"Thank you, Chairman Collins, Ranking Member Casey, and members of the
"My name is Dr.
"I earned my medical degree from
"I began my medical career as a family physician serving the rural, island fishing community of
"This experience has taught me the power of primary care in improving health outcomes and reducing the cost of care. I brought this philosophy to
"As a not-for-profit health care organization serving our local population, offering both primary care and health insurance coverage, we are uniquely positioned to deliver the highest quality care at the lowest cost with the best overall experience for our patients and members. In fact, we are long-standing members of the
"In addition, an increasing number of our seniors are chronically ill. Adding to the complexity of this issue, 31 percent of our senior population lives below 200 percent of the poverty line and 51 percent live in rural areas (Cubanski, Casillas, & Damico, 2015).
"In the nation's most rapidly aging state,
"Because many of our senior health plan members also receive care as patients in our practices, we have unique access to both their health record and claims/utilization data. Through the use of clinically oriented data analytics--a cutting-edge function complete with a dedicated team of data scientists and distributed analysts--we glean the information we need to support our chronic disease management and care coordination efforts for our most vulnerable seniors. We then use additional data to drive performance and track overall progress.
"Below you will find several examples of innovative programs and methods of care we have developed to support the seniors we serve. At Martin's
PROGRAMS AND METHODS OF CARE
Addressing Quality: Annual Quality Metrics
"In 2018, Martin's
"This integrated set of quality measures includes five areas of focus to deliver evidence-based care for adults and seniors:
* Annual physicals
* Diabetes recommended testing (retinopathy screening; nephropathy screening; HbA1c screening 2x/year)
* Breast cancer and colorectal cancer screenings
* Hypertension management
* Medication adherence for cholesterol management
"As 2018 is the first year following these measures, we are still in the evaluation phase of these efforts. To date, we have met most targets through the second quarter of 2018 and are on track to meet our third quarter targets.
"The combined quality measures are also one-quarter of our annual staff incentive plan, creating motivation and reward for performance of our providers who directly support better health outcomes for our patients and members.
"In addition to the preventive health benefits of these quality measures, we have also found they create a meaningful touch point with our members. For example, interns from local colleges recently made outreach phone calls to our members overdue for preventive care visits. The simple act of calling and connecting was appreciated by many of our members--showing that someone cared enough to talk with them about their health.
""Ever since I started seeing my Martin's
""I have had my Martin's
Diabetes Care Management
"The Martin's Point Diabetes Care Management program was created to improve quality of life and health outcomes for our members living with diabetes. Through member engagement, care management, and the removal of barriers, the program works to improve quality, manage disease progression, and reduce costs.
"Martin's Point Health Plan Diabetic Population:
* 21 percent of our 2017 total health plan population have diabetes.
* They account for 32 percent of our health plan medical costs.
* 70 percent of these members have at least one of the following comorbid chronic conditions: chronic obstructive pulmonary disease, congestive heart failure, and coronary artery disease (most notably with CAD present in 32 percent).
"2017 Utilization and Cost of Care Data:
* Across all members, 31 percent of ER visits and 36 percent of inpatient admissions were those of diabetic members.
* Those who were readmitted within 30 days of discharge represented 44 percent of all health plan membership readmissions.
* The average fee-for-service cost per diabetic member was 73 percent higher than a member without diabetes in 2017.
"The health plan has three ways it addresses diabetic members' quality and cost of care:
1. Member Engagement: We mail a "diabetic scorecard" to members to share their completion/need for annual recommended preventive screenings and tests to help them track progress with their primary care provider (PCP). We follow up with members who are behind on their screenings and tests.
"Provider Engagement: Network providers are engaged via regular newsletters and reminders regarding quality-of-care gaps, as well as quality incentive payments, for the diabetic population.
2. Care Management: We deploy health plan nurse care managers to assist with individual diabetic members' needs. Generations Advantage Focus DC (diabetes care) Plan Members: This plan is a Medicare Advantage Chronic Condition Special Needs Plan (C- SNP) targeting care and services to individuals with diabetes. Qualified members are assigned a care management nurse who develops a holistic care plan and coordinates care with their PCP and care team, a pharmacist, medical director, social worker, specialists, and other community providers.
"The care plan contains SMART (specific, measurable, achievable, relevant, timebound) goals and interventions that meet the member's needs and provides a framework for monitoring. Care managers use motivational techniques to help members identify barriers and develop interventions, fostering self-management skills enabling members to achieve incremental accomplishments while improving their well-being and health.
