Legislature(2009 - 2010)CAPITOL 106
02/17/2009 03:00 PM Senate HEALTH & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| Prevention - a Concept for State Medicaid Programs | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
JOINT MEETING
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
February 17, 2009
3:11 p.m.
MEMBERS PRESENT
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
Senator Bettye Davis, Chair
Senator Joe Thomas
Senator Fred Dyson
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
Representative Bob Herron, Co-Chair
Representative Wes Keller, Co-Chair
Representative John Coghill
Representative Paul Seaton
Representative Sharon Cissna
Representative Lindsey Holmes
Representative Bob Lynn
MEMBERS ABSENT
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
Senator Joe Paskvan, Vice Chair
Senator Johnny Ellis
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
All members present
COMMITTEE CALENDAR
Presentation: U.S. Preventive Medicine
HEARD
PREVIOUS COMMITTEE ACTION
No previous action to record.
WITNESS REGISTER
FRED GOLDSTEIN, President
U.S. Preventive Medicine, Inc. (USPM)
Jacksonville, FL,
POSITION STATEMENT: Presented USPM's medical care management
programs and services.
ACTION NARRATIVE
3:11:07 PM
CHAIR WES KELLER called the joint meeting of the Senate and
House Health and Social Services Standing Committees to order at
3:11 p.m. Present at the call to order were Representatives
Cissna, Seaton, Herron, Coghill, Holmes and Keller.
^ Prevention - a Concept for State Medicaid Programs
Prevention - a Concept for State Medicaid Programs
CHAIR KELLER announced a presentation by Mr. Fred Goldstein of
U.S. Preventive Medicine, Inc. regarding their innovative
approach to preventive health care. Mr. Goldstein served as the
founder and President of Specialty Disease Management Services,
Inc. and Vice President/General Manager of HealthCare USA and
has more than 25 years of experience as a health care executive
managing hospitals and disease-management programs.
SENATOR DAVIS joined the meeting.
3:13:05 PM
FRED GOLDSTEIN, President, U.S. Preventive Medicine, Inc.
(USPM), Jacksonville, FL, invited the members to ask questions
while he works his way through his slide presentation.
3:13:39 PM
SENATOR DYSON joined the meeting.
MR. GOLDSTEIN said USPM brings together people with extensive
backgrounds in health plans, hospital management, chronic care
management, Medicaid programs and commercial programs; they have
over ten years of Medicaid care management experience working in
rural states. They have worked in excess of ten states and over
14 programs in the Medicaid arena, managing everything from
diabetes to HIV/AIDS and sickle cell disease. That experience
includes diverse populations and over 60 different primary
languages; they have worked in very remote communities as well
as in urban areas and have experience working with Native
Americans. USPM currently has national services available and is
setting up an international service opening in the United
Kingdom in April.
Prevention is their only business. As a company, they walk the
walk and live prevention in their workforce around the country;
each one of them feels he is on a mission to create real change
in the health care system and to help individuals improve their
long-term health. Their slogan is "more good years."
3:15:16 PM
Why prevention? The answer is found in a systematic approach
that identifies current and future risks based on key clinical
indicators. The program is clinically based and built upon
clinical metrics to identify individuals' risk factors; they
believe it is important to intervene with effective programs
based upon those factors, to change individuals' behavior and
provide them with care-management skills. It is also important
to periodically measure results and seek to reduce overall
health care costs including those associated with not only
medical care, but with absenteeism and loss of employee
productivity.
MR. GOLDSTEIN said Governor Tommy Thompson, former Secretary of
Health and Human Services for the United States, is U.S.
Preventive Medicine's National Policy Advisor. He presented a
short video of Governor Thompson talking about the results of a
study he conducted as Secretary of Health, into the health care
needs of all Americans and opportunities to change the country's
health care system for the better. He found three things that
need to be addressed to improve the quality of health of all
Americans are: disease management, prevention and early
detection. U.S. Preventive Medicine, Inc. is bringing those
principles together and incorporating them into a business model
that they will take to the United States and the world. Their
business is based upon finding individuals who need help to
improve their quality of health and using early detection and
prevention methods that really work in order to manage disease
in those individuals who need it. This is a bipartisan effort
that he believes will be able to transform the health care
system of America.
