Improving Care, Changing Lives - Alliance of Community Health Plans

Innovations in Health Care:

Improving Care, Changing Lives

2015 REPORT TO THE COMMUNITY

Table of Contents

Letter from the President . . . . . . . . . . . . . . . . 1 Letter from the Board Chair. . . . . . . . . . . . . . . . . . . . . . . 2 Partnering for Better Care �� 3 Encouraging Patient Engagement ��9 Leading Positive Change ��15 Tribute to Patricia Smith �� 22 ACHP Board of Directors ��23 ACHP Member Organizations ��24 ACHP Year in Review ��25 Top-Performing Plans ��27 ACHP Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 About ACHP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inside Back Cover

Letter from the President

Innovation is a constant driver of progress in health care. New ideas and out-of-the-box thinking often lead to better care, improved processes and cost savings.

The community health plans profiled in this report are among the nation’s best and most innovative. They are finding new ways to integrate care across specialties, bring more services to the homes of frail elders and surround chronically ill patients with more care and more support in the community. Many are also innovating in ways that lead to deeper, stronger connections between individuals and their health care providers. Increasing face-to-face time with members means reaching them in some surprising settings like a mobile grocery store, community center, school or their own homes.

Community health plans are expert at building connections because they are anchored where their members are. Locally rooted, they naturally partner with community organizations, schools and other local groups to support health, wellness and well-being. As the world gets larger and more complex, it is easy to become disconnected. As an antidote, community health plans offer their members what we all want: a strong sense of partnership with our providers and a medical home we can trust and turn to throughout our lives. As the health care marketplace continues to shift and change so dramatically, communitybased health plans continue to provide outstanding leadership and an exciting glimpse of health care’s bright future.

On a personal note, I want to express my profound gratitude for the privilege of having served this organization for so many years. The team of our very talented staff and extraordinary member organizations sits at the core of any and every success. As I step down at the end of 2015, I do so with absolute confidence that the work we have done and the progress we have made will carry forward in the hands of my dedicated colleagues who share our mission of improving care and health for all Americans.

Patricia Smith

President and CEO ACHP

Alliance of Community Health Plans

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Letter from the Board Chair

ACHP remains highly successful against a backdrop of constant change because of its steady focus on quality, innovation, learning and addressing important public policy issues.

For example, ACHP has been advancing the public conversation on the challenges that both patients and providers experience with rapidly increasing drug costs. A complex problem such as this requires thoughtful discussion and evaluation of public policies, regulations and market forces. ACHP marshals expertise in all these areas to advance our understanding and build consensus for sustainable solutions. The steadiness with which ACHP leads stands in stark contrast to the tremendous volatility of the health care landscape. Despite the uncertain environment, ACHP and its member health plans remain sharply focused and deeply committed to quality, innovation and improving the health of communities.

This report highlights the many ways in which these commitments are carried out by community health plans. I am proud to draw your attention to this exceptional work.

ACHP’s ability to navigate so well in challenging seas is due in large measure to the steady hand of CEO Patricia Smith, who steps down at the end of 2015. She and her team of talented leaders have built a strong and highly respected organization that is well positioned to continue leading through the challenges ahead. Our industry and all those served by it owe Patricia our deep gratitude. It is challenging to advance when the landscape around you is constantly changing. But ACHP will continue to focus on our mission to improve the health of individuals and the communities we serve and actively lead the transformation of health care to promote high-quality, affordable care and superior consumer experience.

Patricia R. Richards

President and Chief Executive Officer SelectHealth Salt Lake City, Utah Chair, ACHP Board of Directors

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2015 Report to the Community

Partnering for Better Care Partnerships and collaborations among health professionals and organizations are creating new opportunities to strengthen care and improve health.

Community-Based Approach Transforms Medicaid Program Capital District Physicians’ Health Plan ALBANY, NEW YORK

Sometimes there is no substitute for face-to-face interaction.

This philosophy has helped Capital District Physicians’ Health Plan, Inc. (CDPHP®) dramatically improve care and connections with its more than 100,000 Medicaid members. The health plan has increased its Medicaid engagement rate from 26 percent in 2013 to more than 70 percent in 2015. Tracy Langlais, R.N., vice president of medical affairs operations, attributes this success to the health plan’s ongoing commitment to this population, as well as strategic partnerships with local, state and federal organizations to find and reach out to Medicaid members. “No one company can do it alone, and CDPHP is fortunate to have cultivated several partnerships with

organizations that share the same goals,” says Langlais.

Of particular note is the collaboration with the Homeless Management Information System (HMIS) in Albany County, a national web-based data collection system that helps identify Medicaid members who register with the federal Department of Housing and Urban Development for funding or services. That partnership alone has enabled CDPHP to obtain updated contact information for members who are difficult to reach, triggered case management outreach and put them in touch with community-based organizations to help coordinate their care. “No one else is doing this,” says Langlais, “and the results have been significant. Over the past year alone, emergency department [ED] visits have decreased by 91 per 1,000 members, post-ED follow-up visits with primary care physicians have increased and we’ve helped 1,500 non-utilizers access care.”

Other partnerships and initiatives that have helped CDPHP make substantial inroads with Medicaid members include employing a mobile health unit to provide basic services like well visits and immunizations, working with local county health departments on maternal and child health, participating in local continuums of care and conducting cultural sensitivity training for CDPHP staff through the Bridges Out of Poverty model. Many of these innovations, as well as the shift from a telephonic to interpersonal approach, came about under the guidance of Kathy Leyden, director, Medicaid innovation, and Charlene Schlude, director, care management.

“They have helped us learn some big lessons,” says Langlais, “like the value of face-to-face contact in overcoming barriers.” To boost in-person contact, CDPHP has embedded nurse case managers


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and social workers in neighborhood practices, local emergency rooms, shelters, meal programs and addiction recovery programs. The health plan also deploys community health workers who go door to door to help non-users access the care system.

Langlais says that all these efforts have been a win-win. “Not only is this rewarding for our staff, we are helping our members get the care and support they need. We’ve established trust with people and that speaks volumes.”

Creating Healthy Young Champions Capital Health Plan TALLAHASSEE, FLORIDA

More than 18,000 school children in the Tallahassee area are getting fitter and smarter about their health, thanks to an innovative Capital Health Plan program. Together with key community partners, the health plan created CHP Champions, a health and wellness program now offered in more than 50 schools in the health plan’s service area. The program just celebrated its tenth anniversary. 4


“Ten years ago, childhood obesity was on the rise, and schools were moving away from requiring physical education during the school day,” recalls Tom Glennon, senior vice president of marketing and administration. “As a communitybased health plan, we wanted to get directly involved in addressing these issues.” CHP Champions, launched in collaboration with area school districts, the Greater Tallahassee Chamber of Commerce and Titus Sports Academy, promotes regular physical activity and healthy choices for children in kindergarten through grade 8.

“CHP Champions is fun and effective,” says Glennon. “It is designed to help children improve their gross motor skills, flexibility, posture, balance and coordination. It gives them confidence in their physical abilities, and helps create a positive relationship with exercise. ” Launched originally as an after-school option in one middle school, CHP Champions quickly grew and spread. Today it is offered in the majority of elementary and middle schools in

six north Florida counties. “Because the program meets or exceeds most of the state requirements for physical education, a lot of schools now include it during the school day,” says Glennon. CHP Champions programming is typically offered twice a week in collaboration with the schools’ physical education teachers. With their parents’ permission, participants are assessed at the beginning and end of each semester in areas of health, performance and nutrition. Individual results are entered into a secure database so participants and parents can track their progress. Data show that compared to non-participants, CHP Champions participants have increased aerobic capacity, reduced absenteeism, spend more time engaging in physical activity and maintain more normalized body mass index (BMI) measures. Glennon says the health plan measures participation rates, which are high, and receives lots of good anecdotal data. “We get great feedback from parents, kids and phys ed teachers. People appreciate that Capital Health Plan cares about helping kids get and stay healthy.”

Partnering for Better Care

Building a Support Network Around Kids and Families Dean Health Plan MADISON, WISCONSIN

Raising healthy, happy children is a big challenge. For parents of children with mental health or substance abuse disorders, the task can be overwhelming. Dean Health Plan recently launched an innovative program with an important partner to better support children and families who face these health challenges.

“After a child is diagnosed or hospitalized for a mental health or substance abuse disorder, it is really important that they get appropriate follow-up care,” says Stacy Monahan, education and outreach coordinator for government programs. “Sometimes families need help or reminders to make sure the child gets ongoing care.”

