Healthfirst : An example of Plan Contribution to Joint Health System Design

1. Healthfirst: An example of Plan Contribution to Joint Health System Design Presentation by Jay Schechtman, M.D., MBA Senior Vice President Chief Medical Officer

2. Our Mission is to Improve the Health and Well-Being of Underserved Populations • 544,000 member not-for-profit HMO founded in 1993 • 440,000 Medicaid and Child Health Plus members • 90,000 Medicare Advantage Part D (MAPD), including 45,000 Dual Eligible Special Needs Plan (SNP) members • 14,500 New Jersey Family Care members • Sponsored by 21 unaffiliated New York not-for-profit and public hospitals and hospital systems • Which assume financial risk for members selecting PCPs affiliated with them

3. NY Hospital Sponsors Cover the Territory Beth Israel Medical Center Bronx-Lebanon Hospital Center The Brooklyn Hospital Center Elmhurst Hospital Interfaith Medical Center Jamaica Hospital Lenox Hill Hospital Long Island Jewish Medical Center Maimonides Medical Center Montefiore Medical Center The Mount Sinai Hospital Nassau University Medical Center NYC Health and Hospitals Corp. New York Downtown Hospital North Shore University Hospital Staten Island University Hospital • St. Barnabas Hospital • St. Luke's-Roosevelt Hospital Center • St. John's Episcopal - South Shore • Stony Brook University Hospital • University Hospital of Brooklyn

4. Our Business Imperative is to Operate as Well as any Other HMO… • Efficiency in operations • Member services, enrollment, claims, network, reserves and financial management, medical cost management, quality, information technology, regulatory compliance, business development, innovation • Member satisfaction • Network • 60 hospitals, 20,000 practitioners • Quality • Outcomes

5. …While Working With Our Capitated Providers to Achieve Results Health plans often say that providers fail to cooperate with management of members’ care Our model is based upon comprehensive health plan-provider collaboration in the context of full risk capitation Healthfirst risk model Aligns incentives between payer and provider Frees capitated providers to invest in initiatives that might reduce utilization, e.g., reduce readmissions Hospitals are not driven by need to maximize utilization 5

6. Managed Care for Low-Income Clients is Superior to Fee-for-Service • NYS Department of Health analyses demonstrate superior quality in Medicaid managed care vs. FFS on multiple measures, including management of chronic illness. • Better outcomes have supported State policy to mandate enrollment of SSI (disabled) clients • SSI clients report satisfaction with health plans vs. FFS Childhood Immunization Rate Comprehensive Diabetes Care Well Child/Adolescent Visit Rate Use of Appropriate Medications for People with Asthma Rates Cervical Cancer Screening Rate Source: “Quality Measurement in Medicaid Managed Care and Fee-for-Service: The New York State Experience,” Roohan, et. al., American Journal of Medical Quality 2006

7. What is Good for Medicaid is Better for Medicare • Our Medicare members are: • More medically underserved than our Medicaid members • More likely to have identifiable health condition(s) • Have more stable insurance under Medicare • They have more to gain from coordinated care interventions Care management, Quality Improvement Member and Health plan support Improved Health Status and Quality of Life Identifiable health condition(s) Continuous insurance coverage

8. Our Focus to Improve Outcomes

9. Specific Initiatives Marry Provider Innovation with Health Plan Management • Initiatives differ in specifics but general objectives include reduction of avoidable admissions and focus on specific health conditions (obesity, diabetes, etc.) • Reporting on key performance metrics is fundamental to effective collaboration.

10. Example of Healthfirst-System Partnership Project Project Goal: Reduce the rate of avoidable admissions, medical and surgical readmissions, and emergency room visits • Project Components • Universal: • Identification of members using Healthfirst medical management hospital census • Member outreach within 72 hours of hospital discharge • Confirmed PCP Appointment within 72 hours of discharge • Site specific • (based on resources) • Pre-discharge visit by case manager • Personnel making post discharge phone outreach • Data capture • Designation of leadership team • Defining the scope of the project • Finalizing operational protocols and workflow • Defining site specific data and tracking tools • Participation in steering and site meetings • On-site case managers and case management tool. • Oversight and administrative support • Design/generation of various performance & operational reports • Evaluation of Partnership outcomes 10

11. Using Metrics to Track Progress: Quarterly Summary Partnership Report • Allows for assessment of performance across the network 11

12. Payment Reform is Critical to – But Not a Substitute For – Delivery System Reform • But payment reform is not a substitute for capitation • Full capitation facilitates a population-based view to see and intervene in what is happening to the member through all components of the (reformed) delivery system • Same Applies to EMR and RHIO.

13. Observations on Healthfirst Model • Most hospitals will not become Geisinger or Kaiser • Employed vs. voluntary MD relationship • Geography • Healthfirst’s model enables unaffiliated hospitals and community-based providers to function in a capitated environment with centrally provided HMO back-up • Significant provider risk-sharing requires a different focus and operating rules than the traditional HMO model • Full thickness model compared to ACO

14. AppendixSample Quality Scorecards --QARR/HEDIS --Quality Dashboard

15. Healthfirst QARR/HEDIS Scorecard 15

16. Healthfirst Quality Dashboard 16

17. Healthfirst Quality Dashboard 17