3:17:47 PM
MR. GOLDSTEIN also presented a video clip of Tom Daschle, leader
of the transition health care policy team for then President-
elect Obama, and Lauren Aronson, responding to public comments
about health care that were submitted on "change.gov". The first
comment they addressed was that all Americans would benefit from
a shift in health care that emphasizes prevention and addresses
the causes of illness over treatment of symptoms. Other comments
and suggestions included formation of a "health corp." rather
like the peace corp., so that finishing medical students can
give back to their communities.
MR. GOLDSTEIN added that this really is a bipartisan issue and
recent discussions in Washington D.C. have made it clear to him
that prevention is finally on the radar for this country and
should be for the state.
He offered a clinical definition of the word prevention
according to the American College of Preventive Medicine, the
American Medical Association and others.
· Primary prevention includes those things you do to keep
healthy such as eating well, wearing seatbelts and not
smoking.
· Secondary prevention is early detection, or identifying
individuals who are at risk for something but don't yet
have any symptoms.
· Tertiary prevention is chronic care management, making sure
that people with chronic problems such as diabetes, heart
disease and schizophrenia are treated appropriately and
follow through with their treatment.
3:20:27 PM
He explained that USPM has a suite of services that create a
complete wellness program called the Prevention Plan. They also
have a Chronic Care Management Program which is added to the
Prevention Plan in their Prevention Plan Plus, and the
Prevention Plan Premium, which incorporates advanced diagnostic
and assessment programs.
3:21:24 PM
MR. GOLDSTEIN presented another video that used a car
maintenance analogy to describe their prevention plan.
3:22:29 PM
He said USPM works with a number of important diseases including
heart failures, diabetes, asthma and chronic obstructive
pulmonary disease (COPD). Chronic disease is the number one
cause of death and disability in the United States; 133 million
Americans representing 45 percent of the population have at
least one chronic disease. Chronic conditions kill over 1.7
million Americans annually and are responsible for seven out of
ten deaths in the United States.
Individuals with chronic disease account for 75 percent of
America's total health care spending. During 2005 the country
spent almost $2 trillion; that is now $2.3 trillion and the
number is projected to grow every year. In the public sector,
$0.96 of every Medicare dollar and $0.83 of every Medicaid
dollar are spent on chronic disease.
3:23:28 PM
As the CDC [Center for Disease Control] said, the United States
cannot address escalating health care costs unless it begins to
look for ways to mitigate the issue of chronic disease.
MR. GOLDSTEIN continued; during the period from 1987 to 2000,
2/3 of the $313 billion increase in health care costs was due to
an increased prevalence of people with chronic disease. They are
now seeing an increase in what used to be called "adult onset"
diabetes in children and a recently released study showed
individuals 12 years old with cardiac systems that look like
those of persons 35 years old. Obesity is a nationwide problem;
he displayed a map representing information on body mass index
(BMI) by state. From 1987 to 2005 the number of people with a
BMI over 30 (30 pounds over weight) doubled and the obesity rate
in children has tripled since 1980. Alaska is in the 25 to 29
percent range. These increases account for a 30 percent increase
in health care spending. If the presence of obesity was the same
today as it was in 1987, our health care costs would be
approximately $200 billion lower.
U.S. Preventive Medicine has also found that the vast majority
of chronic diseases could be better managed or prevented. The
CDC says that 80 percent of heart disease and strokes, 80
percent of type two diabetes and 40 percent of cancers could be
prevented if people would do three things: stop smoking, eat
healthy and get in shape. Studies by The Institute of Medicine
and others have found that those who are chronically ill only
receive 56 percent of the clinically recommended preventive
care; so when they visit the doctor, they are not getting all of
the services they should.
3:26:19 PM
The health care system is set up to treat illness instead of
prevent it; typically, people can't get services unless they
have symptoms. The system is also very fragmented, with
superficial programs that bring in only 7 to 12 percent
participation. It has been unsuccessful in changing behavior as
there are few, if any, meaningful incentives for individuals to
make the kind of behavior changes necessary to improve their
health.
MR. GOLDSTEIN said the Milken Institute released a study in 2007
titled "An Unhealthy America: The Economic Burden of Chronic
Disease" which found that if the U.S. started practicing
prevention, early detection and chronic condition management,
the impact on the U.S. economy by the year 2023 would be in
excess of $1 trillion annually. This is $1 trillion a year that
could be saved.
3:27:49 PM
MR. GOLDSTEIN commented that Alaska is unique and faces
different issues than any other state he has worked in or
visited. He wanted to talk about what Alaska's vision for health
care, discuss the issues of reforming Medicaid versus expanding
it and look at the potential benefits of implementing a
prevention-based model.