“...[W]e think building these bridges between the health plan and the schools and families is especially important for families and children in crisis.” – Stacy Monahan, Education and Outreach Coordinator for Government Programs

To strengthen the “village” in which these families are raising their children, Dean Health Plan is partnering with the Madison Metropolitan School District (MMSD) to collaborate on case management services for some at-risk students. Partnering for Better Care

Under the agreement, school nurses can act as nurse case managers, working with families, primary care providers and mental health clinicians to support children ages six and up.

“There is a lot of focus on how to improve behavioral health care, both across the state and across the nation,” says Monahan. “We wanted to strengthen our ability to help young people with alcohol and other drug abuse disorders, and improve our follow-up with patients after hospitalization for mental illness.” Letters are periodically mailed to families whose children are both Dean Health Plan members and MMSD students, introducing the program and explaining the availability of extra support and coordination if the need should arise in the family.

Dean Health Plan’s IT system alerts appropriate providers whenever a health plan member who is also an MMSD student is newly diagnosed with alcohol or drug concerns, or when he or she is discharged from the hospital after a mental health or substance abuse-related stay. The school district lead nurse for mental health is also notified, and acts as a case manager to coordinate with the family. If the family wishes, the nurse at the child’s school will also be notified. This partnership, launched in April 2015, is still new, says Monahan, and will undergo testing and tweaking as leaders learn what works best. “This is a relatively small population, maybe 40 to 50 students per year. But we think building these bridges between the health plan and the schools and families is especially important for families and children in crisis.”

Supporting Healthy Schools and Communities Kaiser Permanente NORTHERN CALIFORNIA, SOUTHERN CALIFORNIA, COLORADO, GEORGIA, HAWAII, MARYLAND, OREGON, VIRGINIA, WASHINGTON AND WASHINGTON, D.C.

Keeping people healthy requires paying attention to more than what happens in the doctor’s office. No organization knows this better than Kaiser Permanente, with its long history of community involvement.

A current Kaiser Permanente initiative called Thriving Schools is the organization’s national effort to support healthier students, staff and teachers through a focus on healthy eating, active living, school employee wellness and positive school climate. In this effort, Kaiser Permanente is partnering with a number of other national organizations focused on health and well-being.

“Schools are a wonderful place to promote health, because you can really make an impact,” says Peggy Agron, national director of Thriving Schools. “You can work with leadership to change policies, the environment and the culture.” Thriving Schools includes broad offerings for K-12 schools; strategic interventions currently target 115 districts across the nation in Kaiser Permanente’s service areas. The Alliance for a Healthier Generation, founded by the American Heart Association and the Clinton Foundation, is a key partner providing strategic support to 335 targeted schools. One offering, Fire Up Your Feet, a program of Safe Routes to Schools (a partner in Thriving Schools), issues challenges and offers awards —

ALLIANCE Alliance OF COMMUNITY of Community HEALTH Health Plans PLANS 5

some monetary — that encourage families, students and schools to increase physical activity. As of December 2014, Fire Up Your Feet had reached 1,800 schools and 75 percent of those registered reported an increase in physical activity.

Thriving Schools recognizes that building momentum for change requires a multi-layered approach, including cultivating and mobilizing grass-roots school wellness champions; advancing and promoting policy and environmental changes through district and school engagement and ownership; and creating and leveraging strong partnerships within communities.

One of the unique ways that Kaiser Permanente is building wellness champions is by working with unions, says Agron. “We are partnering with the National Education Association’s non-profit arm, called NEA Healthy

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Futures, and with other labor unions to find passionate leaders who will work in the schools as champions to promote health and wellness for students and school employees.”

Agron says that about one in five Kaiser Permanente members spends his or her day in a school. “But this is bigger than just our members. This is our recognition that for our members to be healthy, their communities need to be healthy.”

Sharing a Passion and a Position to Support Healthy Habits Scott & White Health Plan TEMPLE, TEXAS

Community health plans are particularly effective at collaborating with other local organizations to support

healthy living. Scott & White Health Plan has created what is believed to be a first-of-its-kind partnership by sharing the cost of a health educator’s salary with a like-minded organization.

“I am employed 49 percent by the health plan and 51 percent by the Texas A&M AgriLife Extension,” explains Family and Consumer Sciences Educator Julie Gardner, MEd. She’s 100 percent focused on helping people in the community develop and maintain healthy habits. Together, with Gardner as coordinator, the two organizations offer healthy living programs to residents in five counties. They offer three programs to help educate and empower people to make healthier choices: a 12-week weight management program called Step Up and Scale Down, a healthful cooking program called Dinner Tonight and an eight-week exercise program called Walk Across Texas.

“One of our local extension agents had worked with the health plan on the weight management program, and both organizations began to see the value of a formal partnership,” says Gardner, who assumed her jointly funded position in November 2014. “AgriLife is a community educator and Scott & White has the health expertise, and bringing those two skills together made a lot of sense.”


The three signature programs, free of charge to health plan members, are offered at various locations throughout the five target counties. Gardner has also worked with employers to provide worksite wellness offerings drawn from the programs’ content. “Two of our larger cities are implementing our programs with their employees,” she says.

“You have to do whatever it takes to deliver health programs that are accessible and effective.”

– Julie Gardner, MEd, Family and Consumer Sciences Educator

The programs have been successful and are on target to meet their first-year goals. Step Up and Scale Down has been offered 14 times for more than 288 participants. Dinner Tonight has reached nearly 500 participants, about 300 of whom are not Scott & White Health Plan members. Walk Across Texas, with a goal of walking 830 miles over the eight-week period, has included 1600 participants. Partnering for Better Care

“Now we are diving deeper into the data and looking at how to impact higher-risk populations, how to target specific chronic diseases or conditions,” says Gardner. As for the unusual partnership, she says, “Both organizations have a passion to serve people, and you can’t do it alone. You have to do whatever it takes to deliver health programs that are accessible and effective.”

The Power of Community Collaborations SelectHealth SALT LAKE CITY, UTAH

SelectHealth recently joined forces with one of the nation’s most widely recognized charitable organizations to share and maintain a rich database of community resources available to health plan members. The database, a joint initiative with United Way of Salt Lake, helps staff accurately refer members and patients to important services that SelectHealth does not directly provide.

Care management and customer service staff at SelectHealth often talk with members who need services outside the health plan’s sphere, such as food programs, affordable housing, employment or support groups. “We realized that care managers kept an array of paper materials and resources in binders, folders, files and drawers, with no centralized method to track them, share them and keep them updated,” says Chris Chytraus, R.N., health services manager. “As a result, sometimes they didn’t have the most accurate or up-to-date information on hand.”

SelectHealth and its parent organization, Intermountain Healthcare, who work together to provide integrated care management, reached out to long-time partner United Way to explore the possibility of tapping into 2-1-1, United Way’s free, confidential referral and information helpline and website, available throughout the United States. “United Way was happy to share its resources and work with us to tailor the tool to our needs,” says Chytraus. “We compared our own lists of resources with theirs, and


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discovered that most of ours weren’t in their 2-1-1 search tool.” Working together, SelectHealth, Intermountain and United Way developed a single, comprehensive online tool to allow care managers to provide information and facilitate referrals to appropriate community-based social service organizations. “We formalized a contract with United Way in which it would provide a private tool that our own care managers could use,” says Chytraus. “The tool combines resources from each organization in a searchable, easy-to-use format.” Care managers can add to and update resources whenever necessary. Since the collaboration was launched in March 2015, SelectHealth staff has provided more than 100 additions to the United Way’s public 2-1-1 resource guide. “It’s really a win-win,” says Chytraus. “We have a robust tool that helps us support our members, and the United Way has enhanced its listing of available services. Patients and members can obtain quick, accurate information when they need it. This partnership and innovative tool support our mission to help people live the healthiest lives possible.”

Creating a Joint Venture Focused on Quality Tufts Health Plan WATERTOWN, MASSACHUSETTS

As the health care marketplace moves steadily away from fee-forservice toward more value-based reimbursement structures, Tufts Health Plan is launching an innovative joint venture designed to align incentives toward high-quality care and lower costs. Called Tufts Health Freedom Plan (THFP), it is a joint venture in New Hampshire between Tufts Health Plan and Granite Health, which includes five of the state’s largest health systems. The company, scheduled to launch operations on January 1, 2016, will provide residents with highly coordinated, cost-effective health care coverage. “The Freedom Plan brings new levels of collaboration between a health plan and provider networks,” says Derek Abruzzese, chief strategy officer for Tufts Health Plan and a THFP board member. “It enables us to collaborate on information and infrastructure, and to take a more coordinated approach to caring for patients than the traditional armslength relationship that providers often have with insurers.”

Granite Health’s population health management program relies on a data-driven approach that supports care coordination. Tufts Health Plan’s insurance products are designed to change financial incentives and behavior. Abruzzese says that combining this expertise in one organization will bring a first-of-itskind option to the region. 8


“With appropriately aligned incentives, and by sharing information and collaborating to identify opportunities for improvement, not only can THFP deliver better health outcomes over time, but also lower costs.”

