Virginia Coordinated Care: A Model of Care Delivery for the - PowerPoint PPT Presentation

Virginia Coordinated Care: A Model of Care Delivery for the Uninsured Wally R. Smith, MD Arline Bohannon, MD, MPH Brian Hurdle, MPH

Outline of Presentation • Background, Description of VCC and early results – Dr. Bohannon • AHRQ Comparative Effectiveness Evaluation and results to date – Aim 1 Dr. Smith – Aim 2 Mr. Hurdle – Summary Dr. Smith

VCUHS’ Medicaid and uninsured patients come from all corners of the state… Losses from Uncompensated care and Medicare totaled $98.6 m in 2011 Indigent Care Cost in $ 67,400,000 to 67,500,000 17,100,000 to 67,400,000 3,600,000 to 17,100,000 1,250,000 to 3,600,000 10,000 to 1,250,000 1 to 10,000 Distribution of Uninsured patients receiving care at VCUHS

Virginia Coordinated Care for the Uninsured (VCC) • Established in the Fall of 2000 • Primary objective is to coordinate health care services for a subset of the patients who qualify for the Commonwealth ’ s Indigent Care program utilizing managed care principles • Target population is uninsured in the Greater Richmond and Tri-Cities

VCC Program Goals • Establish community base Primary Care Physician (PCP) medical homes • Improve the health of the VCC population • Enhance the patient experience of care • Reduce, or at least control, the per capita cost of care delivered

Program Plan • Utilizes existing Indigent Care program financial screening process to initiate enrollment • Virginia Premier Health Plan serves as third party administrator for the program (TPA) • Assigns patients to a “ medical home ” • Assigns Outreach Workers to the VCUHS Emergency Department to educate patients

VCC Enrollment Trends 35,000 Cumulative Enrollees 30,000 Enrollees 25,000 20,000 15,000 10,000 5,000 0 FY2001 FY2002 FY2003 FY2004 FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013* *Cumulative Enrollees are accumulated over time throughout the FY; Enrollees are counted at a point in time (15 th of the last month of the FY); Restrictions in access to VCC were implemented in November 2011.); FY2013 actual based on July 2012-June 2013 using July 13, 2013 dashboard and is not final until January 15, 2014 dashboard. 7

Prior Evaluations • Have shown that VCC is an innovative program that can provide the framework for future health care delivery models • Suggest lessons learned from the VCC program would be beneficial in shaping health care under ACA

VCC Program has demonstrated utilization reductions 38% reduction Continuously Enrolled One Yr Enrollment Multiple Year Enrollment 45% reduction Continuously Enrolled One Yr Enrollment Multiple Year Enrollment

VCC Program has also demonstrated reductions in costs VCC Population Average Cost/Year (2000 – 2007) $8,899 $9,000 $7,604 $8,000 $6,833 $7,000 $6,106 $5,768 $6,000 $4,726 $4,569 $5,000 $4,000 $3,000 $2,000 $1,000 $- Year 1 Year 1 Year 2 Year 3 Year 1 Year 2 Year 3 Multiple Year Enrollment One Yr Enrollment Continuously Enrolled Bradley, C, Gandhi, S, Neumark, D, Garland, S, Retchin, S, Lessons For Coverage Expansion: A Virginia Primary Care Program For the Uninsured Reduced Utilization And Cut Costs, Health Affairs 31, No. 2 (2012): 350-359

Summary of Pre and Post Analyses Year 1 Evaluation of the Complex Care Clinic Year 1 analysis comparing the health care utilization, costs, and clinical outcomes for ACC2 patients before (November 1, 2010 – October 31, 2011) and after (November 1, 2011 – October 31, 2012) enrollment in the clinic showed improvements in: Better Care • Inpatient utilization dropped 44% and emergency department use fell 38% Better Health • Percent of patients with hemoglobin A1c under control (HbA1c <7%) increased from 35% to 47% • Percent of patients with cholesterol under control increased (LDL-C <100 mg/dL) increased from 39% to 50% • Percent of patients with blood pressure under control (< 140/90 mmHg) increased from 39% to 58% Mean body mass index of patients decreased from 35 to 33 kg/m 2 • Lower Cost • Hospital costs were reduced by 49% for a total of $3,930,748 in net savings • Inpatient costs were reduced by 66% • Emergency Department costs were reduced by 36%