Alaska is extremely rural, which makes implementing programs
more difficult thank it would be in the lower 48. It also has
issues around access to services, number of providers and its
very diverse population. These issues must be overcome through
innovative use of people, systems and technology.
3:28:57 PM
The Alaska Department of Health and Social Services (DHSS) in
their 2009 priorities included: care management, improved care
coordination, a disease-management program for chronic disease
and exploring the use of a primary care case-management strategy
for the most disabled populations. They also discussed
developing legislative and systemic recommendations for
reforming Medicaid, aimed at improving Medicaid sustainability.
The idea is to get the Medicaid system to the point where it
won't continue to chew up more and more of Alaska's scarce
budget resources.
As an example, when USPM first began looking at the issues in
Florida in 1997, the state was spending about $7 billion on
Medicaid; now it is spending $16 billion and it is projected to
double by 2015, which means Medicaid spending will represent 50
percent of their budget. Every state is facing a similar issue.
3:29:56 PM
The stated mission of the Alaska Health Care Strategies and
Planning Council is "making Alaskans the healthiest people in
the nation." Their fifth goal is "prevention and personal
responsibility." The Council believes that government has an
obligation to jump-start healthy choices through incentives and,
in addition, build the necessary incentive structures for the
future.
3:30:21 PM
MR. GOLDSTEIN repeated that the Medicaid system as it is
structured today is very fragmented and is designed to take care
of people when they are sick, not to prevent illness; it makes
no sense to expand a system that is not working well. He
recommended that Alaska look at the additional funding that will
be coming from the federal government for Medicaid, prevention
and health IT as an opportunity to shift the focus within its
Medicaid programs in order to affect long-term positive impacts
on cost and outcomes for future Medicaid recipients.
3:31:21 PM
To maximize value, Alaska has to change the incentives for all
players; appropriate reforms can result in savings to fund
expanded eligibility. In addition, there is $1 billion in the
stimulus bill for prevention, of which $60 million will be
transferred to states to carry out "evidence-based clinical and
community-based prevention and wellness strategies authorized by
the Public Health Services Act as determined by the Secretary,
that deliver specific, measurable health outcomes that address
chronic disease rates."
3:32:34 PM
MR. GOLDSTEIN pointed out some that most beneficiaries don't
have the knowledge to manage their own care; they need a
physician or other practitioner, an advocate or health coach to
help guide them in making good health care decisions.
3:33:34 PM
Health care providers typically don't have the time to provide
that kind of advocacy or coaching and they may not have the
expertise or the system in place to provide services around
behavior change.
Some states have tried to implement pieces of the prevention
concept; there have been chronic care management programs in a
number of states with more and less success. In the end, it is
about changing people's behavior; the state can offer a service,
but it will see no results if people don't use it.
3:34:30 PM
MR. GOLDSTEIN stressed that a system must be comprehensive; it
should not focus only on chronic disease as Medicaid does, but
should begin to focus early on primary and secondary prevention
to help individuals and identify who is at risk and provide
those individuals with the resources and services they need to
address and minimize those risks. He believes there should be
shared accountability among providers, beneficiaries and vendors
and that attention should be given to reforming the system of
payment to providers, to offer incentives for taking on this new
role.
3:35:06 PM
A comprehensive prevention approach should start with a baseline
assessment of all beneficiaries; they should know exactly where
they stand. Mississippi provided baseline physicals for everyone
one year, so the state would know what risks it was facing in
that population and could plan for the future. He commented that
a state wide shared clinical information system would be really
helpful.
MR. GOLDSTEIN asserted that each individual should have his or
her own plan and reiterated that the state has to provide
comprehensive support, advocacy and coaching for beneficiaries
across the continuum so that Medicaid patients, for example,
have someone to call who can help them navigate the system and
get the services they need.
3:36:00 PM
He said there should be accountability and incentives for both
beneficiaries and vendors. In Florida, individuals who do the
right things regarding their health earn incentives that go onto
a flexible spending account card which they can use to buy over
the counter products or services, eyeglasses or additional
benefits.
Paying for preventive services is critical and the state should
incent positive outcomes; as providers do a good job with
patients and practices, they should be incented for that. He
added that because of the rural nature of Alaska's population,
the state should look to the stimulus package for help with an
IT data system.
3:37:33 PM
MR. GOLDSTEIN listed some specific target areas from the FY 2009
DHSS overview:
· Reduce the 30 day re-admission rate for Alaska psychiatric
institute to 10 percent from 13.5 percent by putting in a
care management program for persons with severe and
persistent illness.