Sharing financial risk across the two organizations is a key differentiator from most other U.S. health plans. “We are certainly breaking trail in our region,” says Abruzzese. “There are other provider-owned health plans in the nation, but they started out that way. We are carefully and conscientiously building this from two separate organizations, creating a single perspective on how to move forward together.”

“The Freedom Plan brings new levels of collaboration between a health plan and provider networks.” – Derek Abruzzese, Chief Strategy Officer, Tufts Health Plan

Building this joint venture goes a giant step further than holding providers contractually responsible for meeting performance goals, says Abruzzese. “Here, the providers own half the company. That creates a different dynamic, a different level of trust and collaboration, and we think it will all lead to better outcomes and lower costs.” Abruzzese feels that being a community health plan is key to Tufts Health Plan’s ability to create this innovative new company. “We have a local focus. New Hampshire is in our backyard, and Granite Health knows we are a like-minded organization with a focus on quality.”


Encouraging Patient Engagement Most of what affects our health happens outside the doctor’s office. Helping patients take better care of themselves is key to improving population health.

Improving Health All Together Martin’s Point Health Care PORTLAND, MAINE

Some diabetes patients at Martin’s Point Health Care’s West Falmouth practice are getting more time than ever with their doctor, along with the added benefit of insights and advice from their peers. That’s because they are attending group doctor visits for patients with diabetes.

Groups of up to 12 patients, each participating by choice, meet once a month over a six-month period. The two-hour meetings, which are facilitated by a diabetes educator and the patients’ physician, include a combination of education, discussion, clinical evaluation and one-on-one time with the doctor. A nurse and clinical manager are also present. “We review each patient’s chart before the meeting to determine what clinical exams they might be due for,” says Barbara Albert, practice administrator. “We create a folder to give to each patient when they arrive

for the meeting, informing them what they should take care of during their visit. We have clinical stations set up for vital signs, foot exams, HbgA1c PCO testing and phlebotomy that patients rotate through as soon as they are checked in for the group visit.”

“The biggest reaction we get from patients is usually, ‘Oh, I’m not the only one going through this.’” – Barbara Albert, Practice Administrator

Group visits have been around since the early ‘90s, and experts estimate that about 10 percent of physicians use them for a specific population of patients. Successful group visit programs typically include education, shared problem solving and some time for individual consultations with a provider.

“Education is really what makes the group visits so successful,” says Albert. “Patients spend more time learning about their condition from experts, and from each other. The biggest reaction we get from patients is usually, ‘Oh, I’m not the only one going through this.’ People sometimes feel isolated when they have a chronic condition and these group visits allow people to open up and share their experiences. It really breaks down barriers.”

The diabetes educator presents information and facilitates discussion about relevant topics. “For one session she brought in new foods for people to try, like spaghetti squash as a substitute for pasta,” says Albert. “We also partnered with Hannaford Foods, which has a store right across the street, and their nutritionist gave the class a tour of the store and a lesson on reading nutrition labels.” While the diabetes educator facilitates the group discussion, the physician sees patients to address


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their individual needs and concerns. Patient satisfaction with the group visits is high, says Albert, and surveys indicate that patient confidence in managing their condition increases significantly.

Creating an Effective Welcome Mat for Thousands Independent Health BUFFALO, NEW YORK

When Independent Health realized it would receive more than 15,000 new Medicare Advantage members on January 1, 2015, leaders knew they needed to create a robust plan for onboarding. “We knew we would need to understand as much as we could about these new members: their

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health risk status, relationships with current providers and what they needed to learn about Independent Health,” says Jill Syracuse, executive vice president and chief engagement and servicing officer. “So we created a comprehensive plan aimed at both members and providers.” Called The 15,000 Lives Campaign, the yearlong initiative includes comprehensive member outreach and education, as well as a physician engagement strategy and incentivebased compensation.

“First, we created a condensed version of a Health Risk Appraisal [HRA] — just 20 questions — and sent it to all new Medicare members so we could learn about self-reported risk factors, morbidity and whether or not the patient was already aligned with a primary care physician in our network,” says Syracuse. About 70 percent of the HRAs were completed and returned. Staff prioritized them and began calling members, paying special attention

to those who did not have a primary care physician (PCP). They reached about 75 percent of these patients and helped many of them schedule an initial appointment with a physician. The physician incentive was aligned with a new preventive visit called the Enhanced Annual Visit (EAV). The EAV incorporates many of the services that PCPs already provide during typical preventive and wellness visits, with an expanded focus on assessment and management of patients’ chronic diseases. Program leaders suggested this visit could take up to an hour.

To appropriately compensate doctors, Independent Health established a reimbursement rate 78 percent higher than for a wellness visit. Practice supports for the EAV include dedicated phone and email contacts for questions, online resources such as coding tips and patient call scripts, and meetings with physician leaders to exchange ideas and information. About 1200 new members have been seen in an EAV (as well as some existing Medicare members who could benefit from the longer visit), with 64 percent of eligible physicians participating. A phone survey revealed very high member satisfaction. “People said, ‘Wow, you folks really care about me,’” reports Syracuse.

Encouraging Patient Engagement

Keeping Medically Complex Elderly Patients at Home Geisinger Health Plan DANVILLE, PENNSYLVANIA

Elderly patients with complex conditions are often in and out of the hospital, need additional nursing home services or end up in long-term care facilities. Geisinger Health Plan’s Medically Complex Medical Home program enables many older patients to remain at home and manage their often-changing health status.

Introduced in 2014, the Medically Complex Medical Home model uses care teams with a nurse and a community health assistant to coordinate care and services for elderly patients with complex conditions. Each team visits hospitals or nursing homes to meet patients and arrange for postdischarge home visits. During home visits, the team assesses overall health, nutritional support, the home environment and the level of support patients receive at home. It also reviews and reconciles medications. “This is so important, because medication Encouraging Patient Engagement

problems are typically a big reason for readmissions to the hospital,” says Janet Tomcavage, R.N., MSN, chief population health officer. The team, which can also involve a pharmacist or social worker when needed, aims to help patients continue to live at home with the right resources and manage their health conditions proactively to avoid frequent visits to the emergency department or hospital. “Mary” is a typical patient in the Medically Complex Medical Home program. With a history of heart failure, COPD, kidney disease and atrial fibrillation, she has been in and out of the hospital. She lives alone, is hard of hearing, does not drive, eats poorly and struggles to care for herself.

After visiting Mary, the Geisinger team arranged for home-delivered meals, transportation services and some in-home care. Team members also taught her about self-care for her heart failure and chronic lung disease. In the nine months before she enrolled in the program, Mary had two urgent hospital admissions, one skilled nursing facility (SNF) stay and

one emergency room (ER) visit for heart failure. In the first eight months after her enrollment, she had no inpatient admissions or SNF stays and one ER visit. Mary’s experience was typical of other patients in the program. During a nine-month pilot, the care teams managed 75 medically complex patients and closed 433 gaps in care related to plan of care optimization, 201 gaps related to safety, 21 gaps in end-of-life planning and 416 gaps related to medication management. Over the same period the program realized a 20 percent, $1000 permember-per-month cost reduction primarily from fewer ER visits and hospitalizations.

Understanding and Supporting Cultural Norms

Presbyterian Health Plan ALBUQUERQUE, NEW MEXICO

New Mexico’s population is among the nation’s most diverse. While demographers often combine all Native Americans into a single category, there are 23 different


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Native American tribes, nations and pueblos in New Mexico. “They are as diverse as any other cultural groups,” says Travis Renville, MBA, director of Native American affairs at Presbyterian Health Plan. Renville is a member of the Sisseton Wahpeton Dakota nation, located in South Dakota and North Dakota. Renville’s job is to boost the health plan’s engagement with this diverse and sometimes hard-to-reach population. He has approached this through benefit design, strategic deployment of staff, creation of advisory boards and traditional community outreach.

Renville’s advocacy led the health plan to provide coverage for traditional healing, a vital part of health care for many Native Americans. Techniques and practices vary across tribes, but traditional healing rituals are culturally, physically and spiritually important. Today the health plan’s Centennial Care Plan for Medicaid recipients covers Native American members for

$200 worth of traditional healing per calendar year.

The health plan also employs four tribal liaisons who work with Native communities to address needs and solve problems. Liaisons in the provider relations department work directly with the Indian Health Service, sorting out billing, claims and contracting issues for tribal members. Other liaisons work in the health plan’s call center where they can speak to Navajo callers in their native language. Renville says this amounts to between 80 and 100 calls per month.

