, fully integrated. Then I think we need to give the fully integrated plans the flexibility to really do the things that are going to have an impact for people.

SUSAN DENTZER: Last word?

SANDRA WILKNISS: Since you are asking a legislative question, caveat this is Sandra Wilkniss’s opinion, not the NGA opinion. Just, whatever we do around value based purchasing and coordinated care, I totally support that. Behavior health has to be a focus, because it’s completely undervalued and the data always comes back to this population needing more supports and more investment.

SUSAN DENTZER: And many of the models where teams of physicians and others have been involved make that point over and over again. They need the assistance of those behavior health providers.

SANDRA WILKNISS: We’ve got to put our money where our mouth is.

SUSAN DENTZER: Right. Well, it will be an interesting and important journey. Join me in thanking this group for laying it out for us.

SARAH DASH: Thank you so much to our panelists, to our fantastic moderators, and to all of you for being here. I would like to once again thank the sponsors of this event. Health is Primary, Anthem, Ascension, CapG, Devita, and Express Scripts for their support. Thankfully, hangry is not a chronic condition, you can get lunch out here in Union Station. If you are needing some lunch, we really appreciate it. Join us on September 8th for a follow-on, we will be doing a Congressional briefing and we need your input. So, if you look in the back of your packet, there is an evaluation form in there. Please fill it out and let us know what you would like to learn as a follow-on to this. Please join me once again in thanking our panel.