proactive approaches in nicu management · neonatal intensive care unit (nicu) program national...

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Proactive Approaches in NICU ManagementMedicaid Health Plans of America Annual Conference

Today’s Presenters

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Dr. Ellen Stang

Founder and CEO

ProgenyHealth, LLC

Dr. Marketa Wills, MBA

Sr. Corporate Medical Director

WellCare Health Plans

Dr. Robert S. London

Chief Medical Officer, SC

WellCare Health Plans

All numbers are as of June 30, 2019

*Includes states where the company receives Medicaid and Medicare revenues associated with Dual Eligible

Special Needs Plans (D-SNPs)

14KASSOCIATES

6.3MMEMBERS

607KHEALTHCARE

PROVIDERS

68KPHARMACIES

Medicaid

Medicare Advantage

Medicaid & Medicare Advantage*

#155FORTUNE 500

Health Insurance Marketplace

Medicare Prescription Drug

Plans (50 U.S. states & D.C.)

WellCare – Who We Are

WellCare’s Presence

Medicaid (Pending) &

Medicare Advantage†

† Anticipated beginning Nov. 1, 2019, WellCare of North Carolina will administer the state’s Medicaid Prepaid

Health Plans (PHPs). 3

WellCare – Who We Are

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Our Approach

At WellCare, we foster strong partnerships with providers; offer an integrated

care model; establish trusting partnerships with our state and federal

partners; and address barriers to care in our local communities.

WELLCARE’S APPROACH

WellCare’s Maternal & Child Health

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Population Snapshot

1.3MFemales of childbearing

age (12-44)

165,025Pregnant members

116,156Babies delivered

13,873 NICU admissions

2.5M Children and adolescents

ages 0-17

Members receiving support and services that fall into the Maternal and Child

Health category make up approximately 80% of WellCare’s membership.

2018 Medicaid – All Markets


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Overview of Clinical Programs

National maternity care management

program focused on improving mother and

newborn outcomes and care.

Utilization management program designed to

ensure the right care at the right NICU level

and provide care management to the NICU

graduate’s family for the first 15 months of life.

WellCare BabySteps

NICU Program

Neonatal Abstinence Program

The program is designed to address the

increased incidence of prenatal exposure to

opiates through care management of female

members at risk of or abusing opiates.

Maternal & Child Health Scope

• Female members of childbearing age with a focus on

family planning and reproductive health

• Female members throughout the continuum of

pregnancy and postpartum care with a focus on pregnant

adolescents and high risk pregnancies

• Children from birth until their 21st birthday including a

focus on children with special needs


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WellCare BabySteps Maternity Program

National maternity care management program targets timeliness of care, early

identification of risk factors and management of health conditions that complicate

pregnancy

• Improve birth outcomes

• Improve quality of maternity care

• Increase member engagement

• Reduce cost of care for mothers and

infants


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Neonatal Abstinence Syndrome (NAS) Program

National NAS Program that targets at-risk mother and NICU graduate through early

identification, intensive prenatal and postnatal care management services

• Timely treatment of exposed newborns

• Improve outcomes and reduce cost of

care for mothers and infants

• Prevent opioid exposure in

newborns

• Stabilize pregnant members who

are using opioids


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Neonatal Intensive Care Unit (NICU) Program

National NICU program aligns care to newborn and pediatric care guidelines through

care management and coordination of services. Targets appropriate best practices in

the hospital, engages caregivers and family during hospitalization and post discharge

through first year of life.

• Improve birth outcomes

• Improve the quality of maternity care

• Reduce cost of care for NICU newborns

• Increase member engagement

• Increase provider engagement

Improving Lives Together

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WellCare – ProgenyHealth Partnership

Plan Integrate

Coordinate Expertise

Program Requirements

Integration with community providers

Partnership with community partners

Seamless integration with WellCare’s care model

Measurable outcome and quality metrics that

target industry benchmarks for population

Average

Length of Stay

(ALOS)

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Missouri

20.019.0

16.0 16.3

0

5

10

15

20

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National Benchmark Pre - Progeny Baseline Year 1 All Claims Data Year 1 Baby Trax Data

ALO

S (

Days)

Plan Year One 8/1/16 – 7/31/17

*Baseline Cases Only; does not include NAS, Expired, ECMO, and Trach

NICU Program Impact

*Based on Progeny BabyTrax data PY 2017, PY 2018 results and 2019 YTD data (Jan-Aug).