· Make sure 80 percent of all two year olds are fully
immunized.
· Reduce post-natal death rates to 2.7 per thousand live
births by 2010; implementing a high risk care management
program for those with maternity issues as one way to
reduce the incidents of preterm delivery.
3:38:48 PM
MR. GOLDSTEIN provided examples of successes in the Medicaid
program. According to the March of Dimes, preterm births cost an
average of $32,000 per child during their first year and
Medicaid tends to have a higher percentage of preterm births. In
one Medicaid program that enrolled only high-risk mothers, the
percentage of preterm deliveries was reduced to 9.4 percent as
compared to the national average of 14.8 percent. This program
cost $350,000 and the estimated gross savings based on a
reduction of preterm deliveries was $900,000 in one year. The
estimated savings per baby was $30,000.
The cost of mental illness also falls disproportionately within
Medicaid, particularly for those living with severe and
persistent mental illness such as schizophrenia or bi-polar
disorder. USPM did the first program in the nation for persons
with schizophrenia and medical co-morbidities and experienced a
54 percent reduction in per member per month costs for emergency
room (ER) visits. As individuals began to get better access to
health care and to follow through with the recommendations of
their physicians and other practitioners, there was less need
for emergency room visits. In that same program, they saw
medication adherence rates go from 22.9 days per month to 27.9
days per month in year two for atypical antipsychotics. That
change of five days per month is the equivalent of filling two
extra months of prescriptions per year.
3:40:54 PM
Representative Lynn joined meeting.
CHAIR KELLER asked Mr. Goldstein to talk about the members of
U.S. Preventive Medicine.
MR. GOLDSTEIN said the mental health program he described was
implemented in Colorado to manage individuals with severe and
persistent mental illness who had schizophrenia with a medical
co-morbidity such as diabetes, asthma or heart failure. The goal
of the program was to improve the clinical outcomes for those
individuals as well as to reduce costs. Individuals were
identified through claims data or referred by mental health
practitioners. Nurses on the ground worked with the
beneficiaries, their physicians and their mental health
providers to ensure that they got appropriate care and followed
through with recommendations.
3:42:12 PM
REPRESENTATIVE HERRON asked Mr. Goldstein who are the USPM
members.
MR. GOLDSTEIN explained that USPM members are Medicaid
beneficiaries who are enrolled in programs that USPM was
contracted by the state to provide. He said they sell their
programs to employer groups but also work with state Medicaid
programs, contracting directly with Medicaid agencies and the
state to provide services.
3:42:54 PM
CHAIR KELLER asked Mr. Goldstein to clarify for the record
whether USPM is a private company and how it works.
MR. GOLDSTEIN said it is private; they contract with employer
groups or with state Medicaid agencies.
3:44:00 PM
MR. GOLDSTEIN continued with slides showing the results of a
program done for persons with asthma, coronary artery disease,
emphysema, COPD, diabetes, heart failure, sickle cell,
depression, schizophrenia, schizoaffective and bi-polar
disorders. He explained that the chart represents the overall
population within the Medicaid claims data and is an average per
member per month of total medical and pharmacy costs; these
patients averaged $953 per member per month to the Medicaid
program. USPM enrolled only patients who averaged $1191 per
member per month and after six months in the program, their
average medical costs had dropped over $300 per member per
month. Hospital admissions among enrolled patients were reduced
by 192 per thousand patients per year and ER visits by 266 per
thousand per year.
3:45:30 PM
REPRESENTATIVE SEATON asked Mr. Goldstein to explain how the
aggregate eligible population relates to the enrolled patients.
MR. GOLDSTEIN answered that the first column represents the
patients they could potentially enroll. The second column is a
subset of that, representing the patients who were actually
enrolled in the program. The state wanted USPM to do a pilot
with 500 patients; so columns two and three show figures for
that subset of the total population.
REPRESENTATIVE SEATON asked if he knows what the aggregate
eligible population did during that following year as compared
to the target group.
MR. GOLDSTEIN said he believes their numbers were flat; so these
reductions were statistically related to the management of the
patients.
REPRESENTATIVE SEATON talked through the slide with Mr.
Goldstein to be sure he understood.
MR. GOLDSTEIN continued; the next slide shows clinical
improvements in a group of very high-cost individuals through
the use of in-home telemonitoring devices for blood pressure,
weight, respiratory, glucose etc. In that population, the
aggregate eligible population per member per month cost was
$2000 and they enrolled a subset of people whose per member per
month cost was $3200, or $40,000 total per year. The average in-
patient cost was $1000 per month for the group and the bed-days
were 12,000 per thousand. Again, there was a strong drop in
hospital costs to $700 per month.
