Care Integration and Network
Models: How to Become a Player
Chris Palmieri, BS, MHA,
President,
VNSNY Health Plans
Samuel Heller, BA, MBA,
Senior Vice President, CFO,
VNSNY
July 29, 2013
Table of Contents
I.
II
II.
III.
IV.
V.
VI.
VNSNY: Who We Are
The Changing Healthcare Landscape
VNSNY CHOICE: Our Heath Plan
What We Have Learned: Our Model of Care
Market Opportunities: Moving Forward
Our Vision For The Future
1
I. VNSNY: Who We Are
The Visiting Nurse Service of New York
VNSNY: Who We Are
Lillian Wald
• Founded in 1893 by Lillian D. Wald, VNSNY is the
largest non-profit
non profit community
community-based
based healthcare
agency in the U.S.
• Serves 33 counties in New York with its core
market in the five boroughs of NYC
• Continues to expand statewide
• Provides a range of services to customers
enterprise-wide
enterprise
wide, from newborns to seniors
• 18,900 employees comprise our interprofessional
team
• Serve a socio-economically diverse population
(28% speak a foreign language)
2
VNSNY Offers a Wide Range of Services &
Integrates Care Across Settings
Charitable
Care
Traditional Home
Health Care
Hospice &
Palliative Care
Private Pay
Services
Children &
Family Services
Congregate
Care
Health Plan
Community
Mental Health
• MLTC
• MA
• HIV - SNP
VNSNY Stands Apart from the Competition
Mission
People
Quality
Finance
Growth
Critical Differentiators
Opportunities
Scale
Practice Model Advancement
Management of Vulnerable Populations
From Community Anchor to the C Suite
Care Coordination / Interprofessional Team
Administrative and Operational
Simplicity and Nimbleness
Product Line Diversification
Migration to a best in class IT architecture
Research Center
Geographic Expansion
3
II. The Changing Healthcare Landscape
The Healthcare World is in Flux
& Change is Imminent
Value-Based
Purchasing
Consolidation
Declining
Reimbursement
Shared Risk
More Patients
at Risk
Increased
Competition
Greater
Application of
Technology
Health Reform (ACA)
Evolving
Models of Care
Integrate Care
for Duals
CrossContinuum
Partnerships
4
Prevalence of Chronic Illness in U.S.
Population will Continue to Increase
Populations with multiple chronic diseases have greater
risk of disability and greater need for care coordination
The Need for Superior Care Management
and Care Coordination is Growing
U.S. population is aging and chronic illness increases with age
High prevalence of
comorbidities among the
elderly make care
management particularly
important for this group
5
Controlling Spending is Vital
Other Health Care
Spending
16.2%
National Healthcare
Expenditures 2012:
18% GDP = $3 Trillion
Other Personal
Health Care
12.7%
ACOs
Hospital Care
31.1%
Home Health
Care
2.6%
Nursing
Home Care
5.9%
Prescription
Drugs
10.1%
Physician/
Clinical Services
21.4%
The Affordable Care Act & The Triple Aim
• Designed to be a collaborative process that focuses on receiving
feedback from various stakeholders including payers, providers, and
patients
–Multi-year strategy designed to make sure the healthcare needs of
States’ populations are met
ACCESS
Improve Health
1
Member satisfaction &
improved patient
outcomes
COST
Spend Less
Interdisciplinary team
approach
Triple
p Aim
2
3
QUALITY
Improve Care Experience
Reduction in Readmissions
Leveraging Care Management to Balance the Triple Aim
6
III: VNSNY CHOICE: Our Health Plan
Our Health Plan at a Glance
Historical & Projected
Membership (2011 – 2015)
Current
Future Footprint
Currentand
& Future
Footprint
70 000
70,000
60,000
CT
(Membership)
50,000
40,000
30 000
30,000
20,000
• New York: 62
Counties(1)
10,000
• New Jersey: 13 Counties(2)
0
'11
(1)
(2)
By Year-End 2013
By April 2014
Long Term Care
'12
'13
Medicare Advantage
'14
'15
Medicaid SNP
7
Why Should a Provider Also Be a Health
Plan?
