Designing Care Management Programs to Improve Outcomes

Transcription

1 Designing Care Management Programs to Improve Outcomes Society of Actuaries June 13-15, 2007 Holly Michaels Fisher, Senior Consultant Reden & Anders SPH81Fisher Ingenix, Inc. 2

2 Traditional Components of Medical Management Utilization Review Pre-Authorization Concurrent Review Case Management Demand Management Disease Management Specialty Case Management Population Health Management Ingenix, Inc. 3 What is care management? An umbrella term Incorporates components of traditional medical management In concept, reflects a more integrated approach to managing care A few examples A set of activities which assures that every person served by the system has a single approved care (service) plan that is coordinated, not duplicative, and designed to assure cost effective and good outcomes. Initial and continuing authorizations are generated by care coordinators. Case Management Society of America Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. Ingenix, Inc. 4

3 Overlapping Definitions Disease Management Association of America Disease management: A system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant. National Quality Forum Care coordination Is a function that helps ensure that the patient s needs and preferences for health services and information sharing across people, functions, and sites are met over time. Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved healthcare outcomes. Ingenix, Inc. 5 What we know There is no single definition of Care Management Care management is a broad term that describes approaches to medical management that are changing and evolving Terminology is imprecise, is not standardized, and is evolving and changing Care management means different things to different people Can be considered narrowly as one component of medical management Can be considered as the overarching medical management framework or umbrella Measuring outcomes, especially financial outcomes is difficult Common themes that cross definitions Coordination Stratification Targeting/Focus Involves the provider and the member Ingenix, Inc. 6

4 Key Reasons Why Care Management Initiatives Often Fail Problem 1 Too many initiatives and not enough focus Problem 2 Institutionalization of programs Problem 3 Physician support assumed, not earned Problem 4 Misalignment with provider risk sharing arrangements Problem 5 Other organization activities not supportive of initiatives Problem 6 Little rigor in estimating costs and returns on investment Problem 7 Evaluation metrics for savings or quality not planned Ingenix, Inc. 7 Too many medical cost management initiatives are unfocused or unnecessary, and as a result, not optimally productive Problem 1 Plans initiate multiple individual care management programs at the same time without testing for overall impact or integration HEDIS has diverted resources from high cost and high acuity cases Since a large percentage of medical costs are attributed to a small percentage of members, fewer resource-intensive and focused initiatives are generally most productive Ingenix, Inc. 8

5 Once a medical management program is initiated, it becomes institutionalized and, therefore, difficult to change Problem 2 Most programs produce some positive results As a result, marketing and other executive staff are fearful of discontinuing or changing the programs Metrics are usually weak or absent, but anecdotes are prevalent and powerful Programs without clinical value make providers and members cynical Example Pre-authorization program implemented for specific procedures by a health plan Program in place for many years Large number of resources required to manage process which is highly manual No process or outcomes measurements in place to monitor operational costs, operation efficiency, outcomes, or savings Retrospective analysis: Low cost high volume procedures approved 100% of the time Changes implemented without analysis of underlying data Ingenix, Inc. 9 Physician support of care management initiatives is often assumed, not earned Problem 3 The true payoff from care management programs is dependent on the understanding and cooperation of the members physicians Care management interventions often rely extensively on a change in physician practice Physician to physician communication is critical to ensure appropriate Not enough resources are devoted to physician communication Example 1 Implementing a cardiac disease management program without involving plan physicians in intervention design or outcomes metrics Beta blocker use post-mi only rose 5% despite a significant educational effort Example 2 Health plan held a series of physician focus groups to obtain input and test ideas for a series of pharmacy-related care management interventions Interventions incorporated physician feedback Outcomes included a nearly 50% improvement Ingenix, Inc. 10

6 Care management programs are often mis-aligned with provider risk-sharing arrangements Problem 4 The relationship of the intervention cost to the savings and provider payment incentives and structures is sometimes not considered in program design The distribution of costs and savings between providers and the plan is sometimes not estimated The plan may incur the cost for the intervention but the provider realizes the majority of savings Example Administrative cost for intervention at $1,800 per participating member and cost is borne by health plan Medical cost savings at $5,400 and is accrued by providers in full risk arrangement Health plan return on investment = ($1,800) Provider return on investment = +$5,400 Ingenix, Inc. 11 Other plan activities and initiatives do not always support care management initiatives Problem 5 Network Strategy HMO vs. PPO vs. POS medical management programs and strategies sometimes different but networks often overlap causing physician confusion Delegation in the HMO vs. centralization for some products may challenge a uniform, state-of-art, approach Provider Reimbursement Specialty and ancillary contracting may be inconsistent with care management programs Risk arrangements may not be aligned with care management programs Payment incentives at odds with care management interventions Effects of risk sharing do not reach to individual providers within medical groups or institutions Product Design & Pricing Benefit design does not incent appropriate use of services by members Marketing may sell what can t or shouldn t be delivered Insufficient time spent on designing after - sales - service and reporting Ingenix, Inc. 12

