1. Transforming Service Delivery, Producing
Quality, Cost-Effective Outcomes
In Maine’s Medicaid Program
Presented by Mary C. Mayhew, Commissioner
Maine Department of Health and Human Services
Robert Wood Johnson Foundation
Super-Utilizer Project
Year Two Summit
July 31, 2013

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4. Camden Coalition’s Snapshot
Of Maine’s High-Cost Users
• 1 percent of all MaineCare patients accounted for over 30 percent of
total hospital costs across the three counties
• 20 percent accounted for 87 percent of costs.
• Most prevalent diagnoses:
– Alcohol-related disorders (over twice as likely as non-High Utilizers)
– Mood disorders
– Chronic obstructive pulmonary disease and bronchiectasis (almost twice
as likely)
• 1.8 times more likely to have an IP diagnosis of diabetes compared
to non-High Utilizers
• 72% of all IP High Utilizers were over age 34

5. Camden Coalition Snapshot
Of Maine’s High-Cost Users
ED High Utilizers
• Almost 1.5 times more likely to have an ED diagnosis of "anxiety
disorders”
• Almost 1.5 times more likely to have an ED diagnosis of
"spondylosis; intervertebral disc disorders; other back problems”
• 1.4 times more likely to have a diagnosis of "Headache; including
migraine“
• 67% of all ED High Utilizers were under age 35

6. • A relatively small number of MaineCare members are responsible for a large
percentage of the costs
• High utilizers cluster in “hot spots” across the state
• Improved integration of behavioral and physical health is a necessity
• Many high utilizers’ health may be improved through access to primary care,
preventive care, and chronic disease management
Our strategy must be:
• Community-based
• Address integration of behavioral and physical health
• Strengthen access to and use of patient-centered primary care
• Provide care management for high need members
• Social service agencies must address social/environmental barriers
What the Data
Tells Us

7. Emergency Department
Care Management Collaborative
• Began as a one-hospital
pilot project in 2011
• Identified 30 frequent ED
users
• Managed care with
delivery in most
appropriate setting
• Recognized more than
$100,000 in savings

8. Emergency Department
Care Management Collaborative
Expectations for participating hospitals:
– Investment of available care management resources for monthly case conferences
– Daily sharing of ED and inpatient census data
The State’s responsibilities:
– Bringing all resources together
– Providing care management resources
for hospitals/communities with insufficient capacity
– Daily census analysis
– Sharing of diagnosis, medical compliance,
PCP provider visits, and other utilization data
– Technical assistance

9. Emergency Department
Care Management Collaborative
As of June 2013
– All hospitals in Maine have
constructed their lists of high
utilizers.
– Now working with 1,700 members
– State staff dedicated to the
program.
– We are working with the larger
health systems to help
standardize processes and
facilitate clear communication
– Savings of over $4 million
annually.

10. Liz’s
Story
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• Introduced to program after 13 inappropriate hospital visits
• Took her case to upon referral of a local hospital
• Type II Diabetes, anemia, chronic pain, COPD, tobacco use,
drug abuse, epilepsy, incontinence, adult failure to thrive and
anxiety; suicidal.
• Recent right hip fracture and repair, neurogenic bladder, Bell’s
palsy, opioid dependence, deficits in mobility, which have been
helped by a wheelchair
• -Discharged from nursing home about a year ago

11. Liz’s
Story
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12. So Far,
So Good
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• In-home supports have allowed Liz to remain independent.
• Behavioral health services are provided in her home.
• No longer has thoughts of suicide.
• Has not visited the Emergency Department since February.
• Credits this program with saving her life.

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Maine’s High-Cost Utilizers
Cost Per Member
Cost PMPM Top 5 90 to 95% 80 To 90% Bottom 80%
$5,713 $1,750 $766 $78
Annual Cost

14. The Top
Five Percent
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15. The High
Five Team:
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• Form a group with at least two representatives from each of
the offices within DHHS
• Empower this group to act and ensure a holistic approach is
considered when services are made available
• Focus on services delivered and needs present NOT cost
• Benchmark is to bring the top 5 percent closer to the second
5 percent in service and cost by improving quality of care and
services provided

16. The High Five Team:
An Example
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• Two adult females
• Both receiving rent subsidy and MaineCare
• SSI disabled
• Diagnosis: depression
• Risk scores comparable
• Medical costs 2011
– Member #1 : $12,530
– Member #2 : $47,254

17. Maine Health Homes
A Key to Long-Term Sustainability
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Stage A (ongoing):
•Health Home = Medical Home primary care practice + CCT
•Currently have 150 enrolled practices and 10 CCTs
•Payment weighted toward medical home
•Eligible Members:
• Two or more chronic conditions
• One chronic condition and at risk for another
Stage B (Fall Implementation):
•Health Homes = CCT with behavioral health expertise + primary care
practice
•Payment weighted toward CCT
•Eligible Members:
• Adults with Serious Mental Illness
• Children with Serious Emotional Disturbance

18. Other Keys
To Sustainability
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• ROI; Quality Outcomes; Cost Effectiveness
• Federal Medicaid Policies Reflective of Social/Medical Model;
& Community-based services: Homemaker services/Peer
Supports; Any Willing Provider
• State Policy Reforms; Payment Reform
• Standardized practices/systems
• Commitment to Continual Process Improvement
• State Investments in the Model
• Integrated DHHS System
• Robust Data Systems/Data Analytics/Predictive Analytics

19. Thoughts from the Field:
Sustainability
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