• We are focused on vulnerable populations, those with Medicare
and/or Medicaid, and special needs populations
• VNSNY seeks to serve our patients because we have an
opportunity
t it to:
t
–
–
–
–
–
Repair the fragmented care system
Remove unnecessary utilization of services
Better serve the poorest and sickest patients
Improve consumer and family experiences
Move furthest upstream
• Opportunity to fill consumer niche as a low cost, high quality
managed
d care plan,
l
ffocusing
i on th
the medically
di ll frail
f il and
d people
l with
ith
limited income
What We Offer…
Managed Long Term Care (MLTC)
- VNSNY CHOICE Managed Long Term
Care
Medicare Advantage (MA)
- VNSNY CHOICE Medicare Maximum
- VNSNY CHOICE Medicare Preferred
- VNSNY CHOICE Medicare Enhanced
Dual Eligible
- VNSNY CHOICE Total
HIV – SNP
- VNSNY CHOICE SelectHealth
- Fully Integrated Duals Advantage
(Demonstration Project)
8
Expanding Our Product Base…
State Demonstrations to Integrate
Care for Dual Eligible Individuals
•
Fifteen states across the country were
selected to design new approaches to
better coordinate care for dual eligible
individuals:
– California, Colorado, Connecticut,
Massachusetts, Michigan,
Minnesota, New York, North
Carolina, Oklahoma, Oregon, South
Carolina, Tennessee, Vermont,
Washington, and Wisconsin
•
The Fully Integrated Duals
Advantage (FIDA) program is a
demonstration project in
collaboration with NYS and CMS
•
Integrates all Medicare and Medicaid
physical health, behavioral health,
LTSS, and transportation services
•
A comprehensive benefit package
that includes all Medicare and
Medicaid medical, pharmacy,
behavioral health, long term services
and
d other
h supplemental
l
lb
benefits.
fi
•
A model of care that incorporates
both CMS and State requirements
•
A comprehensive provider network
that ensures access to Medicare and
Medicaid services
VNSNY Geographic Footprint:
Committed to Regional Expansion
Presently Operating in NYS
Anticipated Approval in NJ in 2013
Further Expansion throughout NY, NJ, &
CT in 2013 and 2014
9
Over 18,700 Providers in Our Network…
• NY Counties:
62
• NJ Counties:
13
• Primary Care Physicians:
4,100+
• Specialists:
10,000+
• Hospitals:
70
• Nursing Homes:
55
• Pharmacies:
4,200+
• Labs:
301
19
VNSNY Revenue Is Shifting to Managed Care
2013 Expected
2012
2012
Hospice, 5%
Hospice, 4%
Home Care, 23%
Home Care, 41%
VNSNY CHOICE, 71%
VNSNY CHOICE, 52%
Private Care
Care,
1%
Private Care, 1%
Family Care Services, 1%
Family Care Services, 1%
10
VNSNY Revenue Drivers
2013 Changes
in Rates
Home Care CHHA
Medicaid –
No Trend
Home Care
CHHA
Managed Care excluding CHOICE as a Payor –
2% increase
All Programs
Medicare
Medicare Sequestration – (2%) reduction
VNSNY CHOICE
MLTC
PMPM rate –
(3%) reduction
VNSNY CHOICE
Medicare Advantage
PMPM rate –
4% increase, despite (2%) drop in underlying benchmark
VNSNY CHOICE
HIV SNP
PMPM rate –
6% increase
VNSNY CHOICE Revenue Drivers
Revenue(millions)
Total DollarsTotal
Revenue
PMPM Revenue
$1,600
$1,400
$1 400
$1,200
$1,000
$800
$600
$400
$200
$0
2012
Projected
2012
MLTC
MA
2013 Budget
Budget
2013
HIV-SNP
Total
MLTC:
MA:
HIV-SNP:
2012
2013 Budget
A decrease of 3% in 2013 vs. 2012
An increase of 4% in 2013 vs. 2012