Pre- and Post- Clinic Study (n=365) • Evaluated patients with at least one visit VCC Patient Costs* to the clinic between November 2011 and Pre- and Post-Complex Care Clinic October 2012 Enrollment $8.0 • Cost of care for the population was $8.0 reduced by approximately 49% $7.0 • Inpatient utilization dropped 44% $6.0 • Emergency Department use fell 38% $4.1 $5.0 Millions • Percent of patients with hemoglobin A1c under control (HbA1c <7%) increased $4.0 from 35% to 47% $3.0 ■ Percent of patients with cholesterol under $2.0 control (LDL-C <100 mg/dL) increased $1.0 from 39% to 50% $- Pre-Clinic Post-Clinic • Percent of patients with blood pressure under control (< 140/90 mmHg) increased from 39% to 58%

Transition to Populations Health Management Model • Stratification of population • Enhanced case management model • Medical home assignment based on diagnosis • Payment reform • Enhanced data analytics

COMPASS ( Coordinated Care Options to Manage Patient Access to Systems and Services) Information Care Medical Community Payment Coordination/Case Exchange and Neighborhood Partnerships Reform Management Data Analytics VCC Population Results: - Improve Care for Patients - Improve the Health of the Population - Reduce per capita costs

INTERVENTIONS Redefining the VCC Model • Population Stratification • Level 3 Identification • Enhanced Care Management Model Care Coordination • Complex Care Clinic • Community Case Management focus on transition of care Case Management • Daily Planet Behavioral Health Initiative • Richmond City Health Department Referral Initiative • The Healing Place Referral Initiative Community Partnerships • Phase I: September 2012 - Hospital Discharge Quality Initiative • Phase II: January 2013 – Enhanced Diabetes Care Management Payment Reform • Enhanced analytics through OHI • VCC Dashboard Developed & Improved Information • Patient Keeper Exchange, Data & Analytics

Summary • Transition to Population Management Model – VCC risk stratification – Medical home assignment based on diagnoses – Complex clinic started for superutilizers – Enhanced care coordination – Physician incentive model

Outline of Presentation • Background, Description of VCC and early results – Dr. Bohannon • AHRQ Comparative Effectiveness Evaluation and results to date – Aim 1 Dr. Smith – Aim 2 Mr. Brian Hurdle • Summary – Dr. Smith

Preliminary Results, Comparative Effectiveness of Virginia Coordinated Care Delivery System AHRQ MD-10-012 Wally R. Smith, MD, Donna K. McClish, PhD, Patricia Carcaise-Edinboro, PhD, Gloria Bazzoli, PhD, Alton Hart, MD, MPH, Arpital Aggarwal, MD, MSc, Arline Bohannon, MD, Peter Boling, MD, Linda Cummings PhD,, Brian Hurdle, PhD Virginia Commonwealth University America’s Essential Hospitals

Aim 1 • Comparative analyses of utilization (done) and adverse outcomes (planned) among VCC and control cohorts • Comparisons between PCMHs, group practices within the VCC (planned)

Finding a Suitable VCC Comparison Group: Visits Patients with at least 1 Visit per Year 14000 12000 10000 8000 VCC Self Pay 6000 Indigent 4000 2000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 • No. VCC pts with at least one visit to a VCUHS facility increased, though not in every year. • Grant to help with patient navigation hired 4 outreach workers to recruit into VCC.

Patient Selection Aim 1 • All Patients – Age 18 to 63 years – 2003-2009 utilization or enrollment – Live in VCC-eligible geographic areas during analysis period(s) – Uninsured for at least a part of the study period • Experimental cohort – VCC enrollees • Control cohort – VCC eligible or self-pay – Used VCC zip codes – Selected controls with FPL<400% poverty – Frequency matched on employment

Analytic Methods, Aim 1 • Each patient followed for up to 4 years via claims data – grouped by VCC exposure – Assess changes over time pre-post VCC enrollment. • Compare various risk subgroups by exposure to VCC – consider models with interactions between risk covariates and enrolee status

Comparative Hospitalizations Hospitalizations /1000/6 months 2004 cohort 2007 cohort 300 300 250 250 VCC - not 200 200 150 150 engaged 100 100 VCC - 50 50 0 0 Engaged Control Percentage of Hospitalizations at VCU 2004 cohort 2007 cohort 100% 100% 80% 80% 60% 60% 40% 40% 20% 20% 0% 0%

Percent with Hospitalizations Initial Enrollees Reenrollees 18.0% 18.0% 16.0% 16.0% 14.0% 14.0% Percent with any 12.0% 12.0% hospitalizations, 10.0% months 7-12 10.0% post enrollment 8.0% 8.0% 6.0% 6.0% 4.0% 4.0% Percent with 2.0% 2.0% any 0.0% hospitalizations, 0.0% months 19-24 Mean Mean Mean Mean Mean Mean Mean Mean post enrollment Control VCC Control VCC Control VCC Control VCC N=4104* N=4055 N=3582 N=3531 N=647* + N=1035 N=407** N=1005 + ++ 2004 2007 2004 2007