To prepare for the rollout of the Affordable Care Act, and an influx of new members, Presbyterian created the Native American Advisory (NAA) Board to focus on how to best serve Native American members. NAA Board members represent the Navajo, Apache and Urban Indian areas, as well as the Eight Northern Pueblos, Ten Southern Pueblos and Indian Health Service system. Meetings are held quarterly in different regions throughout the state. Renville knows from his own culture the importance of respect in Native communities, and he makes sure health plan staff are well trained

in cultural norms. “I put together a computer-based training module with scenarios related to cultural sensitivity and competency,” he says. “I update it regularly with various scenarios that I’ve seen in the Native American community. More than 10,000 employees have received the training, and every new hire gets it, too.”

Learning About Seniors’ Needs Through Home Visits New West Health Services HELENA, MONTANA

By sending a nurse practitioner to the homes of its members for an in-depth health assessment, New West Health Services (dba New West Medicare), a Medicare Advantage health plan, is gathering and uncovering information that leads to better, more comprehensive care.

“Members tell us how great it is to not feel rushed.” – Bonnie Barnard, MPH, CIC, Director of Quality Improvement and Risk Adjustment

“This is about so much more than just capturing diagnoses for risk evaluation,” says Bonnie Barnard, MPH, CIC, director of quality improvement and risk adjustment. “Our home evaluation program adds tremendous value for our members.”

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A nurse practitioner from Matrix Medical Network, an in-home medical assessment service with whom New West contracts, makes a home visit and spends up to an hour with the member, conducting a health assessment and a medication evaluation. “The nurse practitioner documents her findings and makes referrals if the member has specific needs for care,” says Alicia Hess, LPN, clinical outreach specialist at New West. Hess reviews all the assessments, even those where no referral was needed. “Occasionally I’ll follow up on something the nurse practitioner didn’t flag.”

The hour-long visit gives members a chance to ask questions and share concerns in a setting that is far less stressful than the doctor’s office. “Members tell us how great it is to not feel rushed,” says Barnard. “Nurses typically have great listening skills, and members appreciate that.” Medication reviews are an important component of the visits and often reveal issues that require attention, such as medications that are contraindicated or two different medications prescribed by different providers for the same purpose. “Sometimes the member isn’t taking their medication because they can’t afford it. This is more likely to come to light during a home visit than in a doctor’s office,” says Hess.

There have also been occasions when an acute problem such as a carotid blockage has been found during a home visit, and immediate followup care has prevented a potential medical crisis. Community resources such as medication assistance programs, Meals on Wheels and transportation to medical appointments are often Encouraging Patient Engagement

recommended to members as a result of things learned during the home visit. In addition, a home visit provides information that is simply not available in any other way. “Are there throw rugs or electrical cords that represent a tripping hazard? Is the refrigerator empty? Are there other safety or psychosocial issues that can be addressed?” says Barnard.

New West uses claims data to target members who haven’t seen a doctor in 12 months or more for home visits. During 2015, about 3,000 members will have received a home visit and assessment.

Boosting Parents’ Health Literacy

Security Health Plan MARSHFIELD, WISCONSIN

To help parents gain confidence overseeing their children’s health, Security Health Plan teamed up with Wisconsin Health Literacy and the Indianhead Community Action Agency to provide parents

with a handy source of accessible information about children’s health. What To Do When Your Child Gets Sick is a straightforward book that gives parents easy-to-read health information and guidance about when to seek care from a health care provider. “Through a community assessment we learned there was a need to strengthen health literacy,” says Jay Shrader, director of disease management and wellness. Health literacy is an individual’s ability to find, understand and act upon basic information about his or her health.

“Health literacy touches people across all socio-economic and educational levels,” says Shrader. Research shows that literacy skills are the strongest predictor of health status: Low health literacy is associated with poorer health and higher health care costs. “This book is aimed at improving parents’ health literacy,” says Shrader. It includes information on a range of ailments and health concerns, including newborn safety, stomach aches, rashes, nosebleeds and more

18% 18%

82% 82%

YES

40% 40% 60% 60%

NO

Was there an instance in which you avoided calling a hospital or clinic because of the book?

Was there an instance in which you avoided going to the ED or urgent care because of the book?

82 percent of parents who used the book indicated that the information helped them deal with a health problem at home instead of calling a hospital or clinic. 60 percent of parents avoided unnecessarily visiting an emergency department or urgent care based on information provided in the book. Source: Security Health Plan

Of 2,300 parents who received books in clinics, 184 filled out surveys.


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serious concerns such as fever, infections, bleeding and broken bones. The book is free of charge, and given to parents by pediatricians and other health care providers, or by childcare workers who have enrolled in Security’s training program for childcare physical activity and nutrition programs. “We’re also partnering with hospitals, health departments and other entities that work with families to get the book into parents’ hands,” says Shrader.

“Our research shows that parents are far more likely to use the book if their doctor or another professional has personally given it to them and recommended it,” says Shrader. For this reason, periodic Train the Trainer workshops help pediatric providers and support staff learn about effective communication techniques with parents about newborn health, and how to identify gaps in health literacy. Workshop leaders also explain how best to introduce the book to parents during well-child exams.

“Through a community assessment we learned there was a need to strengthen health literacy.” – Jay Schrader, Director of Disease Management and Wellness

Surveys show that 82 percent of parents who used the book found the information helpful in dealing with a health problem at home instead of calling a hospital or clinic. Sixty percent of parents avoided unnecessarily visiting an emergency department or urgent care center based on information provided in the book.

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Expanding the Care Team in New Directions Group Health Cooperative of South Central Wisconsin MADISON, WISCONSIN

Pharmacists have always been important members of the health care team, dispensing medications and answering patients’ questions. At Group Health Cooperative of South Central Wisconsin, pharmacists are working more closely than ever with providers. The health plan has embedded pharmacists into four of its six primary care clinics, where they proactively look for and work with patients who may benefit from closer medication management. “It has always been our role to support the physician and the care team,” says Erica Guetzlaff, PharmD, clinical administrative pharmacist. “Our dispensing role is still critical. But our clinical role is also important, and being physically located with the care team gives us a better opportunity to provide clinical support in a more direct way.” The embedded pharmacists comb through medical records to conduct medication reconciliation, find opportunities to replace high-cost brand-name drugs with equally effective generic medications and schedule medication management visits for members. They also conduct targeted outreach to specific categories of patients: those with hypertension and hyperlipidemia; taking five or more medications; recently discharged from the hospital or emergency room; and those struggling to adhere to their medication regimes.

“We proactively make recommendations to the providers,” says Guetzlaff. “We put a note in the patient’s chart before they see the doctor that this patient might benefit from a pharmacy referral.”

“…[B]eing physically located with the care team gives us a better opportunity to provide clinical support in a more direct way.”

– Erica Guetzlaff, PharmD, Clinical Administrative Pharmacist

The embedded pharmacists have had a measurable effect. “We’ve seen great reductions in out-of-control blood pressure,” notes Paul Baum, RPh, MBA, director of ancillary services. “In three months there has been a 58 percent improvement in blood pressure control for the group of patients that interfaces with the pharmacists.”

There have been financial wins as well: During a six-month period in 2014, the health plan moved 70 patients off an expensive hyperlipidemia drug onto an effective generic, saving $2,000 per patient per year. Guetzlaff acknowledges that gaining trust from providers was an early hurdle, so pharmacists started by focusing on low-hanging fruit. “We knew we could make a difference with hypertension, and that was a great way to show providers our worth,” says Baum. Now, he says, some of the doctors who were most hesitant at the start have changed their minds. “If you’re helping the patients, that’s what the doctors want to see. Before long, they started asking for our input.”


Leading Positive Change Innovation is everywhere in health care today. Promising new care models, partnerships and perspectives are delivering better results and generating optimism.

Prescribing Healthy Food to At-Risk Patients CareOregon PORTLAND, OREGON

Can food be a kind of medicine? CareOregon believes the answer is yes. The health plan, which serves more than 200,000 Medicaid members, has created a Food Rx program to provide access to healthy food for patients who struggle to maintain good nutrition. “A lot of ‘health’ happens outside of clinics,” says Tom Wunderbro, MPA, Food Rx program manager. “The Food Rx program fills in some gaps that have typically been outside the provider’s scope.”

“We believe that food has developmental, preventive, curative and palliative properties,” says Rose Englert, senior business leader for community health innovation. “We wanted to create a program to address food insecurity and poor nutrition. We also believe food can play a role in reducing social isolation.” The importance of good nutrition for pregnant women is well known, and that is one of the program’s target populations. But healthy food is also essential in wound care,

says Wunderbro, because the body needs adequate protein to form new skin and heal. Providers at a local wound clinic give Food Rx vouchers to patients at risk for poor nutrition. “The prescription can be for up to three meals a day for as long as it takes to address background malnutrition and condition-specific healing needs,” says Wunderbro.

