By Andrew Kitchenman
Posted July 26, 2013
UnitedHealthcare worked closely with the Camden Coalition of Healthcare Providers to share information and manage care for 16 Medicaid patients in the city.
While the coalition had already facilitated the sharing of information among hospitals, doctors, and other providers in Camden, United was in a position to add information for patients it insures, such as visits made to providers outside the city. This is one of the key ways the partnership differed from earlier attempts.
Another important difference: UnitedHealthcare paid for the aggressive, face-to-face care coordination the coalition is known for.
“The only thing that’s going to work is face-to-face contact . . . to shift resource out of the buildings and out of the cubicles and into the communities,” said Executive Director Dr. Jeffrey Brenner, who also serves as the medical director for the Cooper Health System’s Urban Health Institute.
The results of the partnership proved promising: lower costs and more appointments with primary-care providers.
These results could lay the groundwork for a much larger project that is expected to launch in multiple areas across the state next year — Medicaid accountable care organizations. This project is intended to transform the payment system for healthcare to low-income residents by rewarding providers who deliver high-quality care at lower costs.
The coalition has received national attention for its work in coordinating care and sharing patient information across a wide spectrum of providers in the city]. They’ve used this data in “hot spotting,” targeting services to those neighborhoods where patients have been making the highest number of unscheduled hospital visits.
“They were using that information to identify not only the patients who were the so-called superutilizers, but also the level of care and care coordination” those patients who frequently are hospitalized should receive, said Ernest Monfiletto, United’s vice president of provider network strategy. “It demonstrated to us a level of sophistication” in how to use information.
“We really understood that our objectives and their objectives were in line,” Monfiletto said. “The more we talked about the opportunity of collaborating, the more we saw commonality.”
UnitedHealthcare Community Plan of New Jersey President Scott Waulters concurred, allowing the company to strike a two-stage agreement with the coalition. The community plan manages the care for more than 300,000 Medicaid patients in the state.
For his part, Brenner said he was interested in health plans willing to spend resources in their members’ communities, rather than solely managing care by telephone.
The first stage of the partnership was choosing a select group of UnitedHealthcare’s most frequent hospital users to receive more intensive care-coordination throughout 2012. The company planned to determine whether the experiment was worthwhile by tracking the results and comparing them with the patients’ healthcare use in 2011.
If the project saved money, the savings would be shared with the coalition, which in turn would share them with providers.
While 50 of these patients were identified, only 29 remained eligible for UnitedHealthcare plan membership throughout the two years of the project. Sixteen of these patients agreed to participate.
The coalition began coordinating care for these patients from their first hospitalization in 2012. A coalition care coordinator would meet them at the hospital, discuss their conditions, and help schedule follow-up appointments with primary-care providers. They would also work to ensure that patients then made it to those appointments, helping to arrange transportation, for instance.
“Many of [the patients] have had expensive involvement with the healthcare system,” but that experience hadn’t been interactive, Monfiletto said.
Brenner said it was a challenge to bring the coalition and the health plan’s management models together.
“It took a lot of planning and a lot of midcourse adjustments,” Brenner said, adding that both sides recognized the requirements of the other in measuring performance goals.
After a year, the results were clear and the savings were real, according to both parties. Patients made more visits to primary-care providers and fewer visits to specialists, which lowered the cost of care. In addition, they received fewer prescriptions at a lower total cost, although the prescriptions they did receive had a higher average cost. Perhaps most importantly, the participants had fewer high-cost hospitalizations, although their emergency visits stayed the same.
The healthcare habits of the 13 patients who chose not to have their care coordinated remained unchanged
“To us, what that showed was a movement away from episodic care” toward better-managed care for the project participants, Monfiletto said.
Brenner said the results were “what you would expect” from paying more attention to each patient’s care, leading to fewer unnecessary prescriptions and an improved relationship with primary-care providers.
Now UnitedHealthcare and the coalition are in talks for phase two of the project — a contract that would cover a broader share of the plan’s members in the city. The contract will be based on the regulations that the state has prepared for Medicaid ACOs.
But UnitedHealthcare is not completely satisfied with those regulations. For instance, the ACOs are intended to involve all of the providers in an area, but UnitedHealthcare wants to focus on four that have fully integrated a new approach to care coordination.
“We want to be sure that all of the opportunities for building a foundation for a future will be in place from the start,” Monfiletto said.
Brenner said the contract would fit into the broader ACO framework of community-based collaboration among hospitals, doctors, other care providers, and patients.
The greatest challenge for the coalition is meeting its goal of having primary-care providers who are able to uphold the same level of care coordination that it has been trying to build.
The current primary care model “doesn’t work,” Brenner said, adding that it is based on “meaningless 10- to 15-minutes encounters,” between providers and patients.
Instead, providers need additional well-trained staff members who are able to coordinate patient care.
“You can’t turn the switch on an entire delivery system overnight,” but the UnitedHealthcare contract can be a “perfectly digestible bite,” Brenner said.
He hopes to strike similar contracts with Horizon and other Medicaid managed-care plans.
While the initial stage of this partnership may have been small, it has encouraged Allison DeBlois, executive director of the Affiliated Accountable Care Organizations, an initiative of the nonprofit New Jersey Health Care Quality Institute.
“This is more than just getting people out of the ER and really giving them the primary care and the social services that they need,” she said. “The first phase was more of a trial — I feel like the next phase is the real launch to the ACO.”
DeBlois said the implications of successful care coordination are significant for more than just Medicaid recipients.
“We really believe that is going to show that we can really bend the cost curve,” she said, referring to the national effort to reduce the growth in healthcare spending.