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Lexus Hybrid

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Long Term Care Integration Project San Diego Personal Visiting Physician Delivery System & the Care Management for High Cost Beneficiaries Demonstration Presented by: Joseph W. Spooner, MD, MBA SVP Outcomes, Academic & Government Relations

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Presentation: Components of the Personal Visiting Physician ™ Delivery System Discussion of the Care Management for High Cost Beneficiaries ("CMHCB") CMS Demonstration

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2005 CBO Report High Cost Medicare Beneficiaries [Top 25%] Top 5% = 43% aggregate uses Av. yearly gathering cost = $64,000 Av. yearly cost = $7,300 High versus Minimal effort Beneficiary Profile MD visits: 11 versus 6 every year Hospital concede: 75% versus 2.5 % SNF concede: 16% versus 0.1% ER visit: 63% versus 14% High Cost Trend 14% kick the bucket every year, 40% in 4 years half survivors were high cost for a long time

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Care Level Management Single Disease Healthy Multi Disease End of Life Hospice 2% 100% Patient & Care Stratification Figure 5

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Care Level Management THE STEP DOWN PRINCIPLE ICU M/S LEVEL OF CARE SNF HOME SPECIALIST CCRN MD LEVEL OF PROVIDER RN LVN NON SKILLED Figure 6

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Components of the Personal Visiting Physician Delivery System: day in and day out scope by load up ensured internists, family doctors & geriatricians Direct mobile phone contact Routine upkeep and critical home intercessions by the PVP

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Components of the Personal Visiting Physician Delivery System: Intensive home drug store administration Intensive on-going instruction in the home by the PVP and by telephone by the PCAN Post-doctor's facility follow-up Post-ER follow-up :

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Components of the Personal Visiting Physician Delivery System: Home Hospitalization :

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Home Hospitalization In-home doctor administration of restoratively stable patients with group obtained, uncomplicated pneumonias ; urinary tract contaminations ; cellulitis ; or potentially drying out Patient constantly given choices

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Home Hospitalization CLM CLINICAL RESULTS 1407 AVOIDED ADMISSIONS 378 HOME HOSPITALIZATIONS FINANCIAL RESULTS ALOS FOR HOME HOSPITALIZATION 4 DAYS AVERAGE COST OF HOSPITAL ADMIT $ 6,000.00 COST OF HOME HOSPITALIZATION $ 1,190.00 NET SAVINGS PER CASE $ 4,810.00 TOTAL SAVINGS FOR 378 HOME HOSPITALIZATIONS $ 1,818,180.00

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Care Level Management PCP OFFICE PCP Stand By Referral SNFist Case Manager Rapid Diagnosis Rapid Treatment ER MD Hospitalist Case Manager HOME ER SNF Referral Logistic issue or Uncontrollable Referral Out Patient Services Referral Unmanageable Event HOSPITAL Hospitalist/Case Manager Figure 13

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Care Management for High-Cost Beneficiaries ("CMHCB") Demonstration

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CMHCB Demonstration Background Section 721 of the Medicare Modernization Act, 2003 accommodated the Chronic Care Initiative Program (CCIP) now known as Medicare Health Support (MHS). Turned out to be obvious that CCIP was not intended to show the estimation of doctor based techniques for overseeing perpetual sickness in the elderly

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CMHCB Demonstration Background CCIP was composed particularly for Disease Management organizations' ways to deal with interminable ailment The main choice given CLM by the Centers for Medicare and Medicaid Services (CMS) was to contract with a DM organization

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CMHCB Demonstration Background Robert Berenson, MD, internist, Urban Institute, declaration to the House, Health Subcommittee, May, 2004: "… as I would like to think it [CCIP] is inadequate for really tending to unending consideration needs in Medicare since it does not have an engaged doctor segment [our emphasis]…

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CMHCB Demonstration Solicitation Components Finally, in October, 2004 CMS discharged a Solicitation for the Care Management for High Cost Beneficiaries (CMHCB) Demonstration Solicitation : "This deliberate exhibit is a piece of a push to create and test different procedures to enhance the coordination of Medicare administrations for high-cost FFS recipients… …

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CMHCB Demonstration Solicitation Components "… However, one approach which stays to be concentrated on is escalated medicinal administration for high-taken a toll recipients with different restorative conditions to diminish cost and additionally enhance nature of care and personal satisfaction for those recipients"

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CMHCB Demonstration Solicitation Components Eligible associations : "1) doctor bunches; 2) doctor's facilities; 3) incorporated conveyance frameworks. Different associations may apply yet just as a part of a consortium that incorporates doctor gatherings, healing centers, or coordinated conveyance frameworks."… .

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CMHCB Demonstration Solicitation Components Population-based study, with Intervention Group and Control Group Risk-based : Awardee needs to deliver no less than 5% net funds to CMS in 3 years or must give back every managerial charge paid the awardee {not expenses paid for genuine doctor visits/services}

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CMHCB Demonstration Awardees, July 1, 2005 ACCENT - Consortium of doctor centers in Oregon & Washington, Health Hero Network (home observing innovation organization), and American Medical Group Association Care Level Management-day in and day out doctor home going to doctor program… .

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CMHCB Demonstration Awardees, July 1, 2005 Mass General Hospital/Mass General Physicians Organization Montefiore Medical Center, Bronx, NY RMS DM, LLC — renal ailment mgmt organization., LI, NY Texas Senior Trails - Consortium of Texas Tech Univ. Wellbeing Sciences Center, Texas Tech Physician Associates

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CMHCB Demonstration CLM Implementation Began selecting recipients October, 2005 Intervention Group: 15,000 high-cost benies in California, Texas, and Florida. Approx. 13,000 to be enlisted in CA. Around 6,000 in Control Group Established CLM Enrollment Center in Phoenix, AZ.

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CMHCB Demonstration Implementation Expanded Networks: Physicians –17 to 91 (74 new contracts) Overall Staff Increase - >350% Geographic Footprint - Increased zone > 25 times Engaged Independent External Experts Milliman, Inc—actuarial bolster RAND - ACOVE estimation instrument Sullivan/Luallin: fulfillment study

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California Geographic Reach for Care Level's CMS Demonstration

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California Geographic Reach for Kaiser Permanente

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CMHCB Demonstration CLM Implementation Expanded Existing Services and Systems CLM University/Academic Programs/Residency Programs Enrollment Center Expanded Existing and Added New Offices Community Relations Managers Augmented Information Systems EMR; Seibel framework in Enrollment Center

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CMHCB Demonstration Challenges Competing BIPA Congestive Heart Failure DM Demonstration in CA by PacifiCare/Allere wiped out a great many CHF recipients from beginning Intervention & Control Group February, 2006 PacifiCare ended BIPA demo 10 months right on time because of 'absence of enthusiasm by recipients' On revive of populace, we would like to access these recipients

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CMHCB Demonstration Challenges Ultra quick develop of frameworks and faculty foundation Overcoming a few recipients dread of misrepresentation against seniors: would we say we were the genuine article? Creating compelling approaches to persuade essential care doctors that we supplement, not supplant, their care

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Summary We trust that CLM's CMHCB 3-year Demonstration will have the capacity to approve the viability and proficiency of doctors frequently going to the fragile elderly in their homes, and in addition different offices as fundamental. We additionally trust that this Demonstration, will make the general population, media and political players more mindful of the novel points of interest of giving consideration in the home to incessantly sick high cost patients.

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Thank you… .

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