HMO tackles tough-to-capitate group: Severely disabled Medicaid patients
Managed care for severely disabled populations is virgin territory for most Medicaid programs. However, with this segment of the Medicaid population experiencing steep increases in both costs and enrollment, states are feeling pressure to better manage their care. The Community Medical Alliance in Boston, a mini-health maintenance organization (HMO) for the sickest of the sick, has been serving a severely disabled Medicaid population under a capitated plan since 1992. The Massachusetts Medicaid program has set the clinical eligibility for the capitated plan, which currently enrolls about 200 patients. Patients enrolled in the program must be financially eligible for Medicaid and have no third-party commercial insurance. They also must meet these criteria:
• be functionally quadriplegic or triplegic;
• qualify for personal care attendant services;
• have cerebral palsy;
• have traumatic brain injury;
• be functionally paraplegic with qualifying complication, including recurrent urosepsis requiring admission, recurrent pressure ulcers, or substance abuse.
"Many of our patients are dually entitled with both Medicare and Medicaid," notes Mary Glover, RN, CS, NP, MS, vice president and nurse practitioner with Boston’s Community Medical Group, which participates in Community Medical Alliance’s capitated plan. (For the plan’s patient population, see box, at right.)
The capitated rate set by the state Medicaid program is $1,681 per patient per month, says Robert J. Master, MD, president and medical director of Community Medical Alliance. The plan has found that new enrollees cost more than the capitated rate in the first year, but once they are stabilized, patients can maintain a high degree of stability for about $1,000 a month. "We tend to get people when they have a high degree of unmet needs that have to be addressed early on," he says. "Once we make that front-end investment, the costs come down and balance out over a period of several years."
The plan can afford to make high front-end investments thanks to its low mortality and high retention rates. "Right now, our mortality rate is less than 1% a year, and our disenrollment rate is less than 1% a year. Our long-term focus pays off because once we get a patient enrolled, we tend to keep them," Master says.
In fact, Community Medical Alliance spends closer to $800 per month for the majority of its patients. Average monthly costs per patient in the capitated plan include:
• $130 for nurse practitioner services;
• $63 for primary care physician services;
• $35 for specialty care;
• $180 for acute care;
• $400 for durable medical equipment (DME).
It’s no surprise that the plan spends the majority of the capitated rate each month on DME. Glover and Master credit their success to the ability of providers to authorize all necessary services. "We’ve been given the empowerment to order whatever is medically necessary," Master says.
Transportation, oral pharmacy costs, and personal attendant care are not covered by the plan, which covers most other medical costs including mental health services, he says. "The nurse practitioner and the physician have full authority to order any network resources. The authorization has moved from the health plan to the provider, and that means that patients receive needed services in a more timely manner."
"If I want a pressure-reducing mattress for one of my patients, I can order it now and have it paid for by Community Medical Alliance," agrees Glover. "There’s no delay. And DME is part of the solution to high inpatient costs. We depend on DME as part of our strategy of alternative care, and as providers, we have a much better handle on the overall services our patients receive."
Nurse practitioners not only provide care, they coordinate it, note Master and Glover. "The role of the nurse practitioner is pivotal to the program’s success," Glover says. "Each nurse practitioner follows between 40 and 50 patients with the caseload organized primarily by geography. For those patients, nurse practitioners are both clinicians and case managers. We are the first to respond to acute problems. We make home visits for assessment and follow-up, prevention, and teaching. We also organize all the services patients receive." (For details on other members of the care team, see box, p. 189.)
Most primary care visits are provided by the nurse practitioners in the patient’s home, Glover says. In 1994, 89% of all visits were made by nurse practitioners and 11% by physicians. Of those total visits, 87% were made in the home and only 13% in the office setting. "The average patient receives 1.2 visits each month. We feel this is essential to avoiding devastating and costly complications such as pressure sores," she says.
The plan monitors the incidence and cost associated with pressure sores and finds evidence that frequent primary care visits reduce their severity. "The lowest cost I’ve ever heard quoted was $55,000 for a skin flap procedure on a pressure sore," Glover says.
Community Medical Alliance compared total cost of hospital admission, length of stay, and number of total flap procedures performed for pressure sores for the two-year period before the capitated plan and found the plan scored favorably. "The number of admissions was about the same, but all other factors, such as length of stay and total costs, were cut in half," Glover says. "Because we see patients frequently and can initiate interventions at a moment’s notice, we are much more proactive and successful in our care."
Patients also report a high degree of satisfaction with the plan. A 1996 survey found that 96% of patients were satisfied with their nurse practitioner care, and 94% were satisfied with their physician care. Community Medical Alliance also measured access to and satisfaction with mental health services. "Access to mental health is a hot-button issue for HMOs," Glover says. Patients in the plan reported 92% satisfaction with the time it took to access mental health services and 87% satisfaction with mental health services received.
Finally, Community Medical Alliance looked at patients’ perceptions of their health status. "True, it is self-reported health which could be considered subjective, but studies indicate that self-report of health is one of the best predictors of clinical outcomes," says Allan R. Meyers, PhD, professor/research director of the New England Regional Spinal Cord Center at Boston University School of Public Health. Meyers has worked with the plan on data collection and analysis. "We compared patients in the plan to other similar patients not enrolled in the plan and found that nearly half of plan members reported that their health is very good compared to less than one-third of the control group. And you must remember that these are sick, very disabled patients."
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