"An annual interdisciplinary care team (ICT) meeting assesses current state and sets goals. PCPs are in-network, ensuring adherence to nationally-recognized clinical protocols which are used for their care. Social workers assist with an emphasis on addressing behavioral health and social well-being. A clinical pharmacist provides a comprehensive medication reconciliation and review, identifies adherence and cost barriers. The Medical Director is on site and present at the ICT meetings to provide medical direction, if needed. Members and providers are also invited to join the ICT to promote engagement and alignment.
"Other Generations Advantage Plan Members: All Martin's Point Generations Advantage members are eligible for services as part of our Care Management program focused on chronic diseases. Diabetic members can enroll based on their diagnosis, or any other chronic comorbid illness. Care managers work with members, both in their homes and telephonically, to close gaps in care, reduce risk for complications and progression, and decrease ER and hospitalization utilization. These nurses focus on helping members achieve their goals by providing diabetic self-management education, aiding in navigating community resources, and ensuring collaboration between PCP and specialty providers.
3. Removing Barriers to Care:
"Access to Care: Better diabetic and preventive care occurs when members have regular visits with their PCP. When data shows these visits have not taken place, or that gaps in care persist after visits, we offer health-plan-sponsored mobile health visits or in-home nurse practitioner visits to provide recommended preventive screenings and tests to members with limited access to care. The visits include point-of-care testing including diabetic eye exams, A1C testing and overall health risk assessments. We always recommend the member return to their PCP for follow-up care.
"Medication Adherence: Pharmacy claims data is used to identify members who may not be taking oral diabetic, statin and ACEI/ARB medications as directed. Written and telephonic outreach from pharmacists, pharmacy residents, and senior pharmacy students remind members of the importance of medication adherence and provide guidance in the case of cost or other barriers. Similar outreach and information is shared via mail with diabetic members' provider offices.
"Pharmacy Data and Trends:
"The three pharmacy outcomes we measure are:
* Non-insulin diabetic medication adherence
* Angiotensin Converting Enzyme Inhibitor(ACEI)/Angiotensin Receptor Blocker (ARB) medication adherence
* Statin use in patients with diabetes
"Health plan pharmacy outreach efforts have yielded an average of 2 percent increase in adherence in the above measures on a year-over-year basis following implementation.
"Quality Data and Trends:
"Key diabetic quality-of-care measures are: rates of retinopathy screening, nephropathy screening, and blood sugar control (measured by A1c < 9). Our 2017 Healthcare Effectiveness Data and Information Set (HEDIS) sample performance data for these are as follows:
* Diabetic eye exam: 86 percent
* Kidney disease monitoring: 95 percent
* Blood sugar controlled: 88 percent
"Health plan interventions have yielded positive results on these measures. When the plan launched the diabetic scorecard to engage and educate members, all three measures increased by a range of 2 to 5 percent. Similarly, our efforts to engage members and eye care providers to schedule diabetic exams yielded a 2 percent increase in year-over-year performance.
"Care Management Data and Trends:
"Diabetic members engaged in care management have shown a greater than 10 percent reduction in 12 month pre- versus post-program enrollment for
"Inpatient admissions rates and inpatient cost reductions have shown similar success with a greater than 30 percent decrease in 12 month pre- versus post-program results.
Home-Based Care: Comprehensive Care Program
"The program, implemented through our partnership with
"Comprehensive Care Program nurses are community-based and trained to the advanced preventive model developed at
* Provide personalized health assessments, education, and support
* Teach the individual to manage their chronic health conditions
* Encourage the individual to receive preventive care and services to lower the risk of complications
* Monitor and work with the member's doctors as needed
* Visit the member at home or wherever they receive care (rehab, hospital)
* Go with the member to doctors' visits and coordinate follow-up care
* Help to manage medications and treatment plans
* Provide an individualized action plan based on the member's goals to stay healthy
* Assist with long-term planning to help the member stay as independent as possible
"Exceeding expectations, 54 percent of invited members are accepting our nurses into their home for the first visit and then inviting them back again and again.
Embedded Nurses: Integrated Care Connection Program
"Another way we care for our senior population is by embedding nurse managers in our primary care practices to help manage complex care, advocate for our patients and doctors, and help patients navigate an increasingly complex healthcare system. In 2016 we launched our Integrated Care Connection (ICC) Program, which is designed to improve the coordination of care for Martin's
"ICC nurse care managers partner directly with participants and their health care providers to ensure participants get the best care possible from everyone who is involved in delivering care. ICC nurse care managers work to promote participant well-being in a number of ways, including:
* Working to develop realistic health goals
* Coordinating care by sharing participant health information with other providers or facilities in the community
* Helping to manage medications
* Supporting participants, and their families/support systems, as they manage their medical conditions
* Identifying and reducing barriers to getting the care needed
* Facilitating and conducting advance care planning and end-of-life discussions
* Closing gaps in care and promoting preventive health care
"The trusting relationship formed between participant and nurse care manager is a core component of the program. Many patients face social barriers, including isolation and loneliness. The nurse care manager focuses on building both autonomy and community connections, while honoring the participant's personal goals.
