Controlling Advanced Diagnostic Imaging With Specialty Benefits Management: Two Case Studies. Mark D. Hiatt, MD, MBA, MS & Timothy R.

Transcription

1 Controlling Advanced Diagnostic Imaging With Specialty Benefits Management: Two Case Studies Mark D. Hiatt, MD, MBA, MS & Timothy R. Johnstad, MBA 1

2 Agenda Introduction to Speaker & HealthHelp Objectives Background Challenges faced by Medicaid plans Specialty Benefits Management (SBM) Case Studies Background Methods Results Conclusion Questions & Answers 2

3 Introduction to Speaker Mark D. Hiatt, MD, MBA, MS Chief Medical Officer HealthHelp Chief Medical Officer of HealthHelp, a specialty benefits management company Former clinical department leader & board member for a health system Fellowship in cardiovascular imaging at Stanford University Residency in diagnostic radiology at the University of Virginia MD from Wake Forest University MBA from Wake Forest University Master s in Health Evaluation Sciences (with an emphasis in medical informatics) from the University of Virginia 3

4 Introduction to HealthHelp HealthHelp enables patients to receive appropriate care, provides education and risk management for providers, and generates savings for payors Patient advocacy Get the right test at the right time Reduce unnecessary & inappropriate procedures Less radiation exposure Lower spend by managing utilization Inclusion in 85% of MLR improves profitability Creates a content provider network No hard denials mitigates legal risk 3-year URAC and NCQA accreditation Peer-to-peer model without denials embraced by physicians Clinical education & support Documentation of evidence for procedures helps providers manage risk Minimizes potential lawsuits 4

5 Objectives Explain how Specialty Benefits Management (SBM) can achieve appropriate utilization of advanced diagnostic imaging Describe the experience of 2 Medicaid plans with SBM Commercial State-run 5

6 Agenda Introduction to Speaker & HealthHelp Objectives Background Challenges faced by Medicaid plans Specialty Benefits Management (SBM) Case Studies Background Methods Results Conclusion Questions & Answers 6

7 Challenges Faced by Medicaid Plans Challenges Greater reliance on Medicaid because of Affordable Care Act Limited resources to provide comprehensive health services Inconsistent quality measurements Difficulty aligning disparate providers to meet patient needs Difficulty maintaining a satisfied provider network Solutions Emphasis on collaboration & education Guidance from practicing academic subspecialists Evidence-based guidelines that educate on clinical best practices Clinical decision support that suggests alternatives 7

8 Specialty Benefits Management Seeks to improve health outcomes & decrease costs through reducing unnecessary medical care Achieves appropriate utilization through prospectively guiding providers to the right procedures Provides assessments through multiple tiers of progressive clinical expertise MRI/MRA CT/CTA PET/CNM Quality Oversight 8

9 Specialty Benefits Management Consultation * Rules met Education Request received for procedure Quality tracking number issued Assessment performed Rules not met Nurse reviews case Rules not met Physician specialist consults Procedure changed Procedure not performed Consultation No consensus Certification Certification Auto fax educational material Auto educational material Denial * Levin DC, Bree RL, Rao VM, Johnson J. A Prior Authorization Program of a Radiology Benefits Management Company and How It Has Affected Utilization of Advanced Diagnostic Imaging. J Am Coll Radiol 2010; 7:

10 Agenda Introduction to Speaker & HealthHelp Objectives Background Challenges faced by Medicaid plans Specialty Benefits Management (SBM) Case Studies Background Methods Results Conclusion Questions & Answers 10

11 Case Studies: Background Many Medicaid plans are considering SBM to improve outcomes & decrease costs through reducing unnecessary care To consider: What is the impact of SBM on the utilization of advanced diagnostic imaging for Medicaid patients? Any difference in impact between commercial & staterun plans? 11

12 Methods: Selection Selection of Medicaid plans Commercial ~150K patients Southwestern state State-run ~850K patients Northeastern state SBM selection One of the major SBM companies managing the utilization of imaging in the U.S. Approach focused on educating providers on the latest evidence-based standards Imaging modalities overseen: CT, CTA, MRI, MRA, PET & cardiac nuclear medicine No hard denial if the peer-to-peer conversation ends with continued disagreement, emphasizing the collaborative basis of the selected approach 12

13 Methods: Timelines Commercial: SBM implementation in 2006 Commercial SBM implementation State-run: SBM implementation in April 2011, focusing on the results from June 2011 September 2012 * April 2011 June 2011 September 2012 State-run SBM implementation Results from SBM implementation * The 1 st 2 months of April and May 2011 were excluded, as the program was being ramped up during this time. 13

14 Results: Commercial High vs. low tech Month After Implementation Using January 2006 utilization as a benchmark, high-tech utilization progressively decreased under SBM (by ~20% in total), whereas unmanaged low-tech utilization slightly increased. 14

15 Results: Commercial By modality Month After Implementation Utilization declined in all modalities, except PET. 15

16 Results: Commercial Savings Month After Implementation Using 1Q06 average prices for all time periods (to adjust for price variation), we see reductions of ~$1.35 PMPM * in 2011 vs *PMPM (per member per month) is a measure of cost. 16

17 Results: State-Run Utilization of advanced diagnostic imaging declined by 13% (Consults per 1,000 Members * declined from in June 2011 to in September 2012) Month After Implementation *Consults per 1,000 Members is a proxy for utilization. In this determination, a utilization rate index approach compares the June 2011 baseline to all subsequent months. 17

18 Conclusion SBM can assist Medicaid plans, both commercial and staterun, in decreasing costs through reducing unnecessary medical care. SBM Medicaid 18

19 Questions & Answers Mark D. Hiatt, MD, MBA, MS Chief Medical Officer, HealthHelp Find me on To learn more, view the HealthHelp Difference video: (Scan the QR code with a smartphone to download video) 19