3:49:50 PM
Monitoring and testing rates among these high-cost individuals
also improved substantially in a six month period. For example,
foot exams among diabetics went from 12 to 65 percent and A1c
testing rates went from 47 to 100 percent. Blood pressure
monitoring went from 14 to 32 percent; those on an asthma action
plan as recommended by the National Heart Lung and Blood
Institute (NHLBI) guidelines went from 26 to 93 percent.
He stressed that it is not an issue of simply reducing costs
through fewer services, but of ensuring that individuals get the
appropriate services and reduce costs through better management
[of medical conditions]. He made it clear that in programs of
this nature, one typically sees pharmacy costs go up because
patients actually fill their prescriptions and do not skip or
miss doses. Savings are created by fewer emergency room and
hospital visits.
3:51:16 PM
MR. GOLDSTEIN said that a number of other states are exploring
the idea of putting more control in the hands of beneficiaries,
with incentives they can earn by doing the right thing for their
health. This is fairly new in the Medicaid arena so he was
unable to say yet whether it will have a measurable effect.
MR. GOLDSTEIN commented that small incentives are often very
effective when seeking to boost enrollment or to get people to
complete clinical assessments. He has seen enrollment rates as
high as 80 percent of those eligible within a population.
Typically, in the Medicaid populations USPM has worked with,
individuals like the program so the number of individuals who
leave is very low, generally less than two percent on an
annualized basis.
For Alaska's high-cost clients, he recommended that the
telemonitoring programs with in-home devices and data managed
daily could be very cost-effective even though the products are
expensive. Also, E prescribing systems provide better control of
prescriptions, reduce inappropriate utilization and improve
safety.
3:53:00 PM
Finally, the Alaska Health Care Strategies Planning Council
says:
By improving the place of prevention and personal
responsibility in the health and health care decision-
making rubric of Alaskans, costs of health care could
be lower than they otherwise would be. With
concentration on a wellness model of health care, as
well as state support for the Community Health Center
system and a robust public nursing program, the
current access problems could be significantly
reduced.
3:53:29 PM
REPRESENTATIVE SEATON wondered if USPM works with providers
other than Medicaid and asked if they show the same kind of
results.
MR. GOLDSTEIN said yes, they have similar quality and cost-
savings results in the commercial market. They have not worked
with insurance companies because individuals are afraid to share
their data with insurance companies for fear the information
they provide may adversely effect their ability to get health
care. That is one of the most common concerns they hear from the
companies they contract with; those companies want to ensure
that USPM is independent and that their data will not be shared
with insurers or employers. U.S. Preventive Medicine is a HIPPA
compliant organization and does not share that data. In
addition, the average tenure of an insurance company [with an
employer] is 28 months; so by remaining independent, they can
stay with companies over a longer period of time. They do have
contracts with companies that have fully insured products and
their program is offered as an add-on.
3:55:37 PM
CHAIR KELLER asked if USPM assists patients when they change
providers.
MR. GOLDSTEIN answered that they use a primary nurse model; so
each individual has his or her own nurse or health coach who
communicates with the individual's providers. The prevention
plan itself includes a comprehensive personal record that can be
populated by the individual; lab data comes in directly.
Individuals can also choose to have their health data
transferred into Google Health; so even if a person changes
employers, he or she can pay for the plan and keep that data in
one place for life.
3:57:07 PM
REPRESENTATIVE SEATON admitted that the legislators' ability to
evaluate this is limited. He asked if individual insurance
providers like Blue Cross are doing the same kind of thing and
if they are seeing the same cost-saving results. He doesn't
understand why this wouldn't work through their plans.
MR. GOLDSTEIN said some insurance companies do offer some of
these services; typically state insurance regulations require
some kind of wellness product or accreditation by the National
Committee on Quality Assurance. He believes that the intensity
of services offered in USPM's plan is much higher and that is
why they have been able to generate better results. Both of Mr.
Goldstein's sons have asthma and he said that the disease
management program they receive from their insurer is only one
phone call per quarter and a mailer.
3:59:59 PM
REPRESENTATIVE COGHILL tried to summarize what he understands
from this presentation. The way the insurance system works for
getting help to a patient is to work with the doctor, while USPM
maintains a closer relationship with the patient for health care
management. He asked how their system of health prevention and
care management works with the insurance payer delivery system.