* Collaborative office visit with patient, PCP, ICC nurse care manager
* Access through face-to-face and telephonic support
* Core components to guide conversations and educate
* ICC nurse care manager and patient develop patient-defined goals and action planning
Topics of Discussion Between Nurses and Their Patients
* Symptom-response plans
* ER use and inpatient hospital services
* Monitoring health at home
* Meal planning
* Adding activity
* Managing medications
* Recommended testing and follow-up appointments
* Emotional health
* Advance care planning
* Smoking and substance use
* Barriers to care
* Support systems
* 59 percent of those invited agreed to participate
* Up to 65 percent decrease in emergency room utilization
* A significant decrease in hospitalizations, number of inpatient days, and no readmissions for our graduated group
""I just feel so spoiled and attended to! It's almost like 40 years ago when the doctor knew you and insurance companies didn't rule a physician's practice. My ICC nurse care manager makes a BIG difference. I KNOW how big the practices are and I don't expect this sort of attention. I LIKE it but I don't expect it."
""Thank you so much for being such an important part of my Mom's health care. I don't know what we would do without you!"
""Pt successful in remaining tobacco free for 8 months, despite smoking since an early age of 13. Has also recently lost weight. He has done well with an established trusted practice contact and ongoing support (by ICC nurse care manager)."
""With (ICC nurse care manager's) diligent and compassionate care our mutual patients have done SO VERY WELL!!!"
""The ICC nurse care manager researches the patient and prepares the visit so well that they are now well cared for during and between visits."
""The ICC nurse care manager helps the patients feel engaged. Patients love her and the extra attention."
"Reflections from our ICC nurse care manager, Christina:
""One of the unfortunate realities of modern medicine is that care is often fragmented.
"Patients receive care from multiple providers, from different systems, including the
"Medication errors are one of the leading causes of adverse events and readmissions. As part of the Integrated Care Connection (ICC) program, we can reconcile medication lists from various providers, review what the patient is actually taking, remedy errors, and help with cost issues. We then provide the patient with a corrected medication list, ensure they understand it, and empower them to carry it with them and advocate for themselves.
"We are able to facilitate care and help patients and families navigate the medical system. For example, I was able to help a veteran and his family, who were overwhelmed, contact the
"We are fortunate to have the time to develop relationships with patients and families, get to know them as people, understand their goals, concerns and questions, and facilitate communication with the health care team.
Staying on Top of Trends: Congestive Heart Failure Pilot Program
"While representing only 3 percent of the total health plan population, members with CHF accounted for 28 percent of the total health plan inpatient hospitalizations in 2017. This represented the highest hospitalization rate of any of the plan's chronically ill population, including those with CAD, COPD, diabetes and asthma. In addition to having the highest hospitalization rate of any chronically ill cohort, the CHF population experienced the most rapid month-over-month increase in hospitalizations, averaging a 5 percent month-over-month hospitalization rate increase from 2015-2018.
"The hospital costs on the health plan side were unusually high. In 2017, the average health plan medical cost of a 65+ year-old member with CHF was over three times that of a similar member without CHF. Even more striking were the stories of human suffering--patients not understanding their conditions or triggers and, as a result, being displaced from their homes when hospitalized, sent to an unfamiliar rehabilitation unit and then back home only to end up returning to the hospital. The situation was a revolving door of confusing and disruptive moves.
"In response, we pulled a multidisciplinary team of leaders and technical experts together to perform a root-cause analysis. The group was led by senior clinical staff (medical directors from plans and practices, nurse and nurse practitioners, embedded care managers from the practices, pharmacist leaders, primary care physicians and a cardiologist). The team focused on creating goals to decrease hospitalization, reduce medical expense, and improve quality of life.
"Leveraging the in-home assessment/care team model we had initiated through our association with
* Each member would have at least one in-home assessment
* A full medication reconciliation would be completed while in the home
* Each member would be offered telemonitoring devices
* Each member would receive a CHF educational packet
"The CHF Pilot Program launched in
"After six months, the CHF pilot team from the delivery system and the health plan met to review preliminary outcomes, discuss success stories and opportunities. The decision was made to extend the pilot program.