7 Little rigor in quantifying care management program costs and returns on investment leads to confusion about program effectiveness Problem 6 Plans do not develop sound business cases for investments or define expected outcomes prior to implementation The measurement of programs ROI is complex and varies by program and disease type For disease management programs, measurement must take into account the natural course of the disease (regression to the mean) Program costs are often underestimated, not consistently defined or measures Multiple methods to track disease management program savings include: Comparing total disease-related costs before and after program implementation Comparing affected member costs before and after program Concurrent and prospective risk scores Savings must include quantifying costs of avoided care less costs of substitute care Ingenix, Inc. 13 Metrics for evaluating care management program effectiveness are often not built into the program s design Problem 7 Metrics that are not built into the program upfront are therefore unavailable during the program evaluation phase Clinical and financial outcome measurement is complex Clean claims data and total health related costs can be a challenge to obtain and measure in a timely manner Programs are sometimes instituted for a specific customer, and development time is often limited Example A health plan instituted a congestive heart failure disease management program A year later it wants to evaluate the program s effectiveness Not able to measure outcomes and quantify cost savings because: Appropriate claim and clinical data were not collected initially or at the appropriate intervals during the program Ingenix, Inc. 14

8 Developing effective care management programs: Start by measuring current performance against comparative benchmarks to identify opportunities and set priorities Example: Physical Therapy Costs Visits/member Cost/visit $65.80 $70.20 Best practice National Average Gross PMPM $60.00 $64.00 $1.30 $1.35 $1.05 $1.25 HMO 1999 National Average Best Practice Savings Opportunity Visits/member Cost/visit Gross PMPM Total savings opportunity $70.20 $ $64.00 $ $60.00 $1.05 $6.20 $0.10 $1.6 Million Ingenix, Inc. 15 Development of interventions: Identify multiple interventions for each opportunity, based on data, analyses, and clinical input, pilot and/or vet with key stakeholders before implementation Example: Physical Therapy Costs Possible Interventions Central authorization on non-targeted diagnosis of physical therapy visits after 20 visits rather than 30 visits Implement case rates for certain conditions Increase the list of procedures requiring prior authorization Narrow provider network Implement annual benefit cap at visits per year or graduated copayments Ingenix, Inc. 16

9 Care Management Program design and implementation: Facilitated by work groups and a collaborative process to enhance buy-in throughout the organization and with providers Project sponsors Project Manager Steering Committee Primary work groups Pre Authorization Care Management Disease Management Benefit design, Pricing Network Strategy Pharmacy Project Facilitator/Integrator Ingenix, Inc. 17 An Example Ingenix, Inc. 18

10 Population-Based Care Management Population-based care management disease-neutral compared with disease management which focuses on patients with target conditions. Population-based care management approach includes: Data analysis Predictive modeling Selective management of members predicted to be at highest risk 2002 study by Lynch, et al 1 of population management reported: Reduction of 5.3 percent in total commercial admissions 3.0 percent reduction in total Medicare population admissions Reduction of 35.7 percent in claims for the high-risk sub-set of the combined Medicare and commercial populations Diabetes as an example Numerous valid studies that show clinical improvement in diabetic populations as a result of DM interventions 2 Causal link from clinical to financial improvement has not been proven with respect to diabetes 1- Lynch, J. P., S. A. Forman, S. Graff, and M. C. Gunby High Risk Population Health Management--Achieving Improved Patient Outcomes and Near-Term Financial Results. American Journal of Managed Care 6 (7): Dove, Henry G. and Duncan, Ian An Introduction to Care Management Interventions and Their Implications for Actuaries, Paper 3: Estimating Savings, Utilization Rate Changes, and Return on Investment from Care Management Interventions Selective Literature Review of Care Management Interventions, March 2005 Ingenix, Inc. 19 Medicare analysis suggests positive causal relationship between compliance and cost for diabetic population Analysis of the relationship between compliance with evidence-based testing standards and preventative care and Medicare fee-for-service (FFS) claims costs Medicare-eligible population with diabetes Medicare % FFS Standard Analytical File Evidence of compliance measured as the presence or absence of claims with procedural codes for particular diagnostic tests and preventative care services Findings: Medicare beneficiaries with diabetes who are compliant on average have lower medical expenses compared to noncompliant beneficiaries Lower Medicare costs primarily the result of reduced hospital admissions Ingenix, Inc. 20

