How to Measure Care Quality - A Practical Guide

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1 Benchmarking n TC Claim anagement Deborah Grant, Principal Consulting ctuary illiman, nc. Joan tear, BN, RN Vice President Claim/Case anagement Penn Treaty Network merica tephen R. a Pierre enior Vice President Claim/Case anagement & Policyholder ervices Penn Treaty Network merica

Joan tear, BN, RN Vice President Claim/Case anagement Penn Treaty

2 Today we will... Benchmark: What is it? Getting started with Benchmarks Good, Bad, and Ugly Benchmarking & ctuarial cience Q & 2

3 Benchmark standard or reference by which something can be measured or judged. 3

4 Benchmarking To measure outcomes according to specified standards in order compare it with, and improve one s own result. 4

5 Where did it begin? 80 s & 90 s anaged care movement Before you can improve quality, you have to measure it Outcomes management emerging 5

6 Ultimately in TC... benchmark will be a disease/condition specific projection of the cost, units of service used, and duration of services provided to individuals on claim for the associated disease/condition. 6

7 laim anagement Eligibility Established Case anagement Care Coordination Care anagement ssessment Plan of Care Benchmark Claim Examining/Processing Confirming Coverage Explanation of Benefits Forms & Documentation nvoice Receipt / Review Payment Processing

Claim Examining/Processing Confirming Coverage Explanation of

8 laim anagement Case anagement Care anagement Plan of Care Benchmarking

9 Necessary Definitions 9

10 Case anagement: Underlying Premise Everyone benefits when clients reach their optimum level of wellness, selfmanagement, and functional capability: the clients being served; their support systems; the health care delivery systems; and the various payer sources ccmcertification.org 10

capability: the clients being served; their support systems; the

11 Case anagement: Defined... 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. t is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes 1 ccmcertification.org 11

monitors, and evaluates the options and services required to meet the client's health and human

12 Care anagement: Defined [subset of Case anagement] set of activities which assures that every person served by the system has a single approved plan of care that is coordinated, not duplicative, and designed to assure cost effective and good outcomes. 12

has a single approved plan of care that is coordinated, not

13 Office1 C Care gmt & TC: The challenge... ack of standardized measures ack of a standardized measurement process kepticism about the effectiveness of care management 13

14 lide 13 Office1 How do you know if you are getting your money's worth out of care management when you have nothing to compare the outcomes to- How would the claim have played out had there been no care management? Benchmarks will tell you what to expect and then actual performance can be measured against those benchmarks,, 2/12/2007

have played out had there been no care management?

15 benchmark provides... standard against which you can measure the effectiveness of your care management efforts Consistency with the management of targeted diseases/conditions starting point for projecting total costs of care for claims related to the benchmark disease/condition. Ultimately impacts pricing 14

management efforts Consistency with the management of targeted

16 Where do you start? Determine which disease/conditions to benchmark High frequency cute Greatest potential to impact Research practice patterns of medical community Review internal data et it [but don t forget it] benchmark Target percentage 15

17 Establish first benchmarks elect disease/conditions to measure Capture and analyze data Revise benchmarks as needed 16

18 naugural Benchmark Components Disease / Condition ge / ex verage expected duration [ncurred date to last date of service] 17

19 Benchmarks Total Hip Replacement [10-12 wks] Total Knee Replacement [8-10 wks] Coronary Bypass [4-6 wks] Fractured Hip [12-14 wks] troke [10-12 wks] 18

20 Company Results Data collection Demographic factors nfluence of acute care settings essons learned 19

21 Deeper Details Utilize data collection spreadsheet for discussion 20

22 ummary Observations Results and revisions of benchmarks anagement take-aways and application 21

23 ctuarial Perspective What is the benefit of a benchmark? Building a benchmark: Formal continuance tables Variation of parameters 22

24 Review Benchmark Definition benchmark is a conditionspecific projection of: Cost Units of service used Duration of services provided 23

25 ct. ci. 101 Claim cost at age x = Probability of going on claim at age x (i.e., frequency including probability of using services), Times average length of stay (O) (determined by continuance curve, benefit period and salvage), Times average cost of claim (cost per service times # of services/mo.) 24

26 verage O is determined by the Continuance Curve Continuance Curve Example: 67-year-old female, home care only Duration from claim (months) # of Claimants Remaining (out of 1000) 0 1,

27 Variation of Parameters Disease tate/condition Co-morbidities 26

28 Variation of Parameters (cont.) ttained age ssue age Duration Policy Type ( NH, HHC, Comprehensive) ex arital status 27

29 Variation of Parameters (cont.) Geographic rea ifetime vs. shorter benefit periods Distribution ystems (Broker, Captive) 28

30 Data crubbing dentify missing fields dentify fields with data issues (example marital status) Example: coding every day of service as opposed to a range of service dates 29

31 Data crubbing alvage: The degree to which i) the maximum daily benefit is not paid, and ii) services are not received every calendar day. Claims closing due to payment of the maximum benefit. 30

32 Continuance Curve (repeat) Continuance Curve Example: 67-year-old female, home care only Duration from claim (months) # of Claimants Remaining (out of 1000) 0 1,

33 verage O from Continuance Curve (Termination Rates) 1 * 869 = * 780 = * 55 = * 13 = , 859 life-months 5,290 lives verage O = about 9 months 32

34 How do you deal with Claims Closing due to aximum Benefit Payment? nswer: Calculate Termination Rates for Each onth adjusting for ax. Ben. Terminations Calculate verage O from Termination Rates 33

35 Example onth Claims w 2 yr. BP Claims w ifetime BP Total

36 Example (cont.) onth Claims w 2 yr. BP Claims w ifetime BP Total Continuance Rate onth 23 = 80/100 or.8 Continuance Rate onth 24 24/80 or.3 Rather Continuance Rate onth 24 = 24/50 or.48 35

37 How many do we Expect to Continue? Continuance Curve Example: ade-up for Hip Replacement Duration from claim (weeks) # of Claimants Remaining (out of 100)

38 sk an ctuary tart to nalyze Termination Data as You Go Review claims near average duration verage Charge 37

39 ummary tatements Benchmarking in TC is evolving Capture your un-harvested claim intelligence Understand the total cost of care for a condition. Observe how treatment options impact resource utilization Each company must compare their internal resource utilization data to external national and regional benchmarks, and thereby gauge performance 38

40 ummary tatements Understand effectiveness of your C interventions mprove consistency of interventions ore accurate forecasting of claim costs ore accurate data for claim reserving Valuable pricing/valuation data 39

41 Q & The End 40

Using Medicare Hospitalization Information and the MedPAR. Beth Virnig, Ph.D. Associate Dean for Research and Professor University of Minnesota

Using Medicare Hospitalization Information and the MedPAR Beth Virnig, Ph.D. Associate Dean for Research and Professor University of Minnesota MedPAR Medicare Provider Analysis and Review Includes information