“It is a challenge to serve all the different needs,” says Englert. “We hoped there would be one food vendor who could do it all, but there have to be numerous options because

Launched as a six-week pilot in 2014 and then implemented in 2015, Food Rx enables providers to write prescriptions for fresh, healthy foods, prepared foods, shelf-stable foods or meal programs. Prescriptions can be used at designated local vendors, markets or soup kitchens.


15

some patients are high functioning, and some are homeless and need specially tailored services.”

CareOregon is funding the program, helped in part by Oregon’s waiver allowing Medicaid dollars to be spent on non-traditional goods or services related to health. “We don’t get additional funding,” explains Englert, “but we do have more flexibility around how we spend what we have.”

The Food Rx program remains a work in progress as leaders evaluate the program design and results. “We are still exploring the intersection of food and health,” says Wunderbro. “We know it is important and we are doing our best to put our money where our mouth is.”

Supporting Elders Aging in Place Fallon Health WORCESTER, MASSACHUSETTS

Imagine a coordinated care and coverage program for older adults that keeps them in their homes, decreases rates of hospitalization, readmission and nursing home 16


stays, and has nearly 100 percent satisfaction ratings.

In fact, the program that does all this is about 40 years old: PACE, a Program of All-Inclusive Care for the Elderly. There are more than 100 PACE programs across the country, including Fallon Health’s Summit ElderCare®, which provides care to more than 1,000 participants.

“PACE is for people 55 and older who are nursing home-certifiable,” explains David Wilner, M.D., Fallon’s medical director for Summit ElderCare. “They might have cognitive or functional impairments that, if not for PACE, would land them in a nursing home.” Wilner says the program is built on the belief that chronic care needs are best met at home. “Each participant has an 11-discipline care team that coordinates clinical services including medical care, geriatric case management, social services, functional assistance, rehabilitation, adult day health services, full insurance coverage and in-home support,” says Wilner. A robust electronic health record supports this care model, facilitating

the development and implementation of a comprehensive care plan and the efficient exchange of information among care team members. Also key to the program’s effectiveness are PACE adult day centers that most participants visit on a regular basis, on average two to three days per week. Currently, Fallon Health has five such centers across central and western Massachusetts. “Participants aren’t required to attend the center, but most do,” says Wilner. “It allows our team members to interact with participants on a regular basis and monitor them for any concerns.”

Fully 100 percent of participants say they would highly recommend the program to others.

A program under Medicare, PACE can also be provided by states to Medicaid recipients. Financing for the program is capped, which allows providers to deliver all services participants need and not just those reimbursable under Medicare and Medicaid fee-forLeading Positive Change

service plans. Summit ElderCare is the only PACE program in the country offered by a private health plan, rather than a hospital system or other provider organization. Fallon Health’s Summit ElderCare program has achieved impressive results. “We have a 15.7 percent readmission rate, compared to 23.5 percent among skilled nursing patients,” says Wilner. Fully 100 percent of participants say they would highly recommend the program to others. “Staff love the program, too,” says Wilner. “They are very enthusiastic about their work.”

A Care Model for Thriving with a Chronic Condition Group Health Cooperative SEATTLE, WASHINGTON

As the former executive vice president of Group Health Physicians, Marc West led an organization well known for its focus on caring for the whole patient. Diagnosed in 2011 with ALS, or amyotrophic lateral sclerosis, West has an even keener understanding today of what whole-person care can mean. Now a consultant for Group Health Cooperative, West is leading a crusade to transform care delivery for patients with chronic conditions.

Called the Chronic Disease Life Pathway (CDLP), the care model West and his team have developed is designed to transform care from episodic visits to comprehensive, collaborative and technology-enabled care in partnership with community organizations and support systems. West has piloted it for his own care and says, “I am not just surviving, I am thriving.” It has also reduced the total cost of his care.

The CDLP consists of two intersecting tracks: a clinical pathway that brings care to the patient, and a resource pathway that bundles tools and resources to support patients and their caregivers. Collaborating with community organizations, such as the ALS Association, legal services, volunteer and other support groups, is key.

The pathway begins with a home visit to educate the patient and family, provide information and resources, and assess the home. The patient’s first clinical visit is with his or her entire multidisciplinary care team, after which the team develops a personalized care plan. Once the plan is developed, the patient’s care is largely managed at home.

“Remote monitoring is an important way to keep people with chronic disease at home,” says Hugh Straley, M.D., former president and medical director for Group Health Permanente and Group Health Cooperative, and part of West’s team. “The idea is to proactively anticipate problems before they become acute or catastrophic. The cost of the technology is greatly offset by the cost of avoiding emergency room visits and hospital stays, which are the most expensive part of health care.” Paying providers for telemedical care is also key to making this model work. West recently testified before the state legislature on a bill that would further compensate providers for telemedicine. “The financial model is based on the accountable care idea: Everyone shares in the wellness of communities,” says West. West and his team will pilot the model soon with Washington state’s dual-eligible homebound patients, and are also discussing pilots with a number of other payers.

“My vision started as an ALS care pathway, expanded to a chronic conditions management pathway and has now grown to a new approach to transform our fragmented health care system,” says West, who speaks through an eye-operated computer system. Leading Positive Change


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Helping People Talk About Mental Illness HealthPartners MINNEAPOLIS, MINNESOTA

To shift the public perception of mental illness and help erase the stigma of shame and fear, HealthPartners is using the tools of modern marketing: print, radio and television ads, a website and even a documentary series that won a regional Emmy award. The campaign, called Make It OK, has been viewed in some form an estimated 250 million times since it began.

Launched in 2013, Make It OK is aimed at helping to shed misconceptions about mental illness, get people talking and break down barriers to care. “The stigma associated with mental illness can keep people from seeking care,” says Donna Zimmerman, senior vice president for government and community relations. “We wanted to address this in a very public way.” The public campaign grew out of an internal effort to educate HealthPartners staff about how to think and talk about mental illness. 18


“We put together a training program with the Minnesota chapter of the National Alliance on Mental Illness [NAMI MN] and felt it was effective. We decided to take it to the community,” says Zimmerman. HealthPartners joined with other organizations in addition to NAMI MN, including Twin Cities Public Television.

A variety of ads (as pictured above) depict people with an awkward silence between them, and urge viewers to “start the conversation.” The makeitok.org website offers tips on what to say if someone brings up mental illness. “We know from our analytics that this is the page many people go to first,” says Zimmerman. “It is clear people want help knowing how to talk about mental illness.”

In addition to helping people talk about mental illness, the campaign is also designed to educate that mental illnesses are treatable. “It’s a common misperception that you can’t get better, so people don’t seek treatment,” says Zimmerman. “We think opening up the conversation earlier is the first step toward getting treatment.”

About 250,000 people have viewed the four documentary programs, and 1,400 people have attended presentations to become Make It Ok ambassadors. Representatives from the campaign also lead education and coaching sessions for businesses, community groups, churches and even the city of Red Wing, Minn. Zimmerman says HealthPartners has intentionally not branded the campaign as a health plan initiative. “This really is a community effort, supported by many partners,” says Zimmerman. In addition, she says, “The campaign is not specific to Minnesota. Other health plans can use these materials. We want to see it spread everywhere.”

Providing and Paying for Integrated Care

Rocky Mountain Health Plans GRAND JUNCTION, COLORADO

Rocky Mountain Health Plans (RMHP) is pursuing an ambitious, multifaceted strategy to integrate primary Leading Positive Change

care and behavioral health services and support that integration with value-based payment structures.

RMHP’s work dovetails with Colorado’s State Innovation Model (SIM), a statewide effort to broadly integrate medical and behavioral health care and ensure payment structures are in place to support it. In 2014 Colorado SIM received a $65 million federal grant to pursue this work. One of the initiatives that could be brought to scale via Colorado SIM is RMHP’s “SHAPE” demonstration — Sustaining Healthcare Across integrated Primary care Efforts. Through SHAPE, the health plan is working with the University of Colorado to develop alternative payment models for integrated care. The health plan selected advanced practice sites and control sites to test the effect of RMHP’s global payment structure on cost and clinical outcomes. A comprehensive evaluation by the University of Colorado and Milliman, due in late 2015, will help leaders assess the model’s effect on chronic conditions management, patient activation, anxiety, depression, substance abuse and practice productivity.

