Improving the Management of the Dual Eligible Population

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1 Improving the Management of the Dual Eligible Population Kathryn Eshelman, MD, MPH October 26, 2012

2 Discussion Objectives Since dual eligibles are often and increasingly members of risk adjusted, disease management and quality programs, strategies are needed to effectively ensure proper analytics and interventions are used in this population. We will cover: Integration of Medicare and Medicaid models when performing analytics for risk adjustment gaps, quality and disease management Utilization of analytics to coordinate care across multiple providers and programs Case studies that illustrate these best practices Application of best practices refined over years of working with Medicaid and Medicare Advantage populations to the dual eligible 2

3 Uncoordinated Outreach Leads to Fragmentation of Care When outreach to members and providers is poorly coordinated, the message may be misconstrued, goals blurred, care fragmented, and the opportunity for highly productive physician-patient encounters may be squandered. INV Integrating Chronic Care with RA and 5-Star QI ( ) v

4 Programs Lack Integration Across Key Functions Historically, the healthcare landscape has had disparate programs operating independently with limited collaboration. Disparate data, programs, and member outreaches results in: Limited insight into member health and outcomes Lack of transparency and collaboration Incomplete information to address complex issues Lower program impact Inefficiency and higher cost INV Integrating Chronic Care with RA and 5-Star QI ( ) v

5 Integrated Approach The integration of otherwise disparate health plan initiatives, with the support of highly granular data-driven analytics, improves clinical and financial outcomes in a rapidly changing healthcare landscape. 5

6 What is Risk Adjustment? With the implementation of fully risk-adjusted capitation reimbursement models, Medicare Advantage, Managed Medicaid, and an increasing number of commercial plans are financially dependent upon the specific documentation of each individual member diagnoses as classified within the CMS Hierarchical Condition Category (HCC), ACG, CRG, DxCG, CDPS, or other risk factor model system. Coding vs. documentation the outpatient physician. Retrospective Risk Adjustment Updated Risk Score Accuracy for Prior Date of Service Prospective Risk Adjustment Updated Risk Score Accuracy for Current Date of Service Target Medical Records for Review Outreach to Member & Doctor 6

7 Current Risk Adjustment Models Medicare Medicaid Fee for Service Plan A Plan A State Medicaid Plan A Plan B Plan A Plan A Maximum Benefit for the System, Plan, Patient, and Provider 7

8 HCC Risk Adjustment Model The CMS-HCC Model is designed to boil down the ICD-9 system of approximately 35,000 codes into 3,100 codes which are applicable under the model. These codes and only these codes are classified into 70 qualifying groups referred to as HCC(s). Hierarchical Condition Category Model 35,000 ICD-9 Codes 3,100 Qualifying Diagnosis 70 HCCs 8

9 Medicaid Risk Adjustment Models Because the Medicaid population is often more heterogenous the Medicaid risk adjustment models (including CDPS, CRG, and ACG) are much broader. CDPS model, which is used in many states, includes approximately 7,000 ICD9 diagnosis codes. Common conditions that include coronary artery disease and hypertension are a part of CDPS but those conditions are not a part of HCC (part C). Chronic Illness & Disability Payment System 35,000 ICD-9 Codes 7,000 Qualifying Diagnosis 80 CDPS Subcategories The CRG model is even more broad with more than 15,000 ICD9 diagnoses 9

10 Plan Membership Inovalon generated an analysis of a health plan s December 2011 dual eligible to illustrate disease condition and co-morbidity prevalence. Based on the analysis of the health plan s membership, 4,515 have the following core chronic condition prevalence rates. Non-unique member condition detail: 2,761 Diabetes 2,113 CAD 1,340 Heart Failure 2,493 COPD 1,513 Asthma 2,945 members with two or more conditions (65%) 1,718 members with three or more conditions (38%) 10

11 Dual Eligible Member Analysis As part of the analysis, Inovalon performed comparative analytics across population age distribution for a health plan s Dual Eligible members as compared to regional averages to assess comparative disease incidence prevalences. The analysis identified: The average age of Plan s Dual Eligible population is years and the average risk score is The average age of the regional Dual Eligible population is 69.8 years and the Average Risk score is Number of HCCs Number of Members Average Risk Factor Amerigroup Medicare Advantage (MD) Population Distribution by Age Amerigroup Members Normalized Regional Baseline 11

12 The Advantages of a Coordinated Dual Eligible Prospective Approach Prospective risk adjustment offers an even greater benefit because in prospective risk adjustment the clinician and the patient are directly involved in the documentation. Who Benefits? Member Provider Plan 12

13 The Advantages of a Coordinated Dual Eligible Prospective Approach for the Provider There is great benefit from maintaining a centralized source of information. Showing centralized information to the provider can help: Prevent unnecessary ER and hospital visits Give the provider the information they need to address and close risk adjustment gaps Give the provider the information they need to close gaps in HEDIS and Star quality measures including medication adherence Care coordination with respect to appropriate specialists, labs, tests, and equipment 13

14 The Advantages of a Coordinated Dual Eligible Prospective Approach for the Member Benefit for the Member Dual eligible members often have extremely complicated health conditions When all of the member s care is coordinated through one source, the provider can see the total picture When the provider can see the total picture, the member will benefit Members assume that their care is more coordinated than it really is, a coordinated approach gets us one step closer. 14