An increase of 6% in 2013 vs. 2012
11
VNSNY CHOICE Guiding Principles
VNSNY CHOICE Health Plans:
• Offer benefits that improve access to appropriate care, including
assistance with navigating an increasingly complex health care system
• Shift the focus of care from the institution to the home and community
• Believe care coordination is the cornerstone of all plan options and all
members are provided with a care manager that facilitates integration
across all care settings
• Target and customize interventions
IV: What We Have Learned: Our Model of
Care
12
Four Cornerstones of VNSNY Care Coordination
Four Cornerstones of VNSNY Care Coordination:
Person Centered
• Holistic, integrative
• Physical,
Physical Emotional
Emotional,
Social, Spiritual
• Personal goal-setting
• Address psycho-social
complications
• Self-management a key
objective
• Personalized plan of care
• Culturally congruent
13
Four Cornerstones of VNSNY Care Coordination:
Evidence Based
• Data collection and data
mining
• Timely and ongoing
assessment
• Protocols and best
practices
• Expected outcomes
defined for each
component of model
• Center for Home Care
Policy & Research
• Proprietary Risk
Stratification
algorithm
• Nurse Researcher
Four Cornerstones of VNSNY Care Coordination:
Mission Driven
• History and legacy
• Commitment to
community
• Where locus of care
is shifting
• Dedication to most
vulnerable
• Expertise in high risk
populations
• Safety
S f
net
• Public policy leadership
14
Four Cornerstones of VNSNY Care Coordination:
Nurse Led
• Clinical expertise
• Compassion + savvy
• Embedded in
community
• Advocate
• Integrator
• Navigator
The VNSNY Model of Care
15
The VNSNY Model of Care was Recently the Subject of a
Case Study by the Respected Commonwealth Fund
•
•
•
•
•
•
Integration of care across settings
Bridging gaps between hospital and home
Outcomes-driven Transitional Care protocol
54% reduction
d ti iin h
hospital
it l admissions
d i i
24% reduction in 30-day readmits
27% reduction in emergency visits
Examples of The
VNSNY Model of Care
16
The VNSNY Heart Failure
Transitional Care Program:
The VNSNY Heart Failure
Transitional Care Program:
Reduced 30-day hospital
readmissions 43%
17
VNSNY CHOICE
Medicare Advantage:
VNSNY CHOICE
Medicare Advantage:
Reduced 30-day
readmissions by 24%
18
VNSNY Strong
Foundations™
Falls Prevention:
VNSNY Strong
Foundations™
Falls Prevention:
Reduces falls and
falls-related complications,
hospitalizations
and
d ER visits
i it
19
VNSNY CHOICE
Managed Long Term Care:
VNSNY CHOICE
Managed Long Term Care:
Keeps members living
safely at home for over
5 years on average
20
VNSNY SPARK Palliative
Care Program:
VNSNY SPARK Palliative
Care Program:
Reduced inpatient
admissions 39% among
high-risk patients
21
VNSNY Behavioral
Health Program:
VNSNY Behavioral
Health Program:
Reduced depression 33%
Improved functional
ability 50%
22
These results
are no accident.
They are the outgrowth of a
unique and comprehensive
model of care.
23
An outcomes-driven
approach to care
coordination for vulnerable
populations to enhance
quality of care and reduce
avoidable costs.
An approach that is the
product of our unique
perspective as both a
provider and a payer.