MR. GOLDSTEIN said they integrate as closely as possible with
insurers, but that is ultimately the individual's decision.
Their goal is for individuals to be better able to manage their
own care and navigate the health care system. They become the
coordinator for individuals' care.
4:02:10 PM
REPRESENTATIVE COGHILL said, what if a patient has high blood
pressure, a heart issue and is taking pain medication for a
tooth issue; would they know what prescriptions he is taking so
they could help him to understand if he is getting a medication
that is not of benefit to him.
MR. GOLDSTEIN said yes and, depending on how potentially severe
the problem with a prescription, they would even notify the
physician. They have found individuals who are getting
prescriptions from four or five different physicians, none of
whom know what the others are prescribing.
4:03:12 PM
REPRESENTATIVE COGHILL continued; so USPM asks patients to go
get specific tests in order to create a database on their health
and coach them on their health care decisions.
MR. GOLDSTEIN agreed. They want the patients to have a
comprehensive understanding of what their health status is, what
their risks look like and what options are available to mitigate
those risks. They provide the health coaching, the care
coordination, the advocacy and a 24 hour nursing service.
4:04:02 PM
REPRESENTATIVE COGHILL asked how proprietary information is
protected. Also, what happens if they make a mistake?
MR. GOLDSTEIN responded that they are URAC (formerly
"Utilization Review Accreditation Commission") accredited in
their chronic care management and are early adopters of the
privacy standards for prevention and wellness programs that the
National Committee on Quality Assurance is coming out with now.
They are also HIPPA compliant, which means they follow the
regulations associated with the sharing of health information;
it typically requires authorization from the individual to share
their data with anyone else. Because USPM has worked with
populations that have illnesses such as HIV/AIDS and mental
illness, which have specialized issues around privacy, they have
systems built in to maintain privacy for those individuals.
4:05:33 PM
REPRESENTATIVE COGHILL asked if it is at the credentialing of
the people doing the coaching where their liability stops. What
if a patient misunderstands their advice and then sues?
MR. GOLDSTEIN assured him that they are not providing medical
advice. They do have a physician in the system who reviews
members' data and provides a physician report; that physician is
licensed in the state where the member lives. USPM faces
liability as does any other care management organization and has
insurance around that process, but they have not had an issue to
date.
REPRESENTATIVE COGHILL said the other problem he sees is
appointments and no-shows; how do they keep close enough contact
with their individual customers so that the program has the most
current possible information and is able to give the best
coaching.
MR. GOLDSTEIN said the first key is ensuring they have qualified
staff. They have been able to recruit great nurses in all of the
communities they work in; they have very high standards and
provide additional training for all nurses who are hired. They
require continuing education for their nurses in every state
even though some of the states themselves do not require it for
licensing. Then they ensure that they have appropriate staffing
levels to meet the needs of the population. For example, if they
are working with a population that has schizophrenia, they need
a much higher staffing level than they might for a program
around wellness or asthma. The nurses develop a care plan for
each individual, which lays out how they are going to work
together with the individual's physician on their care. In some
states that don't have a primary care management model or PCCM,
they try to establish a medical home. Finally, they have a very
high contact level to allow the nurses to keep up with their
individual clients and their physicians. They have seen no-show
rates drop on their programs; sometimes nurses go so far as to
accompany patients to their appointments. Clearly, they want to
get past that high level of "hand-holding" eventually, but that
is the level of service they are prepared to provide.
4:09:31 PM
REPRESENTATIVE CISSNA commented on the number of health care
positions that can't be filled in rural Alaska; there are
workforce shortages even in the urban areas. She asked how their
program would work with that; if they would bring nurses into
the state.
MR. GOLDSTEIN said that is great question. Typically they do
hire within the communities and generally get a lot of
applications because it is the type of work nurses like. They
get to follow patients for a long period of time; they get to
set up their own schedules and really use what they learned in
nursing school. Of course, he said, he hasn't applied this to
Alaska and can't appropriately answer how that might impact
other service providers in the state.
4:11:16 PM
REPRESENTATIVE COGHILL said USPM's brochure talks about four
major plans: a prevention plan, custom diagnostics, a wellness
plan and an advanced diagnostic plan. He asked Mr. Goldstein to
help them understand the cost structure for an individual and
how that might be disbursed in a larger plan.