15 The Advantages of a Coordinated Dual Eligible Prospective Approach for the Plan Benefit for the Plan Less member and provider abrasion All calls and letters are centralized and so the member is not being contacted by multiple plans Conditions that are targeted and documented in one visit lead to higher revenue 15

16 Coordinated Member Outreach Coordinated member outreach facilitates gap closure across multiple programs. In-Home Face-to-Face Mailings SMS Phone Call INV Integrating Chronic Care with RA and 5-Star QI ( ) v

17 Role of Decision Support Tools in Risk Adjustment Recordkeeping, comprehensive clinical history, proper coding, and maintaining communications with members are just a few reasons why health plans and providers are integrating the usage of decision support solutions into their administrative duties. When developing a risk adjustment solution, consider: Does this solution provide various intensities of interventions for your diverse member population and take into consideration the health plan s investment objectives. Does this solution assist providers in identifying member gaps in care and documentation? Will this solution provide you comprehensive clinical data on your members? How does this solution integrate with your existing databases? Can this solution import your native files? 17

18 Case Study Mail and Telephonic Outreach Ms. Vince is a 44-year old female and is a dual eligible member with: bipolar disorder hypertension liver disease Challenges: Has not seen PCP in nearly a year Most of her care is provided by her psychiatrist and ER Solution: Sent letter to encourage her to schedule a PCP visit When monthly analytics reveal that she has not yet seen her primary care provider the member is called by a nurse. Facilitated appointment setting with a warm transfer PCP received complete medical history prior to appointment 18

19 Case Study In-Community Nurse Outreach A patient with CAD who is non-compliant with an exercise regimen or with cholesterol tests and medications may have major depression. be trained to screen for symptoms of depression understand that patients with chronic conditions are at risk for major depression Nurses Must communicate effectively to the affected patient communicate effectively to the doctor (either directly or via the patient) raise awareness which can lead to accurate diagnosis, which in turn enables more effective clinical management and allows precise documentation INV Integrating Chronic Care with RA and 5-Star QI ( ) v

20 Financial Impact Major Depression Risk Adjustment $3, per year Quality (HEDIS and Star) Antidepressant Medication Management Cholesterol LDL Cholesterol Medication Adherence INV Integrating Chronic Care with RA and 5-Star QI ( ) v

21 Health Plans, Providers and Member Working Together Patient Health Plan Provider INV Integrating Chronic Care with RA and 5-Star QI ( ) v

22 Coordinated Provider Outreach In order to facilitate gap closure for chronic care support and risk adjustment (as well as those for Five Star Quality Ratings), provider communication must be highly specific for individual members and must support the provider s plan of care. INV Integrating Chronic Care with RA and 5-Star QI ( ) v

23 Case Study The Primary Care Provider and the Decision Support Tool Mr. Smith is a 45-year old male and is a dual eligible member with: Spinal cord injury Diabetes Hyperlipidemia Anxiety Challenges: He has other diagnoses that are not being treated He is taking two diabetic medications in same class Solution: Member is encouraged to schedule an appointment with PCP PCP is given online tool with complete medical history and claims Perform a PHQ-9 Document all conditions Resolve polypharmacy issue and prescribe statin Give referral for diabetic eye exam 23

24 Case Study An In-Home Assessment Mrs. Jones is a 70-year old female and is a dual eligible member with: Diabetes COPD Hyperlipidemia Alcohol dependence Challenges: Transportation to PCP is difficult Most care is from ER and hospital Solution: In-Home Assessment from NP to update documentation and assessment Additional conditions identified Medications reviewed Preventive care discussed Case management referral identifies new PCP closer to home PCP is equipped with full medical profile and history 24

25 Gap Closure Affects Multiple Programs Outcomes A data-driven, and member-specific approach to chronic care support and care coordination provides a more meaningful and impactful outcome on clinical and financial performance. Mrs. Jones is not simply a member with Type 2 diabetes who is: High risk, Medium risk, or Low risk. Mrs. Jones is actually a unique individual with multiple concurrent issues Member Profile: Ethel Jones Previously diagnosed with diabetes, but not properly coded with LLE trans-metatarsal amputation, known peripheral neuropathy and known vascular disease Suspected diagnosis of COPD due to taking Albuterol and receiving inhalation treatments Chronic Care Support Healthcare Gaps Risk Score Accuracy Five-Star Quality Improvement Rising HbA1c rate Overdue for an eye exam No breast cancer screening for past two years History of elevated blood pressure Medication adherence related to prescribed Beta Blocker post MI Recent hospital discharge INV Integrating Chronic Care with RA and 5-Star QI ( ) v

26 Discussion Objectives Since dual eligibles are often and increasingly members of risk adjusted, disease management and quality programs, strategies are needed to effectively ensure proper analytics and interventions are used in this population. We will cover: Integration of Medicare and Medicaid models when performing analytics for risk adjustment gaps, quality and disease management Utilization of analytics to coordinate care across multiple providers and programs Case studies that illustrate these best practices Application of best practices refined over years of working with Medicaid and Medicare Advantage populations to the dual eligible 26

27 DO NOT DISTRIBUTE Corporate Headquarters: 4321 Collington Road Bowie, Maryland USA CONFIDENTIAL 2012 Inovalon, Inc. All rights reserved. The Inovalon spiral is a registered trademark of Inovalon, Inc.

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