While the health plan is pursuing behavioral health integration across all of its business lines, Associate Vice President Patrick Gordon says that the Medicaid payment reform component is perhaps the most aggressive initiative. Called Medicaid Prime, this demonstration in seven counties targets the Medicaid expansion population, dually eligible beneficiaries, special needs children and low-income families. “This program goes beyond the traditional Medicaid managed care paradigm,” says Gordon. “We have completely replaced fee-for-service with global payments, and have a Leading Positive Change

shared savings arrangement with community mental health centers. We have a full-risk Medicaid contract for pharmacy and health services, with shared data and governance from leaders in public health and human services.” The model relies on a broad alliance of community partners, including federally qualified health centers, hospitals, public health and even employers. “It is more of an accountable community initiative rather than a corporate managed care model. Many players have a stake in its success,” says Gordon.

Gordon is enthusiastic about this community governance process, and hopeful about its prospects. “We are sharing data; we have financial performance transparency and rate setting transparency; the physicians are working on patient activation; and instead of losing money on Medicaid, which was guaranteed in the past, there will be shared savings, a better, more coordinated experience for patients and — we believe — better health outcomes.”

Bringing Healthy Options to Food Deserts UCare MINNEAPOLIS, MINNESOTA

Residents who live in “food deserts” — with limited or no access to fresh, healthy foods — often have poor diets, which contribute to higher rates of obesity, diabetes, heart disease and other diet-related disease. In 2014 UCare became the chief funder for an innovative effort to help address this problem. With UCare’s support, and additional funding from other local contributors and some

in-kind gifts, the Amherst H. Wilder Foundation created the Twin Cities Mobile Market, a grocery store on wheels that sells healthy foods at below-market prices in low-income neighborhoods designated as food deserts.

“We know that as much as 50 percent of a person’s health is influenced by social factors,” says Wendy Wicks, communications/public relations assistant director. “Not having easy access to affordable, healthy food is one of those factors.”

Using a retrofitted Metro Transit bus, the grocery store on wheels makes 18 stops each week at locations that include public housing, community centers, a church and a childcare center. Customers receive information such as shopping and storage tips, cooking tips and a healthy recipe — all centered on the produce of the week. Significant media attention during the project’s first few weeks helped to spread the word. Anyone can shop in the market, and there are no forms to fill out. Credit and debit cards and cash, as well as payment via the Supplemental Nutrition Assistance Program (SNAP)/Electronic Benefit Transfer (EBT) system, are accepted. The Amherst H. Wilder Foundation partnered with other organizations to provide services and information on the bus that could be useful to customers, including SNAP eligibility screening and details about local transit initiatives and Head Start services. Since its launch, more than 2,000 customers have made more than 9,200 purchases from the mobile market, with produce being the top seller. “UCare’s primary business is to provide access to health care for


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thousands of members, but our mission is to improve the health of our members through innovative services and partnerships across communities,” says Wicks. “The mobile market empowers people to prepare healthier meals, and it also helps to improve health equity by providing better nutrition to our many diverse communities.” UCare serves large Hmong, Latino and Somali populations, as well as many elderly residents.

The success of the Twin Cities Mobile Market has led to the purchase of a second bus to bring healthy foods to even more neighborhoods in need.

Comprehensive Community Care for Complex Patients UPMC Health Plan PITTSBURGH, PENNSYLVANIA

It is well known that about 5 percent of the population accounts for 50 percent of health spending. In early 2015 UPMC Health Plan embarked on an ambitious effort to address this problem. 20


UPMC’s integrated community team addresses the needs of high-risk members with complex medical, behavioral and psychosocial needs. The Allegheny County area where the team is initially focused includes an estimated 3,500 members who meet the entrance criteria, based on rates of hospitalization, readmission or other markers of unstable health. “All of these members are quite medically ill. Many have a number of chronic illnesses where care is not well coordinated, and their self-management skills are not what they should be,” explains James Schuster, M.D., MBA, vice president of behavioral integration for UPMC Insurance Division, and chief medical officer for Community Care Behavioral Health Organization.

The traditional approach of telephone outreach is not typically enough support for people with complex challenges that are often compounded by substance abuse and psychosocial stressors, say Schuster. UPMC’s community team serves as a face-to-face case manager that educates and supports patients, and connects them with health care and community resources.

“We want to let them describe the problem, and build the plan from there.” – James Schuster, M.D., MBA, Vice President of Behavioral Integration for UPMC Insurance Division, and Chief Medical Officer for Community Care Behavioral Health Organization

The team includes social workers, community health workers and nurses who engage with a hospitalized member to identify the reasons for high medical and psychosocial needs, and proactively work to address those root causes after discharge. Team members visit patients at home or in the community, and collaborate with them to develop a plan of care that has meaning and relevance for the patient. “It can sometimes be hard to engage people to talk about their blood sugar or their breathing,” says Schuster. “But if you talk with them about how their health limits their life, it can be more successful. We want to let them describe the problem, and build the plan from there.”

Leading Positive Change

The team can connect patients with additional supports from other sources to address problems such as housing or poor nutrition. The goal is to establish a robust and realistic care plan, and forge a stronger connection between the patient and his or her primary care physician in order to follow that plan. Schuster says, “This is hard work that requires a lot of thought, work, planning and ongoing effort. But we think it is best for patients and, ultimately, for the health care system too.”

Creative Collaboration Supports Seniors Priority Health GRAND RAPIDS, MICHIGAN

As the baby boom generation ages, the health system will be stretched to provide care for unprecedented numbers of older patients. Priority Health has prepared for this eventuality by creating an innovative program to keep at-risk seniors at home longer.

Targeted specifically at seniors with multiple chronic care and social needs, the program, called Tandem365, is a collaboration among Priority Health, an ambulance company and four local non-profit skilled nursing facilities (SNF) that also wanted to move more care delivery into patients’ homes.

“This model differs from more traditional home-based programs,” explains Mary Cooley, R.N., BSN, M.S., associate vice president, care management and operations. “Tandem365 focuses on people whose social burdens make it especially hard for them to access care: factors like Leading Positive Change

isolation, frailty, poverty and lack of transportation.”

The SNFs brought an ambulance company into the partnership to explore whether or how emergency medical technicians (EMT) could use their specialized skills to provide some services in the home. This required the state of Michigan to grant EMTs the right to coordinate some in-home care with Tandem’s medical directors. “Previously the state mandated that when an EMT responds, he or she must transport the patient to a hospital,” says Cooley.

When Priority Health refers patients to Tandem365, a nurse and social worker collaborate with the primary care physician to assess the patient’s medical, behavioral and social needs. The goal is to create a “life plan” through which Tandem365 can support patients as long as they wish, rather than during a short time of acute need.

The Tandem365 team provides direct care to patients in their homes and also coordinates additional support from community and volunteer organizations, such as meal delivery, transportation to doctors’ appointments, chore services, adult day care and personal aides. The Tandem365 nurse or social worker accompanies the patient to doctors’ appointments or meets him or her in the emergency department to provide management and coordination. Claims data for 53 members before and after they joined Tandem365 show a 38 percent decrease in inpatient stays; 52 percent drop in emergency department visits; 46 percent fewer specialty visits; and a 35 percent reduction in the total cost of care. “We think this model is heading in the right direction,” says Cooley. “The patient satisfaction rate is high, and the doctors are thankful their patients have this kind of help. There are huge benefits to keeping people at home.”

Comparative data that examines patients before and after enrollment in Tandem365 show significant reduction in emergency room visits, acute inpatient stays and specialty visits, as well as a 34.7 percent decrease in per-member-per-month (PMPM) costs. This data is based on an analysis of 53 patients. Acute Inpatient Stays per 1,000 Member Months

98

ER Visits per 1,000 Member Months

Specialty Visits per 1,000 Member Months

2,449

273 61

Allowed Amount PMPM

$4,264 1,318

131

Pre

Post

Decreased 37.7%

Pre

Post

Decreased 52.1%

$2,785

Pre

Post

Decreased 46.2%

Pre

Post

Decreased 34.7%

Source: Priority Health Alliance of Community Health Plans

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Tribute to Patricia Smith President and Chief Executive Officer, 2006–2015 Vice President, Policy, 2001–2004

Under Patricia Smith’s strong and steady leadership, ACHP has grown not only in size — nearly doubling during her tenure as president and CEO — but also in depth, effectiveness and influence. She has built highly productive teams and led and supported innovative work that has improved both health and health care nationwide.

In March 2015, Smith announced her plans to retire at the end of the year. She leaves an organization that is exceptionally well equipped to continue leading the transformation of health care.