MR. GOLDSTEIN replied that the wellness package, which is the
prevention plan itself, includes health risk appraisal,
comprehensive lab test series, the physician review and report,
the 24/7 nurse line for a year, the coaching and some of the
incentives that they throw in, and would cost $1 per day for an
individual; companies do receive discounts. They can also un-
bundle the program; for example, if a person bought only the
internet piece, that would cost about $60 per year. USPM's care
management is usually priced for a population based on claims
data and can run from a few dollars per member per month up to
about $250 per member per month for a telemonitoring system.
MR. GOLDSTEIN commented that most companies [that offer this
type of service] charge employers a flat per member per month
fee based on the number of employees; so if an employer has
10,000 employees their cost would be the product of that fee
times 10,000 employees. A company that charges that way has no
incentive to enroll a large number of people because the fewer
employees it enrolls, the larger its margin [of profit]. USPM
charges only on the number of employees who enroll; so their
goal is to get as much participation as possible.
4:14:34 PM
REPRESENTATIVE COGHILL opined that it would be interesting to
see what has happened to physicians' and insurance companies'
costs and to mortality in areas where their product has come
into the market.
MR. GOLDSTEIN said they typically see the cost of primary care
visits go up while costs for ER and hospital visits drop. They
haven't looked at insurance overall but have been talking to
reinsurers, who are interested in potentially bundling USPM's
product with a reinsurance package so they can charge lower
rates to providers.
4:15:52 PM
CHAIR KELLER asked Mr. Goldstein to describe the baseline
assessment and appraisal and whether they do one for every
member.
MR. GOLDSTEIN said they typically want everyone to have an
assessment so they can get a feel for what the individual and
aggregate risks are within a population. It is a comprehensive
health risk appraisal including questions about nutrition,
family history and behaviors; that data is combined with lab
data. They can either do blood draws on site for employer groups
or work with LabCorp, which has 1700 sites across the country
where members can go to get lab work done. They have also
established relationships with some hospitals and clinics to do
blood draws for employers in their communities. When all of the
data is in, a risk report is produced which can be accessed by
the member online. He noted that USPM is soon coming out with
prevention plans specifically for kids at little or no cost and
for seniors.
REPRESENTATIVE KELLER asked what the coaching would look like
for a member with pre-diabetes.
MR. GOLDSTEIN said that once a report is done, their staff
actually contacts the individual to go through the findings and
start to develop an action plan. The individual can choose to
continue to work with them online or via telephone for ongoing
coaching regarding nutrition etc.
4:19:10 PM
REPRESENTATIVE SEATON referred to a chart of per member per
month costs that was included in the slide presentation. He
assumed that if this reflects a Medicaid result, Medicaid is
paying [for the care] and asked who pays USPM.
MR. GOLDSTEIN answered that Medicaid pays them.
REPRESENTATIVE SEATON how this is contracted and why, if these
are typical cost savings, federal Medicaid isn't doing this
across the country.
MR. GOLDSTEIN explained that typically these [contracts] are
released through an RFP [Request for Proposal] and the state
selects a vendor they think best fits the RFP requirements. As
to why they haven't seen this used more widely, perhaps it is
because the programs haven't always worked. For example, there
was a huge demonstration project in Medicare involving about
20,000 patients and $25 million. Medicare put out a large bid
called "Medicare Health Support" and chose 10 vendors including
Humana, Signa, HealthWays, McKesson and others, all of whom
attempted to justify their cost savings. These were full risk
contracts; if the vendors didn't produce the projected savings,
they had to pay Medicare back. None of them worked. He believes
the reason the did not work is that they were all very light in
terms of behavior modification and were very telephonically
based; so it took them a long time to get people engaged and
they never did get very high participation rates, which means
they couldn't get the results. It was like pushing a five pound
brick with four pounds of force; it just wasn't going to happen.
USPM started their business in Medicaid, not in the commercial
market and that is a very difficult area; so they have staffed
their programs higher than most models and placed emphasis on
engaging individuals early. He admitted that they aren't always
successful but said they are pretty good at what they do and try
every day to get better. About 20 states have signed on so far
including: Washington, Oregon, Mississippi, Colorado, Montana,
Texas, New Hampshire, New York and Arkansas; some of them have
been successful and some have not. The very first program he was
involved in was with the state of Florida. There were four
vendors doing four different programs; at the end of one year,
only their program remained because the other three produced no
results.
4:22:34 PM
REPRESENTATIVE SEATON asked if what he is seeing is a sample [of
results] and not a whole program.