24
V: Market Opportunities: Moving Forward
Care Coordination
Population-based management
RN
HHA
MD
OT
P ti t P
Patient
Population
l ti
PT
Pharmacist
SW
25
Innovative Models
Health Homes
Cost
Quality
Community
Health Teams
Hospital to Home
26
Payment Innovation
Source: Remedy Partners
Transitions of Care
Patients
C
B
O
H
Hospitals and
S bA t
Sub-Acute
Facilities
Home Care
27
Transitions of Care (Continued)
TOC Team
Health
Information
Technology
Nurse
Practitioner
Insurance
Case
Managers
g
Patient
Hospital
Medical
Staff
Behavioral Health
Plan
a
Notice of
Admission
30 Day
Transitional
Care
7 Day
Home Visit
by LCSW
Outreach
to Hospital
D/C Planner
Inpatient
Visit
28
Health Risk Assessments
Appropriately tailored care plan,
lower rates of disenrollment
High risk (plan uses this to stratify
membership, utilizes RN to
coordinate care)
Post-discharge transitional care
Accountable Care Organizations
High Cost
Limited
Access
ACOs
Patient
Centered
Care
Coordination
IT
Accountability
Primary
Care
Incentives
Alignment
Variable
Quality
Quality
Outcomes
Population
Health
Medical
Home
29
Accountable Care Organizations
(Continued)
“Menu” of Opportunities Through Which to Interface With ACOs:
Governance
Community Health
Outreach and Education
Investor
Primary Care
Care Coordination
p
Hospice
Nurse Practitioner Access
Transitions of Care
Homecare
Health Promotion
Health Information Exchange
Menu of opportunities for HIE interface
Care Coordination
Screening
Back Office MSO
Chronic Disease Management
Health Promotion
Alternative Therapies
Di
Disease
Prevention
P
i
Mother
h and
d Child
h ld
Wellness Intervention
Community Relationships
30
VI: Our Vision For the Future
The Industry Needs to Align Health Plan,
Provider, and Beneficiary Incentives…
HEALTH PLAN
• Accountabilityy
• Reduced fragmentation
• Coordination of care
• Improve network access
BENEFICIARY
• Expense management
• Value
• Superior quality
• Simplicity
• Return on investment
• Improved health outcomes
– Positive patient experience
PROVIDER
– Navigation in increasingly
complex system
– Advocacy
• Autonomy as a
practitioner
• Enhanced choice
• Revenue maximization
• Improve patient
experience
31
Collaboration is Crucial
• Partnering / Coordinating with other healthcare entities and systems is
and will continue to be essential as changes are absorbed from the ACA
and the industry transitions further to Managed Care
Medicare
Medicaid
MLTC
Managed
C
Care
SNP
FIDA
Partnerships Are Key
VNSNY Is Teaming Up With Other Providers and Payers to Improve
Outcomes, Costs and Readmissions
NYU Faculty Practice
Home Visits
Empire BlueCross Blue Shield / White Plains Hospital
Transitional Care
Mount Sinai
Sternal Wounds Program
NYU Langone Medical Center
Bundled Payments
32
At VNSNY, We Will Continue to Convert Our
Core Competencies into New Opportunities
• Down the road…
9 Further integration of care systems for dual-eligible population
9 Well
W ll positioned
iti
d ffor geographic
hi expansion
i
9 Leverages innovative practice design relationships with providers
9 Prepared for ACOs
• Creation of a best-in-class care management organization…
9 Embrace a culture of collaboration and shared governance
9 Pioneer
Pi
new practice
i models
d l
9 Embed passion for improved quality and member satisfaction
9 Drive efficiency at all levels of care delivery and coordination
9 Ensure appropriate of care at all levels
VNSNY Is Positioning Itself For The Future
Vision Statement
“Excelsior”
Ever
Upward
VNSNY will become the most
significant, best-in-class, nonprofit,
community-based integrated delivery
y
p
providing
g superior
p
care
system
coordination and care management
services to vulnerable populations
across a broad regional footprint
33
Our Contact Information
Chris Palmieri, BS, MHA,
President, VNSNY Health Plans
Phone: 212-609-5631
E-Mail: [email protected]
Samuel Heller, BA, MBA,
Senior Vice President, CFO,VNSNY
Phone: 212-609-5701
E-Mail: [email protected]
34