“ACHP’s ability to navigate during these challenging times is reflected in Patricia Smith’s steadiness and constancy. The role of a great CEO is to leave the organization stronger than when she started, and she has more than fulfilled that. She has led ACHP to a position of great strength for the future.” – Patricia Richards President and CEO, SelectHealth Chair, ACHP Board of Directors

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ACHP’s most noteworthy accomplishments under Smith’s leadership fall into the following categories:

LEARNING AND INNOVATION. Working with clinical leaders, ACHP has created an influential learning network that has served member plans and helped shape national policy, particularly in the area of alternative payment strategies and performance incentives. PERFORMANCE EXCELLENCE. ACHP has developed sophisticated tools that help member plans assess and improve their performance in clinical care, access, customer satisfaction and affordability. PUBLIC POLICY. With strong leadership from the ACHP Board of Directors, Smith built the organization’s lobbying capability and visibility in Congress and the Administration. Today ACHP is a recognized player on Capitol Hill and within the Centers for Medicare and Medicaid Services and the Department of Health and Human Services, and respected as an advocate for our member organizations and an important resource for best practices on integrated delivery of care, payment models that encourage high performance and customer value.

VALUE. Smith’s team has advocated for and achieved value-based payment in Medicare Advantage, and ACHP member organizations are recognized for their national leadership in quality, care delivery and payment innovation.

Smith’s outstanding leadership has been marked by foresight, clarity and steadiness amid the turbulence of the health care landscape. Her drive toward excellence never obscured her personal warmth. Her many admiring co-workers and colleagues will miss her, but her dedication on behalf of all those served by our health care system will be her enduring legacy.

ACHP Board of Directors John Bennett, M.D. President and CEO Capital District Physicians’ Health Plan

Bruce Nash, M.D. Senior Vice President, Medical Affairs and Chief Medical Officer Capital District Physicians’ Health Plan John Hogan President and CEO Capital Health Plan

Nancy Van Vessem, M.D. Chief Medical Officer Capital Health Plan Scott Clement Interim President and CEO CareOregon Patrick Curran President and CEO CareOregon Frank Lucia President and CEO Dean Health Plan

Richard Burke Interim President and CEO Fallon Health W. Patrick Hughes President and CEO Fallon Health

Steve Youso President and CEO Geisinger Health Plan

Scott Armstrong President and CEO Group Health Cooperative

Mark Huth, M.D. Interim CEO and Chief Medical Officer Group Health Cooperative of South Central Wisconsin Mary Brainerd President and CEO HealthPartners

Michael Cropp, M.D. President and CEO Independent Health Thomas Foels, M.D. Chief Medical Officer Independent Health

Anthony Barrueta Senior Vice President, Government Relations Kaiser Foundation Health Plan, Inc. For Bernard J. Tyson Chairman & CEO Kaiser Permanente

David Howes, M.D. President and CEO Martin’s Point Health Care Angela Huschka Interim President and CEO New West Health Services

Sharon Levine, M.D. Director and Senior Advisor for Public Policy, Pharmacy, and Professional Development The Permanente Federation Lisa Lujan President Presbyterian Health Plan

Michael Freed President and CEO Priority Health

Steve ErkenBrack President and CEO Rocky Mountain Health Plans

Marinan Williams Interim President and CEO Scott & White Health Plan Julie Brussow Chief Executive Officer Security Health Plan Patricia Richards President and CEO SelectHealth

Paul Kasuba, M.D. Senior Vice President and Chief Medical Officer Tufts Health Plan James Roosevelt, Jr. Chief Executive Officer Tufts Health Plan Jim Eppel President and CEO UCare

Diane Holder President and CEO UPMC Health Plan

Patricia Smith, ex officio President and CEO ACHP


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ACHP Member Organizations Capital District Physicians’ Health Plan Albany, New York www.cdphp.com

Capital Health Plan Tallahassee, Florida www.capitalhealth.com

CareOregon

Portland, Oregon www.careoregon.org

Dean Health Plan Madison, Wisconsin www.deancare.com

Fallon Health

Worcester, Massachusetts www.fchp.org

Geisinger Health Plan Danville, Pennsylvania www.thehealthplan.com

Group Health Cooperative Seattle, Washington www.ghc.org

Group Health Cooperative of South Central Wisconsin Madison, Wisconsin www.ghcscw.com

HealthPartners

Minneapolis, Minnesota www.healthpartners.com

Independent Health

Buffalo, New York www.independenthealth.com

Kaiser Permanente: Kaiser Foundation Health Plan and The Permanente Federation Oakland, California www.kp.org

Martin’s Point Health Care Portland, Maine www.martinspoint.org

New West Health Services Helena, Montana www.newwestmedicare.com

Presbyterian Health Plan Albuquerque, New Mexico www.phs.org

Priority Health

Grand Rapids, Michigan

www.priorityhealth.com

Rocky Mountain Health Plans Grand Junction, Colorado www.rmhp.org

Scott & White Health Plan Temple, Texas www.swhp.org

Security Health Plan Marshfield, Wisconsin www.securityhealth.org

SelectHealth

Salt Lake City, Utah www.selecthealth.org

Tufts Health Plan Watertown, Massachusetts www.tuftshealthplan.com

UCare

Minneapolis, Minnesota www.ucare.org

UPMC Health Plan

Pittsburgh, Pennsylvania www.upmchealthplan.com

*This map reflects 2014 enrollment data collected through AIS’s Health Plan Directory as well as data submitted by members to ACHP. Orange shading indicates those states in which ACHP member plans do business. 24


ACHP Year in Review: Contributing Value to Our Members and Their Communities In 2015, ACHP and its members improved the health of the communities we serve and actively led the transformation of health care to promote high-quality, affordable care and superior consumer experience. ADVOCATING SOUND PUBLIC POLICY

ACHP draws on our relationships on Capitol Hill and in the Administration to achieve our public policy and lobbying goals. We meet regularly with CMS/HHS officials and congressional staff and leaders; we also routinely connect our member plans with the appropriate CMS staff to facilitate problem solving on individual plan issues.

Protecting Medicare Advantage Star Ratings and Funding

ACHP and its member plans are the leading advocates for the long-term importance of the Medicare Advantage (MA) Star Ratings system and quality incentive payments. Through formal regulatory responses, meetings with key congressional committees and agencies, and other communications, we promote stability and transparency in the star ratings and oppose changes that are not in the best interest of quality improvement.

We continue to work with Congress and the Administration to minimize the impact of the MA “benchmark cap,” which reduces quality incentive payments to 4- and 5-star plans. These payments have augmented basic Medicare payments to ACHP plans by more than $3.4 billion since they began in 2012, in turn allowing members to increase benefits to enrollees. ACHP has joined with our plans in a lobbying effort aimed at both CMS/HHS and Congress to allow MA plans to offer telehealth-enabled services as part of the core benefits package — something already recognized in commercial and other lines of business.

are wholly exempt from the tax. The provisions for tax-exempt plans reduce the tax from an estimated 1.35 percent of premium revenue to an estimated 0.8 percent — a reduction from $1.35 million to $800,000 for every $100 million in premium revenue.

Providing ACA Guidance and Additional Support As ACA exchanges become a more important part of business, we keep members updated on new and proposed guidance from CMS, help members solve problems and facilitate shared learning sessions on implementation strategies.

Additional policy and lobbying efforts help members achieve mission and business goals on issues such as tax-exempt status, risk adjustment, provider network requirements, premium tax, industry mergers and others.

SUPPORTING LEARNING AND INNOVATION THAT YIELD RESULTS

To help our members continuously improve health and health care and reduce costs for organizations and communities, ACHP facilitates collaboration and rapid learning. Helping member organizations address the requirements of the new health economy and demonstrate what differentiates them from competitors is central to ACHP’s mission. We focus on health care affordability, emerging consumer needs, innovation within and outside the health care industry, leadership and effective analytics.

Reducing Tax Burdens

Providing Peer Support and Resources to Help Plans Compete Effectively

A tax on health insurance premium revenue took effect in 2014, and ACHP member organizations benefit from our long-standing support of provisions that exempt 50 percent of the revenue earned by tax-exempt health insurers. Non-profit insurers deriving at least 80 percent of revenue from Medicare and Medicaid

The ACHP Board of Directors’ initiative, Marketplace Competiveness and Sustainable Costs, allows CEOs and other senior executives from member organizations to discuss their goals and most pressing challenges, successes and failures in their efforts to reduce cost and compete in an increasingly complex environment. Alliance of Community Health Plans

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ACHP develops and continually refines analytic tools and other information resources to support members in their cost-reduction goals, including online profiles of member initiatives that have yielded lower costs and sustained or improved quality, learning groups on a variety of issues including strategies for member engagement and collaboratives on complex care management, pharmacy and behavioral health issues.

HELPING OUR MEMBERS SUCCESSFULLY COMPETE IN THEIR MARKETS

ACHP resources help members successfully compete in their markets. Shared learning, quality performance, market intelligence and member inventories are all part of ACHP’s toolbox. As a part of this work, ACHP engages senior marketplace and operations executives, quality leaders and MA leaders.