MR. GOLDSTEIN answered that these are whole program results for
one program.
REPRESENTATIVE SEATON said he sees a huge difference between the
[numbers for the] aggregate eligible population and the cohort;
so there must have been a huge difference in size.
MR. GOLDSTEIN agreed. He said this was a pilot program in seven
counties in the Western region of New York. The state asked them
to enroll 500 out of an aggregate eligible population of
approximately 3500.
REPRESENTATIVE SEATON continued; so there are 500 in the cohort
and the total is 3500 and the data here is from 2007. He asked
if the program is ongoing.
MR. GOLDSTEIN said yes, they are doing the last year of data on
that program.
REPRESENTATIVE SEATON said, "So this was a pilot project and you
have a second year of data?"
MR. GOLDSTEIN answered yes. For this project the state had seven
pilots; theirs was the only pilot program continued at the end
of 18 months.
REPRESENTATIVE SEATON queried whether the pilot ran through June
30, 2008.
MR. GOLDSTEIN said it is still going on and they will have the
last year of data available soon.
4:25:00 PM
REPRESENTATIVE SEATON said he looks forward to seeing an update
on that.
REPRESENTATIVE HERRON asked if Mr. Goldstein would agree that
the largest patient America has is Medicaid.
MR. GOLDSTEIN responded that Medicare may be bigger; but
combined they are about $700 billion.
REPRESENTATIVE HERRON commented that is the next challenge
society is going to have to deal with. He wondered what Mr.
Goldstein means when he says that Alaska is unique; all states
are unique.
MR. GOLDSTEIN said the model they typically use is one that has
nurses on the ground work personally with clients; they use this
model in North Dakota where each nurse has a geographical region
and works with the physicians and patients in that region. They
try to bring in culturally appropriate staff to work with the
situation. Here, more even than in North Dakota, there are areas
that are inaccessible in the winter time and he admitted that he
doesn't know yet how best to handle the big issues Alaska faces
around people who are located in places that have very limited
access to services.
4:28:15 PM
REPRESENTATIVE HERRON said he is concerned about returning
veterans and the way the [health care] process works; it doesn't
even matter which process, whether it is the VA, urban providers
or rural providers. Why is it, he asked, that the dollar does
not follow the soldier? Why does the soldier always have to
fight to find medical services?
MR. GOLDSTEIN said he did not have enough information to
adequately answer that question. He thinks the fragmentation of
the system is further increased for people returning from
overseas. In the chronic care management world, USPM would not
exist if every patient and every physician did the right thing
and followed through. They are trying to fix the gaps in care in
coordination and communication between providers and to help the
individual with the least knowledge to navigate the system.
REPRESENTATIVE HERRON said he is almost sold if their company
can help the state deal with Medicaid, which he thinks is an
almost impossible task. But, he said, if they can make the
dollar follow the veterans instead of the other way around, he
will be completely sold.
MR. GOLDSTEIN said they are doing a program in North Dakota
called "Money Follows People" and are coordinating 100 people
through the system so they can get access to the services they
need. That may be a way to help the veterans.
4:30:59 PM
REPRESENTATIVE COGHILL said one of the things that is unique
about Alaska is that we have a relatively small population in a
very large geographical area, which results in big gaps in
service delivery. He asked if USPM can achieve economies of
scale sufficient to deliver the expected services?
MR. GOLDSTEIN answered that he doesn't think it will be an issue
here; there is certainly a large enough population to do it. As
an example, one of the organizations that purchased the
prevention plan is the Amateur Golf Association of Georgia,
which has only nine employees.
4:32:30 PM
CHAIR KELLER commented for the record that a lot of people in
Alaska are looking for solutions. He thanked Mr. Goldstein for
providing what he believes is encouraging information.
MR. GOLDSTEIN said in closing that there was a health care
crisis before there was a financial crisis and it will still be
here after the financial crisis is over. He believes that this
country has to move into a preventive model or health care costs
will continue to increase and will ultimately make the U.S. non-
competitive in the global economy. He used the auto industry as
an example, saying that the single largest cost of a car for
American auto manufacturers is health care. To fix the health
care problem we have to get out in front of the train instead of
dealing with it after it has left the station.
4:33:57 PM
CHAIR KELLER said they will have a presentation from the
Department of Health and Social Services (DHSS) Thursday on
Medicaid reform and he believes this was an appropriate lead-in
to that.
4:34:17 PM
There being no further business to come before the committee,
Chair Keller adjourned the meeting at 4:34 PM.
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