Iggbo and Payers - HEDIS whitepaper

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HEDISWHITEPAPER|JANUARY2017

Shaiv Kapadia, MD | Blake Wehman, MHA

Abstract “Gaps in Care” is a term used to describe the delta (difference) between the average rate of care received by members of both commercial and government payers and the members receiving care at the 90th percentile. Historically, there has been a delta greater than ten percentage points between the average and the excellent.1 As a result, the National Committee of Quality Assurance (NCQA) created a set of clinical measures to monitor and close “Gaps in Care.” The measures are collected and reported to the Healthcare Effectiveness Data and Information Set (HEDIS), which NCQA describes as follows:

“A set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of health care plans.”2

As a result of the NCQA’s HEDIS measures, insurance payers have built programs specifically to address these concerns. This includes Comprehensive Diabetes Care, which has the following measures:3

1. Hemoglobin A1c (HgA1c) 2. Urine Microalbumin 3. Retinal Eye Exam 4. Blood Pressure

1http://www.ncqa.org/publications-products/other-products/quality-profiles/focus-on-diabetes/addressing-the-quality-gaps2http://www.hopkinsmedicine.org/johns_hopkins_healthcare/downloads/Tips%20to%20Improve%20Your%20HEDIS%20Measures-final3-29-12.pdf3http://web.southcarolinablues.com/UserFiles/scblues/Documents/Providers/HEDIS%20Measure%20Provider%20Matrix%20O32415.pdf


Problem Statement Every year there are 4,300 to 9,600 preventable deaths due to poorly managed diabetes. If all diabetics received the best care available, nine cases out of ten could be prevented. Proper diabetes prevention and management would save the US Healthcare System $570 million per year by avoiding unnecessary medical procedures.

Today, healthcare systems targeting diabetes have proven that increased outreach and monitoring can help close gaps in care. Specifically, ensuring that patients have their annual HgA1c, retinal exam and urine microalbumin evaluated directly correlates to improved outcomes. Therefore, many payers contract with disease management vendors today to help improve the outcomes of their members.

Iggbo is transforming this disease management space with an on-demand network of collectors, equipped to close all three gaps in care necessary to monitor and provide comprehensive diabetic care.

Background Iggbo is an on-demand network of highly qualified healthcare professionals ranging from phlebotomists to registered nurses. While Iggbo primarily offers on-demand venipuncture, the network capabilities include (but are not limited to) blood pressure, weight measurement, and drug screening. Iggbo’s network of on-demand healthcare professionals gives market segments, ranging from health systems to laboratories to payers, instant reach and access with a sustainable variable cost model. The problem payers face is with implementing a plan to close the gaps in care identified from their HEDIS reports. As exhibited below in Figure 1, many payers are struggling with managing the care of their members, especially their diabetics. Although payers are aware of the staggering direct and indirect costs that patient mismanagement adds to their health plans, there are few that take on the operational resources necessary to manage their members to the 90th percentile. For diabetic patients as an example, one out of every three inpatient days for patients with cardiovascular, neurological and renal conditions are due to patients battling diabetes. To make matters more difficult, the prevalence of diabetes in America continues to rise (see Figure 2 below).


Figure 1: Average Medicare Health Plan Score (Majority Between 3 & 4) Source: Deloitte analysis based on CMS average star quality ratings on four diabetes measures.

Therefore, more Americans battling diabetes relates directly to the increased investment payers have to make in disease management programs. Although payers clearly understand the downstream costs of poorly managed diabetic members, there’s still an average rating of comprehensive diabetic care amongst health plans of 3.01-4.0. It’s a combination of member education, operational costs for payers, and member non-compliance that is preventing payers from delivering the care they aim to provide.

10%

21%

41%

28%

2014

1.00–2 2.01–3 3.01–4 4.01–5

9%

24%

46%

21%

2015

1.00–2 2.01–3 3.01–4 4.01–5


Figure 2: Prevalence of Diabetes in the United States of America Source: Data from Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Survey. Statistical analysis by the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation.

Solution Iggbo’s mission is to deliver personalized medicine to everyone by optimizing and streamlining current systems of care. Health insurance companies, for years now, have received offers from disease management companies aimed at reducing their costs, increasing their revenue from HEDIS reimbursements, improving outcomes, and changing other population health management metrics. The common threads among all companies focused on population health management are:

• The return on investment ($3 earned for every $1 spent; $5, etc.) • The implementation cost ($10,000/month to implement; $1 million annual costs, etc.)

What makes Iggbo’s solution to the marketplace unique is that it can address HbA1c, blood pressure, retinal exams and various other metrics while requiring no implementation costs. Iggbo’s online portal can be primed for use quickly — and the network can be embedded with tools that the payer can leverage for the right labor at the right place at the right time. Iggbo’s on-demand network of collectors helps payers achieve their goals. The calculator below was built to help outline the returns payers can achieve through Iggbo.


Figure 3: Sample Iggbo HEDIS Calculator

IGGBOASSUMPTIONS % MEMBERSCOLLECTED

TOTALIGGBOCOST

GROSSREVENUETO

PAYER

% of Women Full Cdc Package + Bcs* 10% 20,625 $3,609,375 $8,043,750

% of Women Full Cdc Package No Bcs 50% 103,125 $13,921,875 $35,681,250

% A1c Only 20% 41,250 $1,650,000 $4,702,500

% Retina Exam Only 20% 41,250 $1,650,000 $1,320,000

% Of Men Full Cdc Package 50% 84,375 $11,390,625 $29,193,750

% A1c Only 25% 42,187.50 $1,687,500 $4,809,375

% Retina Exam Only 25% 42,187.50 $1,687,500 $1,603,125

Max Total Members Served 375,000

Max Costs $35,596,875

Max Revenues $ 85,353,750

Max Profits $ 49,756,875

* Comprehensive Diabetes Care (CDC) and Breast Cancer Screening (BSC)