Offering Powerful Benchmarking and Analytic Tools

ACHP gives member plans access to our premier quality benchmarking tool, the HealthPlan Performance Gauge®. This set of custom analytic tools allows plans to dissect their National Committee for Quality Assurance Health Insurance Ratings and CMS Medicare Advantage Star Ratings precisely and target improvement areas. The Medicare Star Ratings Gap Analysis enables plans to target improvement efforts where they are most needed. It provides a customized examination of performance gaps and opportunities for individual plans and models the impact of improving individual measures on the overall star rating for a plan.

At our Marketplace Focus meetings and on monthly marketplace issues calls, member plan leaders explore the unique challenges and opportunities for community health plans in an evolving market, experiences with state and federal exchanges and ways to create a strong value proposition for consumers.

In ongoing member discussions, we examine the implications of market consolidation (provider and insurer) for both the industry at large and regional plans in particular. We consider ways that ACHP member organizations can collaborate to create a more distinctive value proposition in their markets based on member experience, quality and affordability.

COMMUNICATING TO AND ABOUT OUR MEMBERS Illuminating Issues and Successes

ACHP’s goal is to promote our plans’ mission-driven focus, distinctive performance, emphasis on innovation and ability to meet consumer and community needs through close partnerships with patients, health care providers and community leaders. In the increasingly competitive health care environment, ACHP plans have unique capabilities that consumers and purchasers seek. ACHP provides a unified voice for our members on these important attributes.

By maintaining a regular public presence — through reports, briefings, webinars, op-eds and other means — ACHP generates visibility for our member plans and is an important resource for thought leaders and political and industry audiences. ACHP is a leading voice on prescription drug costs with the publication of two infographics highlighting irrational drug pricing for diabetes and multiple sclerosis medications; two external webinars on drug costs featuring ACHP leaders; and a “fly-in” during which many of our plans’ pharmacy directors met with key Hill, CMS and MedPAC staff. ACHP released Telehealth: Helping Patients Access Care When and Where They Need It and held a national webinar for health care leaders. The report highlights the effective use of technology by six ACHP plans to supplement traditional health care visits and service. The report was timed to inform ongoing policy discussion about Medicare Advantage coverage of telehealth services.

ACHP provides high value for our member organizations by selectively focusing our talent and expertise on issues that have particular significance for regional, delivery-aligned plans. We create learning opportunities and facilitate best-practice collaboration; lobby and advocate on our members’ behalf; provide quantitative and qualitative research and data analysis to help members improve performance and understand their markets; and promote the value of mission-driven, high-quality health plans. 26


Top-Performing Plans In the 2015–2016 National Committee for Quality Assurance (NCQA) ratings of health plans, ACHP member plans make up seven of the nine Medicare plans rated a 5, eight of the eleven commercial plans rated a 5 and the only Medicaid plan rated a 5. NCQA’s measurement drives quality improvement that directly affects more than 171 million Americans nationwide. Health plans are rated based on clinical performance, member satisfaction and NCQA accreditation.

Eight members of ACHP earned 5 stars from the Centers for Medicare and Medicaid Services (CMS), the highest score awarded to health plans participating in the Medicare program. Only twelve plans (contracts) in the country received this rating. Overall, 30 ACHP Medicare plans (contracts) that offer combined Medicare Advantage (Part C) and prescription drug (Part D) coverage received 5, 4.5 or 4 stars in the star ratings. Additionally, one plan offered by an ACHP member received 5 stars for its stand-alone Medicare plan (Part C).

ACHP Plans Receiving a Rating of 5 on the 2015–16 NCQA Health Insurance Plan Ratings Commercial/Private Capital District Physicians’ Health Plan (HMO)

Capital District Physicians’ Healthcare Network (HMO/POS)

Kaiser Foundation Health Plan of Northern California (HMO)

Kaiser Foundation Health Plan of the Mid-Atlantic States (HMO) Tufts Associated Health Maintenance Organization (HMO/POS) Tufts Benefit Administrators (PPO)

UPMC Benefit Management Services (HMO) UPMC Health Coverage (HMO) Medicare

Capital Health Plan (HMO)

Group Health Plan (Cost) (HealthPartners) (HMO) Kaiser Foundation Health Plan of Georgia (HMO)

Kaiser Foundation Health Plan of Northern California (HMO) Kaiser Foundation Health Plan of Southern California (HMO)

Kaiser Foundation Health Plan of the Mid-Atlantic States (HMO) Kaiser Foundation Health Plan of the Northwest (HMO) Medicaid

Kaiser Foundation Health Plan – Hawaii (HMO)

ACHP Plans Receiving 5 Stars for Their Combined Medicare Advantage and Part D Plans HealthPartners

Kaiser Permanente California Kaiser Permanente Colorado Kaiser Permanente Hawaii

Kaiser Permanente Mid-Atlantic Kaiser Permanente Northwest Martin’s Point Health Care Tufts Health Plan

ACHP Plan Receiving 5 Stars for its Stand-Alone Medicare (Part C) Plan Dean Health Plan


27

ACHP Staff Lindsay Arrington Innovation Programs Associate [email protected] Kris Aulenbach Consultant and Symposium Manager [email protected] Karlee Averett Communications Specialist [email protected]

Mae Beasley Senior Administrative Coordinator, Policy and Operations [email protected] Holly Bode Director, Public Affairs [email protected] Sophia Bushong Executive Assistant [email protected]

Stephen Cox Manager, Business Improvement Programs [email protected]

Lynne Cuppernull Director, Clinical Learning and Innovation [email protected] Toni Fanelli Manager, Board and Administrative Operations [email protected]

Matthew Fuentes Clinical Learning and Communications Specialist [email protected]

Zoya Haroon Administrative Coordinator, Communications and Public Affairs [email protected] Michael Ly Legislative and Policy Associate [email protected]

Michelle McLean Chief of Staff and Director, Human Resources [email protected]

Front row, left to right: Christine Shen Moreschi, Lindsay Arrington, Jennifer Sulkin, Mae Beasley, Patricia Smith, Michelle McLean, Rachel Schwartz, Howard Shapiro, Holly Bode Back row, left to right: Desiree Wilson, Michael Ly, Matthew Fuentes, Chloe Stier, Adam Zavadil, Stephen Cox, Karlee Averett, Zoya Haroon, Sophia Bushong, Toni Fanelli Not pictured: Kris Aulenbach, Lynne Cuppernull 28


Christine Shen Moreschi Controller [email protected]

Rachel Schwartz Manager, Communications and Public Relations [email protected] Howard Shapiro Director, Public Policy [email protected] Patricia Smith President and CEO [email protected] Chloe Stier Business Analyst [email protected]

Jennifer Sulkin Manager, Innovation Programs [email protected]

Desiree Wilson Administrative Coordinator, Clinical Learning and Innovation [email protected] Adam Zavadil Director, Market Strategies and Analysis [email protected]

About ACHP The Alliance of Community Health Plans (ACHP) is a national leadership organization bringing together innovative health plans and provider groups that are among America’s best at delivering affordable, high-quality coverage and care. ACHP’s member health plans provide coverage and care for more than 18 million Americans. These 23 organizations focus on improving the health of the communities they serve and are on the leading edge of innovations in affordability and quality of care, including primary care redesign, payment reforms, accountable health care delivery and use of information technology. Our Mission

ACHP and its members improve the health of the communities we serve and actively lead the transformation of health care to promote high-quality, affordable care and superior consumer experience. ACHP plans enroll over 18 million Medicare, Medicaid and commercial members in 29 states and the District of Columbia.

We realize our mission by:

Providing a forum to solve our members’ most pressing challenges. Advocating for better health and health care.

Developing quantitative and qualitative tools to improve performance and meet marketplace challenges. Building the evidence base for health care improvement.

ACHP members are:

Not-for-profit health plans or subsidiaries of not-for-profit health systems, or provider groups associated with health plans. Member organizations are located primarily in mid-sized and smaller markets and have deep roots in their communities. National leaders in health care quality that annually rank among the topperforming health plans in the nation. Innovators in delivering affordable, coordinated, multidisciplinary care, and pioneers in the use of electronic health records.

Role models for other health plans in innovating to achieve the industry’s Triple Aim — better health, better care, at a lower cost.

Many thanks to ACHP member plans for supplying photos for this report. Writer: Ann B. Gordon | Designer: Dinsmore Designs ALLIANCE OF COMMUNITY HEALTH PLANS

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ALLIANCE OF COMMUNITY HEALTH PLANS 1825 Eye Street, NW, Suite 401 • Washington, DC 20006 Phone: 202-785-2247 • E-mail: [email protected] • www.achp.org

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