In late July, data from CMS suggested dual-eligible patients—beneficiaries eligible for both Medicare and Medicaid—had among the highest COVID-related infection and hospitalization rates. Commonwealth Care Alliance in Massachusetts focuses on serving this high-risk population, with nearly 40,000 members in its health plan. The alliance also provides direct patient care at two clinics and via in-home and telehealth visits. President and CEO Chris Palmieri talked with Modern Healthcare Managing Editor Matthew Weinstock about caring for this vulnerable population. The following is an edited transcript.
MH: CMS reported seeing high rates of infections and hospitalizations among dual-eligibles. What have you seen among your members?
Palmieri: Our data is preliminary because we’re still very much involved in COVID, but as we looked at data on our 37,000 beneficiaries, we’ve had about 1,262 total cases. And when we look at our cases based on the same groupings that CMS grouped its data around—complexity—those with severe and persistent mental illness, we had 1,399 cases per 100,000. CMS’ data showed 3,794. Our disabled population fortunately did extremely well. We had 300 cases against CMS’ data of 1,663. And those with end-stage renal disease, we had 75 cases versus CMS’ data of 7,665. So we did quite well through this. Again, I want to caution that we’re still very much in this and continue to be concerned about the well-being of our populations.
MH: Were there certain things that you were able to do to reach those patients? You’ve been using data analytics to target services, right?
Palmieri: Philosophically, our approach has been that we put people first as an organization and we recognize that our populations are the most vulnerable for being impacted by COVID-19. It was a struggle to continue routine operations at a time when the world was shutting down and socially distancing. We weren’t able to do that. Our primary-care clinics, of which we have two, remained open. Our inpatient mental health facilities remained open. We assembled a team that, with the appropriate personal protective equipment, was able to continue visiting our most vulnerable in the community.
And then we did everything telephonically, and we were able to reach our population quite effectively and quite often. We did use data analytics to target services. We have, internal to our organization, a predictive analytics team, and we created a COVID-19 dashboard, which allowed us to have up-to-date, risk-weighted guidance for our care teams. We built that on the Google Looker platform and data from our electronic health record system, which included not only medical information but claims and external data. Social data from LexisNexis is synthesized to produce this dashboard, which allowed us to first focus on those with the highest probability of a sentinel event. And then, obviously, we focused on our entire population.
MH: Were you pushing information out to caregivers in the field?
Palmieri: That’s correct. And that was helping us prioritize … to make sure that those who were able to go out into the field knew exactly who they needed to see and re-prioritize their days, if they needed to do that. These were customized for each of our care coordinators.
MH: How have you balanced telehealth versus at-home versus in-clinic visits?
Palmieri: We have nearly 40,000 consumers and only two primary-care clinics that bookend the state. So we have to rely on a network of community resources. And one of the things that has been happening during COVID is the resources that were available back in January and February of this year were closing for a variety of reasons. This (data) tool allowed us to identify if there were access points for healthcare that were no longer going to be available. That helped us not only balance where we were going to send our staff, but how we reprioritize seeing people using telehealth. In the early days, we developed a protocol to find the right balance between care-at-home telehealth and the sort of legacy in-person care that we had provided, either in a clinic or in another outpatient setting.
We focused on questions such as what are the most urgent needs, what absolutely could not be done via telehealth. We had to take into consideration the supply of PPE because we’re not an acute-care hospital system, so we weren’t the essential organization that was going to be receiving the same stockpile as those treating people on an inpatient basis. We found, pretty early on, fortunately, that most of the necessary at-home visits were centered around skilled-nursing care, blood draws, wound and dressing changes, medication adjustments, or delivery of medications. Other things could be completed over video channels that we all know today as telehealth. We were able to leverage advanced-practice clinicians—nurse practitioners and physician assistants—to take over prescribing medications for members who couldn’t connect with their traditional primary-care physician. And we realigned that work so that our clinicians who were previously in the field could take that on as telephonic care partners.
MH: You also set up a $4 million program to help members with supplies. How has that worked?
Palmieri: On an early day back in March, before we were practicing the social distancing that we’re all familiar with today, I had our leadership team in our conference room, and as we were debriefing from one of our business meetings about how we were going to be executing against what we thought was coming at us, I asked a pretty simple question to our clinical leadership: “Are there things that the organization can be doing to ease this very traumatic transition for our members?”
One of our lead clinicians, Laura Black, said: “Our members are going to need things that the benefits don’t cover. Gatorade, toilet paper, paper towels, hand sanitizer.”
Little did we know then that a lot of these items would be very difficult to get but I left that meeting, called our board chair and said I need $4 million, or roughly $100 per CCA customer, and we’re willing to take that out of our operating surplus. We need to provide that to our members because they are going to need some additional lifeline of supplies at a time where, and again, we thought this was going to last for a few months, and here we are in the sixth month—40% of our members have taken advantage.