NICU Program Impact

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Missouri

WellCare MO

ALOS


WellCare SC

ALOS

Top Providers – Facility ALOS* – Pre and Post Progeny

*Baseline Cases Only; does not include NAS, Expired, ECMO, and Trach or applied transfer logic

NICU Program Impact

South Carolina

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0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Facility A Facility B Facility C Facility D Facility E

Year 1 Cost per Discharge % savings from baseline

WellCare SC

Cost Reduction

per Discharge

*Baseline Cases Only; does not include NAS, Expired, ECMO, and Trach or applied transfer logic

-36%

-47%

-22%

-44%

-8%

NICU Program Impact

South Carolina

14*Based on Progeny BabyTrax data PY 2017, PY 2018 results and 2019 YTD data (Jan-Aug).

Levels of Care

Impact of Leveling by ProgenyHealth

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Missouri Care

43%

28%

36%

45%

21%

27%

Rev Code 172 Rev Code 173 Rev Code 174

Baseline

Claims

Provider

Billed-

Claims

$ $$ $$$

Shift to Less Costly Days


19.3

16.7

15.9

16.6

13

14

15

16

17

18

19

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pre-PH 2017 2018 2019 YTD

NICU Average Length of Stay (ALOS) (Days/Admit)

6.0%

1.4%

2.5%2.8%

0%

1%

2%

3%

4%

5%

6%

7%

pre-PH 2017 2018 2019 YTD

NICU Readmit Rate (30 Days)

Reduce NICU ALOS (days/admit) from

WellCare baseline measure of 19.3 daysReduce 30-day emergent readmissions

from benchmark of <6%

Target CM enrollment goal of >65%

Enterprise Goals and ProgenyHealth Results

*Based on Progeny BabyTrax data

PY 2017, PY 2018 results and 2019 YTD data (Jan-Aug).

65%

84%87%

91%

60%

65%

70%

75%

80%

85%

90%

95%

100%

pre-PH 2017 2018 2019 YTD

Case Management Enrollment Rate (%)

Reduce NICU Average Length of Stay Reduce readmission rates Improve CM enrollment rates

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ProgenyHealth

Dr. Ellen Stang

Founder & CEO

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Progeny – Who We Are

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Progeny’s Approach

Purpose-built to help health plans and employer groups reduce costs and ensure quality in the care of

at-risk infants and their families. Our NICU trained teams have the expertise needed to keep a watchful

eye on the baby’s care plan; provide resources, education, and support to the families; and deliver

attentive oversight for each case.

Process Platform People

WellCare Partnership

ProgenyHealth’s Solution

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Live in 10 markets

Program

focus on…

• Seamless member experience

• Clinical integration

• Strong local provider partnership

• Improving health outcomes

Case Management

Key Performance

Indicators

• 6,801 cases managed

• 4,549 successfully

contacted members

• Average of 9 successful

calls per enrolled

member

• 5,100+ successful

SDOH interventions

(education, access,

community, financial)


Market Launch

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NICU

week 1

week 1

week 2

week 2 - 4

week 3 week 4 week 5

week 5 month 8

1st BirthdayNICU

Discharge

Discharge Sick baby

UM team

CM team

Our process monitors the baby from birth to first birthday. On average, our NICU specialized UM team interacts

with the hospital care team 7 times more frequently than a typical UM team. Our NICU specialized CM team

connects with the family early in the hospital stay and continues to support them for the entire 1st year.

Integrated UM and CM that encompasses the social determinants of health


ProgenyHealth Process: Proactive, Data Driven, Integrated Approach

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Importance of extended case management

Familyeducation

Quality /

HEDIS

24/7

Support

Reduction of readmissions

Schedule

Baby Trax app

Family/CaregiverCM team

Social

determinants

1st BirthdayNICU

70% of readmissions happen after the first 30 days. Going above and beyond is our process for CM. The

families with the greatest need are often the most difficult to reach. We have the national expertise and

access to local community resources to provide needed support to the families.

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WellCare Clinical & Financial Results Delivered in 2018

Financial Impact

NAS ALOS*

ALOS

Return on Investment:

>3.45:1

19.3 days: average client baseline

17.1 Days**

13.8 Days***

*Discharged newborns with NAS diagnoses through 12/31/18.

**Tyler N.A. Winkelman, et al, Incidence and Costs of NAS Among Infants With Medicaid: 2004–2014, Pediatrics, March 2018.

***Baseline Cases Only; does not include Iatrogenic, Expired, ECMO, Transplant and Trach cases.

15.7 days: WellCare current


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2.5% (30-day readmission rate)

7.6% (FYOL readmission rate)

Readmission Rates

Member Satisfaction

90% +


Achieving the Triple Aim

Achieving Triple Aim

Through an enterprise NICU management

program we are improving outcomes for

moms and babies, increasing member

satisfaction, and significantly reducing the

cost of care.

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THANK YOU!

Do you have any questions?Please feel free to contact us if you need additional

information.

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