11 Ingenix, Inc. 21 Findings from Diabetes Compliance and Medicare Cost Study Relationship of A1c Testing for Inidivduals with Diabetes to Medicare FFS Claims Experience Relationship of LDL-C Testing for Diabetics and Medicare FFS Claims Expense M edicare Claims $ PM PM $1,200 $1,000 $800 $600 No A1c tests One A1c test One or more A1c tests Tw o or more A1c tests Medicare Claims $ PMPM $1,200 $1,000 $800 $600 No LDL-C tests One or more LDL-C tests One or more A1c tests & one or more LDL-C tests Two or more A1c tests & one or more LDL-C tests Inpatient Acute SNF ER PMPM Compliance Testing Admits/1,000 Admits/1,000 Util/1,000 Professional No A1c tests $261 Two or more A1c tests $272 Difference 38% 54% 32% -4% Ingenix, Inc. 22

12 Diabetes: Relationship of Compliance to Margin 35% 30% 25% Margin 20% 15% Average Margin 10% 5% 0% No A1c tests No LDL-C No lipid panel No flu vac. No DRE Micro./neph. No pneumonia vac. One A1c test No micro./neph. Pneumonia vac. DRE Lipid panel 1+ LDL-C tests 1+ A1c Flu vac. 1+ A1c, 1+ LDL-C 2+ A1c 2+ A1c, 1+ LDL-C Measures of Diabetes Compliance Margin Percentage Average Margin Measured as the difference between average Medicare FFS Ingenix, Inc. 23 medical expense and HCC adjusted payment rates Contact Information Holly Michaels Fisher Senior Consultant Reden & Anders One Penn Plaza, Suite 615 New York, New York Office: (212) Cell: (347) Ingenix, Inc. 24

13 Case Management in a Medicaid Population Denise Christian, M.D. National Chief Medical Officer Presentation No. SPH81 AmeriChoice Overview Founded in Pennsylvania in Acquired by UnitedHealth Group in September Leading public sector health care specialist: Medicaid, SCHIP, and Medicare SNP with 1.4 million members in 12 health plans. 2

14 AmeriChoice MSO Contract with state of Georgia to provide Disease Management Services Fees at Risk based on a combination of Financial and Clinical Outcomes Managing Sickle Cell, Hemophilia, HIV/AIDS, Schizophrenia, Depression and Bipolar Disease Subcontracting subset of population to LifeMasters 3 Medical Management Approach All Members Case Management Members with Chronic, Non-Acute Conditions Members with Chronic, Acute Conditions General outreach and education Encourage preventive care Targeted education Periodic telephone calls Regular review of encounters / utilization Nurse /social worker team assigned Understand total environment Engage family, friends, community organizations Develop individualized care program 4

15 Case Management Interventions Coronary Artery Disease (CAD) or Ischemic Heart Disease (IHD) LDL screening performed on or between 60 and 365 days after discharge for an acute cardiovascular event Members who received a flu vaccination within the last 12 months Congestive Heart Failure Heart failure members taking ACE inhibitors, or in the case of ACEintolerant patients, those taking ARBs Heart Failure members who received a flu vaccination within the last 12 months Diabetes Members with diabetes who had at least two A1C tests in measurement year Members with diabetes who completed one fasting lipid panel test in the measurement year 5 Case Management Interventions Asthma Asthma members with at least one dispensed prescription for inhaled corticosteroids, cromolyn sodium, or leukotriene modifiers in the measurement year Chronic Obstructive Pulmonary Disease (COPD) Members with annual spirometry testing as supported by American Thoracic Society (ATS) guidelines COPD members who received a flu vaccination within the last 12 months Schizophrenia Members receiving maintenance treatment (atypical antipsychotic medication) for at least one year following acute episode 6

16 Barriers to Case Management Fluctuating Eligibility Social Barriers inadequate housing, food, transportation, etc Behavioral Health and Substance Abuse (state carve outs) Low contact rates with mailings and telephonic outreach 7 Impact Pro Capabilities Identifies members at risk before they experience problems Quantifies the relative risk between members Translates risk scores into potential health care costs in dollars Helps to deploy resources effectively by targeting the right members proactively Better understanding of what is driving utilization 8

17 Medicaid Specific Considerations in Implementation Benefit carve outs e.g. pharmacy, behavioral health Forced eligibility ignore gaps in enrollment Multiple sources of data e.g. pharmacy files, new member data Customized case definitions and care opportunities e.g. lead testing, schizophrenia Inclusion of denied claims lack of eligibility; COB (Medicaid is payor of last resort) 9 Impact Pro Implementation ASP Model Implementation kick off: September 2006 Established Weekly IPRO Workgroup Data extract preparation and submission: October 2006 February 2007 Data processing: February 2007 with monthly refreshes 10

