When Cleveland-based MetroHealth System established MetroHealth Care Plus in 2013, the enrollees pool was far-from-expected. MetroHealth Care Plus was intended to help patients who fall through the cracks — those who have no insurance, yet don't qualify for Medicaid.
While demographics mirrored the populations of Cuyahoga County and Cleveland, many enrollees were just a job loss away from Medicaid — and came from zip codes you wouldn't expect, Akram Boutros, MD, president and CEO of Metro Health, said on May 7 of Becker's Hospital Review 6th Annual Meeting in Chicago. It was a fascinating group; they looked like your next-door neighbor, he said.
Twenty-six year old Claire is a good example. Claire was a native of Parma, Ohio, an old Italian suburb of Cleveland. She had an associate's degree and worked part-time at a grocery chain while studying to become a hospital cardiac technician. Claire had received care for depression and arthritis, but her insurance plan was ending. Just two days after it ended, she was admitted to MetroHealth's ED for intense abdominal pain and bleeding.
Without insurance coverage, Claire was concerned her ED bill would empty her savings, setting back her cardiac technician training. Instead, she was able to enroll in MetroHealth's Care Plus program before she even left the ED.
Claire is one of nearly 30,000 patients who sought care in MetroHealth's Care Plus program, which launched Feb. 5, 2013, less than a year and a half after the system began planning and secured the state's buy-in for the program.
MetroHealth Care Plus was launched as a solution to the system's exploding uninsured population. MetroHealth served more than 225,000 visits from uninsured patients in 2011, up 42 percent from 2008.
As part of a partnership with the state of Ohio, the system filed for a 1115(a) Medicaid Waiver Demonstration, which waives parts of the Social Security Act to serve low-income uninsured adults with bridge coverage. Through a number of partners, including community groups, public agencies and local providers, MetroHealth got the word out about the program, and on its first day, more than 9,000 enrollees registered. Enrollment was steady after that, topping out at about 29,000 enrollees. All qualified patients who applied were able to enroll.
More importantly, the program worked. Enrollees had high compliance with diabetic exams, showed improvements in blood pressure control and improvements in depression screening. Roughly a quarter of the program enrollees received care coordination, much more than the norm of 5 to 10 percent.
"The difference in all of this from any other thing you've seen is that every patient was enrolled in a Level III PCMH and the result is we came in 28.7 percent lower than CMS actuarial dollars per member per month," Dr. Boutros said. "We ended up saving $47 million."
The system negotiated an extension with CMS until Medicaid was expanded statewide, and Dr. Boutros said he believes the MetroHealth project spurred the expansion in Ohio.
He credits the success of the program to a couple different factors. First, he said, aim high. "When people are talking about risk and opportunity they are thinking small. They say, 'Can we get a 2 percent improvement in outcomes and spending?' If that's what your aim is and you don't make it, you're going to lose money. If your aim is 40 percent improvement and you hit 30 percent, you're going to do really well."
Second is the staff he inherited at the organization. They worked incredibly hard and appreciated being involved in decision-making. "I tell my staff this: You need to treat each one of these patients as my family, as my wife and my child. I know how they treat my family — the CEO's family — and they treat patients incredibly well," he said.
The third is simple: According to Dr. Boutros, coordinated care and risk-based contracts just work. "My hope was to get 50 percent of revenue from risk contracts or shared savings in five years," Dr. Boutros said. "We will have 45 percent of our patients under risk in two years." He estimates that the system will have closer to 75 percent of revenue coming from risk-based contracts by the five-year marker.
Now, the system plans to launch a total cost of care contract for 72,000 Medicaid managed care members, the largest of its kind in the country. It will be a pure Medicaid HMO total patient care contract with care coordination and population management services provided by MetroHealth, not a payer. It goes into effect July 1.
This project will test the courage of their conviction about coordinated, risk-based care, Dr. Boutros said.