Understanding the above table helps both the payer’s HEDIS team and the Iggbo project management team calibrate their expectations and goals. To calculate the savings in the sample above, Iggbo collects the information in the table below:

PAYER BREAKDOWN #

Total Number of Members 6,000,000

% Diagnosed with Diabetes 25%

Gross Total Diabetic Members 1,500,000

% Members: Women 55%

% Over 40 75%

% Members: Men 45%

Gross Women Total 3,300,000

Women Over 40 2,475,000

GROSS MEN TOTAL 2,700,000


From here, Iggbo can begin to calculate the goals for each measure based on the national benchmarks set by the NCQA that year, as exhibited below:

HEDIS MEASURES METHOD INCENTIVE 90TH PERCENTILE

A1c Collection Venipuncture or Siemens POC Device $114 90%

Retinopathy Screen RetinaVue or IRIS $38 90%

Nephropathy Screen Urine collection $32 80%

Blood Pressure Blood Pressure Cuff $147 80%

Bmi Assessment Height ruler and scale $15 95%

Breast Cancer Screening SureTouch device $44 90%

Max Potential Per Male Member $346

Max Potential per Female Member $390

AT RISK DIABETIC BREAKDOWN

DELTA TO REACH

INCENTIVES

MINIMUM COLLECTIONS

NEEDED NET MEN

NET WOMEN

NET WOMEN OVER 40

% With Outstanding A1c 15% 225,000 101,250 123,750 92,812.50

% With Outstanding Retina Screen 10% 150,000 67,500 82,500 61,875

% With Outstanding Nephropathy Screen 5% 75,000 33,750 41,250 30,937.50

% With Outstanding Blood Pressure 10% 600,000 270,000 330,000 247,500

% With Bmi Assessment 5% 300,000 135,000 165,000 123,750

% With Outstanding Breast Cancer Screening 10% 2,475,000 N/A N/A 247,500

Iggbo can determine the members with gaps in care for specific measures, the projected earnings per member if the incentives are achieved, and the costs of Iggbo per collection.

With the combination of Iggbo’s seamless online ordering system and its compliance messaging system, the payer’s HEDIS team can simply deploy the on-demand collectors to close the necessary gaps in care. There are no costs for implementation and Iggbo charges on a per collection basis; however, Iggbo also offers shared savings models where payment is collected after the results are returned. In either model,


the costs are significantly less than the incumbents in the market. As a result, Iggbo provides payers the following, all at a reduced cost:

• Optimized operations and outreach • Enhanced patient outcomes • Unlocked STARS/HEDIS reimbursements that were previously unreachable

Results Iggbo implemented its on-demand network for a regional payer managing their state’s Medicaid population (and their Medicaid-Medicare dual eligibles) and realized immediate results. An Iggbo pilot project was introduced, scoped and implemented at no cost to the payer in less than three weeks. Iggbo created individual accounts for fifteen patient coordinators who were able to close 20% of their gaps in care. The payer’s HEDIS team received daily goals and quotas. Through the first two-weeks, every individual met their daily quota. At the conclusion of the pilot, the payer surpassed their goal of securing a neutral rating and unlocking previously unattainable reimbursements from HEDIS and STARs.

Iggbo drove 90% compliance through its Glidepath messaging platform. As depicted below, Glidepath provided patients the opportunity to easily and seamlessly reschedule their appointments. In addition, the system sent reminder messages through a variety of channels in order to meet all communication preferences. Figure 4: Iggbo’s Glidepath Compliance Messaging System


By leveraging Iggbo’s on-demand workforce, the health system was able to provide a mobile, flexible catchment in one of America’s densest metropolitan statistical areas that was both convenient for the patient and compliant with the system’s laboratory protocols. The Iggbo Solution Scorecard was built to illustrate the net-impact the Iggbo model had on the system. The Scorecard is a financial calculator linked back to the aforementioned Iggbo PHM Calculator. It demonstrates the health system’s true cost savings and earnings from implementing Iggbo across their entire HEDIS service line.

IGGBO SOLUTION SCORECARD

OutreachSuccess 90%

NumberofPatientsWithGapsinCare 2250

TotalPatientsScheduledPerDayPerMember 3

NumberofTeamMembers 15

EligibleDaystoCloseGapsinCare 45

TotalPatientsScheduled 2025

TotalPatientsCompleted 1923

IggboCompliance 98%

BaselineHedisRating 79%

NetHedisRatingPost-Iggbo 94.96%

AverageReimbursementPerA1cGapClosed $120

NumberofA1cPatients 1500

GrossReimbursementPerA1c $180,000

IggboCosts+OperationalExpensesPerPatient $50

TotalExpenses $75,000

NetProfit $105,000

The result of the Iggbo implementation was a projected net-HEDIS rating of 94.96%, nearly four points above the neutral rating. The average incentive payment from NCQA to payers for closing gaps in care for A1c collections averages $140.00 per member. It is projected that the payer actualized a potential revenue of $180,000 — much of which was previously unattainable.


Conclusion The American healthcare system has focused on the Triple Aim for nearly two decades: reduce costs, increase quality and improve outcomes. Through Iggbo’s on-demand network of healthcare labor, payers can accomplish this goal, as proven by Iggbo’s case study with a payer tasked at closing its gaps in care in record time. In this case study, Iggbo was able to unlock incentives for the payer previously thought to be unattainable — and is projected to be a key operational tool in their upcoming year.

• To see how Iggbo can help your members, download our calculator here and contact Iggbo at [email protected].

• For more information about how Iggbo can help you or your system, please contact Iggbo at [email protected].

Iggbo and Payers - HEDIS whitepaper

Healthcare

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