"Through this combined effort, we learned that most of our patients and members were lacking basic information on their health conditions, use of their medications, and the triggers for their conditions. Most importantly for them is developing a "symptom response plan" that allows them to act earlier and more effectively to prevent an acute worsening of their condition. We checked in with them more frequently--by phone and in-person. We arranged closer follow up with their doctors.
"Our program's approach had yielded improvements in members' medication adherence, and decreased hospital admissions and readmissions. Preliminary outcomes included:
* 3 Months pre-engagement: 69.7 percent
* During engagement: 86.2 percent (23.6 percent improvement)
* 3 Months pre-engagement: 126
* During engagement: 115 (8.7 percent improvement)
* 3 Months pre-engagement: 63
* During engagement: 20 (68.2 percent improvement)
ER Visits Per 1000
* 3 Months pre-engagement: 81
* During engagement: 115
"While we did not see a large reduction in use of the emergency room, we did find a significant reduction in hospitalization rate. We are able to intervene earlier and provide participants with a better quality of life while also keeping them in their home. With these preliminary findings in mind, our two case managers did additional home visits in
* Provide additional education about the disease process
* Complete a full medication reconciliation and collaborate with the PCP and pharmacist, as needed
* Provide information on urgent care centers and walk-in clinics in the
"We have identified that not all emergency room visits for these members are related to CHF. This has underscored the need to understand individual members' barriers to primary and urgent care, and to educate members on their care options during and after normal business hours.
"The in-home component of the pilot was extremely helpful for the case manager, especially in identifying safety concerns, allowing a first-hand view of the member and how they function in their environment. This built additional trust with the member and provided a strong opportunity for the nurse to gain additional understanding of how their social needs impact their overall health.
"Another key finding in this work was our recognition that many patients with advanced heart failure had not had conversations about advance directives and few, if any, had conversations about palliative approaches as they near the end of their lives. As a result, we are now piloting a palliative care program that will support those conversations and allow patients to understand all the options available to them.
In-Home Telemonitoring: Congestive Heart Failure
"For our health plan members with congestive heart failure, we offer an in-home telemonitoring program. This program encourages members to be active participants in their health care by promoting self-management and reinforcing positive behavior, increasing their ability to stay independent in their home. It provides both the member and family peace of mind, knowing they are being monitored and that their health care providers are promptly informed of changes.
"We implemented this program in 2014 and have enrolled 711 members to date--an average of 16 new members per month. In 2017, we averaged 280 members per month and in 2018 that number has jumped to 293 members per month.
Promoting Medicare Benefit and Clinical Strategy Alignment: Opioid Management
Comprehensive Opioid Management Strategy
* Formulary design and management that promote appropriate utilization
* Drug utilization review, both at the time of filling a prescription and retrospectively by pharmacists at Martin's
* Care coordination by care managers and social workers working with physicians and other health care professionals
* Providing access to medication-assisted treatment (MAT)
* Data collection and analysis to assist in conversations with health care providers and identify populations and/or geographies where action is needed
"Using these opioid strategy elements, Martin's
Leveraging Medical Benefit Design
"As we continue to look at opportunities to assist our population in the management of opioid utilization and opioid use disorder, one key consideration is how to align medical benefits and offerings with the clinical needs of the population. The
"To remove barriers to prevent and alleviate opioid overuse, we are reducing member costs and adding additional supplemental benefits. For plans that do not already have
"Most importantly, the new clinically-nuanced benefits require member participation in a plan-sponsored wellness or care management program to incentivize and facilitate member engagement in their care plan and supportive activities. Program components include a behavioral health focus, care coordination, addressing social determinants of health, and member-driven goals and activities for non-opioid pain management.
Opioid Strategy: Looking Forward
"Our success in serving seniors, and all our customers, is directly attributed to our management system. We drew inspiration from the lean health care principles advanced by Dr.
* Developing People
* Deploying strategy
* Managing visually
* Following up
* Standardizing work
"In his book Management on the Mend,
"Leaders throughout Martin's
* Customer focus
* Business acumen
* Learning on the fly
* Process improvement
* Driving for results
* Dealing with ambiguity
"In addition to the core set, Martin's
"For our patients and members, the results of our investment in a lean management system have allowed us to improve the ways we fill prescriptions, schedule patient appointments, and verify accuracy of medical coding. We have not only realized improvements in our day-to-day work, but have also received high marks in recent evaluations from CMS and the
"In all we do at Martin's
* * *
3CDC's Enhanced State Opioid Overdose Surveillance (ESOOS) Program, 16 states reporting percent changes from