18 Impact Pro Implementation December 2006: High Risk definition established by medical team of nurses and physicians Plan-Wide Training (3 locations) February 2007: User Acceptance Testing National Medical Management Dept distributes Top 1% High Risk List monthly 11 High Risk Definition Utilization 4 admits in 6 months; 2 ER visits in 3 months Medical condition that is impactable Critical gaps in care Inpatient Stay Probability greater than 40% in the next 3 months Lack of a Medical Home 12

19 Overall Population Outcome Statistics Decrease in emergency department visits Decrease in hospital admissions Decrease in total inpatient days Increase overall health status of members 13 Demographics and Distributions AmeriChoice Health Plans and the MSO

20 Age Average Age Age ACNJ ACNY ACPA APIPA GLHP UHGFL UHGMD UHGNE UHGNY UHGRI UHGTX UHGWI MSOGA MSOWA 15 High Risk Condition Prevalence Condition Health Plans Member Count % of Total Members Member Count MSO % of Total Members High Risk Asthma % % High Risk CAD % % High Risk CHF % % High Risk COPD % % High Risk Depression % % High Risk Diabetes % % High Risk HIV % % High Risk Kidney Disease % % High Risk Sickle Cell % % 16

21 Asthma Prevalence 6.0% Asthma 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% ACNJ ACNY ACPA APIPA GLHP UHGFL UHGMD UHGNE UHGNY UHGRI UHGTX UHGWI MSOGA MSOWA Percent of Membership Asthma High Risk Asthma 17 CAD Prevalence 4.0% CAD Percent of Membership 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% ACNJ ACNY ACPA APIPA GLHP UHGFL UHGMD UHGNE UHGNY UHGRI UHGTX UHGWI MSOGA MSOWA CAD High Risk CAD 18

22 COPD Prevalence Percent of Membership 5.0% 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% ACNJ ACNY ACPA APIPA GLHP COPD UHGFL UHGMD UHGNE UHGNY UHGRI UHGTX UHGWI MSOGA MSOWA COPD High Risk COPD 19 Diabetes Prevalence 14.0% Diabetes Percent of Membership 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% ACNJ ACNY ACPA APIPA GLHP UHGFL UHGMD UHGNE UHGNY UHGRI UHGTX UHGWI MSOGA MSOWA Diabetes High Risk Diabetes 20

23 HIV Prevalence HIV 2.0% 1.8% 1.6% 1.4% 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% 0.0% ACNJ ACNY ACPA APIPA GLHP UHGFL UHGMD UHGNE UHGNY UHGRI UHGTX UHGWI MSOGA MSOWA Percent of Membership HIV High Risk HIV 21 IP Stay Probability by Age Inpatient Stay Probability by Age Inpatient Stay Probability 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Health Plan Avg = 3% MSO Avg = 11% Age 0 to 5 Age 6 to 10 Age 11 to 15 Age 16 to 20 Age 21 to 25 Age 26 to 30 Age 31 to 35 Age 36 to 40 Age 41 to 45 Age 46 to 50 Age 51 to 55 Age 56 to 60 Age 61 to 65 Age 66 to 70 Age 71 to 75 Age 76+ Health Plans MSO Average Age is 19 for the health plans and 43 for the MSO 22

24 Future Costs by Age Expected Future Costs Per Member $50,000 $45,000 $40,000 $35,000 $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $- Expected Future Costs by Age Health Plan Avg = $2,811 MSO Avg = $33,459 Health Plans Age 0 to 5 Age 6 to 10 MSO Age 11 to 15 Age 16 to 20 Age 21 to 25 Age 26 to 30 Age 31 to 35 Age 36 to 40 Age 41 to 45 Age 46 to 50 Age 51 to 55 Age 56 to 60 Age 61 to 65 Age 66 to 70 Age 71 to 75 Age Expected Future Costs Health Plans AmeriChoice Risk Distribution Percent of Members in Expected Future Cost Range 8% 2% 1% 2% 19% 68% $ $1, $2, $4, $5, $9, $10, $14, $15, $19, $20, and more 24

25 Expected Future Costs - MSO MSO Risk Distribution Percent of Members in Expected Future Cost Range 5% 10% 13% 54% 9% 9% $ $1, $2, $4, $5, $9, $10, $14, $15, $19, $20, and more 25 Conclusions and Next Steps Impact Pro is user friendly and well accepted by staff Data is valuable and a great asset to our case management programs Continue to fine-tune the identification of High Risk and build new case definitions Conduct analysis on the accuracy of identifying the right member Measure effectiveness of the case management program 26