Community Medical Alliance

Clinical Programs Offered Through Neighborhood Health Plan

Neighborhood Health Plan

• Non profit HMO, formed by Massachusetts League of Community Health Centers in 1986. Affiliate of HPHC since 1998
• State wide presence with 121,000 enrollees (September 2001)
  - 105,000 Medicaid
  - 16,000 Commercial
• Medicaid enrollee characteristics:
  - 85,000 low income families
  - 10,000 SSI eligible disabled
  - 10,000 “unemployable” with a mix of social/medical/mental health issues
  - 550 CMA eligible population
• Primary care Network:
  - 48 CHC’s state wide - 66,000 members
  - 14 Harvard Vanguard Medical Associate Health Centers (HVMA) - 15,000 members
  - 12 large Suburban Multi Specialty Group practices
  - 8 Urban, teaching hospital, primary care sites
  - Small medical group practices

Neighborhood Health Plan Structure and Relationship (D-Link)

Characteristics of Medicaid Eligible Populations with Severe Physical Disabilities

(e.g. Those eligible for Massachusetts personal care attendant benefit)

• Clinically and socially very heterogeneous
  • Some historically “wards of the state” e.g. those with severe cerebral palsy/mental retardation
  • Others previously employed/middle class now unable to work because of severe disability
• Vanguard of the “Civil Rights” revolution over the past three decades
• Inadequate connections to primary care with very real barriers in place
• Medical care provision through large impersonal fragmented, specialty clinics in teaching hospital settings
• High prevalence of concurrent mental health issues

Characteristics of Medicaid Eligible Populations with Advanced HIV Infection

• High prevalence of active mental health or substance abuse issues
• Socially marginalized, disempowered, alienated populations
• Erratic connections to medical care. A “personal physician” is a rarity
• High prevalence of transience and homelessness
• Disproportionately in Afro-American and Hispanic populations
• Alarming increasing prevalence in young women

Distribution of FFS Medical Service Costs for Ohio Medicaid Recipients with Paraplegia and Quadriplegia 1993 (D-link)

Cost Analysis of FFS Service Category for Ohio Medicaid Recipients with HIV/AIDS 1993 (D-link)

Community Medical Alliance Clinical Programs within Neighborhood Health Plan

• Fully capitated managed care plan for people with disabilities and chronic illness
• Contracts with MA Medicaid to enroll defined SSI eligible disabled populations via health status adjusted premiums

Community Medical Alliance Program Model

Team Approach To Primary Care

• Organized to “respond 24/7”
• Highly personalized patient relationship
• Empowered to allocate resources “order, rather than request services”
• Integration of case management into care delivery
• New locations of medical decision making

Specialized HMO Functions

• Specialized Networks
• Specialized Benefits
• Specialized reimbursement models
• Specialized management systems to implement primary care benefit allocations
• No “command and control” overlays

Community Medical Alliance Clinical Programs (CY2000-2001) (D-link)

Current:

Planned 2000-2001:

*MD/NP primary care teams; different benefits, different HMO Management system, including specialized member services, primary care team orders rather than request services, specialized network.

**Plans underway to expand third site; see Brightwood above.

In addition, children/adolescents with severe BH problems are served through NHP’s MHSPY Program. This model utilizes a SW rather than a NP.

Community Medical Alliance Programs Clinical Staffing 2001 (D-link)

RNP Role- Physical Disability Program

• Provides primary care:
  • in the office
  • in the home (85% of all visits)
• Responds to new medical problems (triage, diagnosis and treatment)
• Provides health education and self-care teaching
• Authorizes all services in conjunction with primary care team
• Implements and monitors home-based alternative service plans
• Coordinates medical and social services
  

CLINICAL ELIGIBILITY CRITERIA- Severe Physical Disability Program

The patient has one of the following physical disabilities such that Personal Care Attendant services or the equivalent care are required as an alternative to institutionalization and one of the following clinical criteria is met:

• Spinal Cord Injury with functional quadriplegia or functional quadriparesis or triparesis
• Degenerative Neurologic Illness with functional quadriplegia, quadriparesis or triparesis
• Severe Cerebral Palsy with severe spasticity resulting in functional quadriplegia, functional quadriparesis or triparesis or other neurologic illness resulting in permanent quadriplegia, quadriparesis or triparesis
• Traumatic Brain Injury with functional quadriplegia, quadriparesis or triparesis
• Functional paraplegia with documented secondary complications to include one of the following:
  • Recurrent urosepsis
  • Recurrent bacterial pneumonia
  • Persistent stage III decubitus ulcers
  • Substance abuse issues

Clinical Program Eligibility Criteria- End-Stage AIDS Program

• CDC defined AIDS (CD4 count <200) and documented major AIDS defining complications
• CDC defined AIDS with a restored immune system (CD4 count>200) but with active MH/SA issues and no contraindication to HAART

Physical Disability Program Snapshot- Calendar Year 1999

Total Enrollees = 260

Age:
0-20 = 1%
21-30 = 19%
31-40 = 33%
41-50 = 23%
51-60 = 16%
61-70 = 8%
71-80 = 0%

Sex:
Male = 63%
Female = 37%

Major Disabling Condition:
Severe Stable Neurological Illness (i.e. CP) =43%
Spinal Cord Injury = 24%
Severe Degenerative Neurological Illness (i.e. MS) = 14%
TBI = 4%
Other (Mental Retardation, paraplegia with complications, etc.) = 15%

Total PMPM Costs for CMA Members with Severe Physical Disabilities (Medicaid Only) - 1990-91 (FFS) and 1992-99 (Capitated) (D-Link)

For CMA-covered benefits only. Data include Mass. Medicaid data (1990-1991) and CMA Managed Care data (1992-1999).

Includes pharmacy since 1998.

Acute Hospital PMPM Costs for CMA Members with Severe Physical Disabilities (Medicaid Only) 1990-91 (FFS) and 1992-1999 (Capitated) (D-Link)

For CMA-covered benefits only. Data include Mass. Medicaid data (1990-1991) and
CMA Managed Care data (1992-1999)

Distribution of Medical Service Costs for CMA Members with Severe Physical Disabilities and Ohio Medicaid Recipients with Paraplegia and Quadriplegia (D-Link)

*CMA data based on experience 1/1/95-9/30/98
Ohio data based on experience in 1991.

Community Medical Alliance Distribution of Capitation Payment on Medical Services- Severe Physical Disability (Medicaid Only) (D-Link)

Data covers dates of service 1/195-9/30/98
Oral Pharmacy included a/o 7/1/98

Community Medical Alliance Distribution of Primary Care Visits for CMA Members with Severe Physical Disabilities 1999 (D-Link)

Distribution of Primary Care Visits for CMA Members with Severe Physical Disabilities 1999 (D-Link)

AIDS Program Snapshot As of 10/00

Total Enrollees: 234

Age:
0-20 = 0
21-30 = 3%
31-40 = 33%
41-50 = 50%
51+ = 14%

Sex:
Male = 57%
Female = 43%

Risk Factors:
Male to Male Sex = 11%
IDU/Male to Male Sex = 3%
IDU = 48%
IDU/Heterosexual Sex = 10%
Heterosexual = 25%
Other/Unknown = 3%

Ethnicity:
White = 31%
African Am/Black = 31%
Hispanic/Latino = 31%
Haitian = 6%
Other/Unknown = 1%

Current CD4 Spread:
100 or less = 51
100-500 = 140
>500 = 41

Intermittently Homeless = 32%
MHSA Diagnosis = 63%

Total PMPM Costs for CMA Members with Advanced HIV/AIDS - 1990-91 (FFS) and 1992-99 (CMA) (D-Link)

(excluding pharmacy until 1998)

CMA-AIDS Care Program Annual Mortality Rate (D-Link)

Community Medical Alliance Distribution of Capitation Payment on Medical Services - RC3A (Medicaid Only) (D-Link)

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