Predictive Modeling 2008: The BlueCross BlueShield of ... · Soyal Momin MS, MBA. September 23,...
Transcript of Predictive Modeling 2008: The BlueCross BlueShield of ... · Soyal Momin MS, MBA. September 23,...
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Soyal Momin MS, MBASeptember 23, 2008
Predictive Modeling 2008: The BlueCross BlueShield of
Tennessee Experience
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Outline
• Maximizing the Value of Predictive Modeling: A Health Plan Perspective
– Care Management Challenges:
• Understand Population Care Management Needs
• Identify
• Stratify
• Triage
– Care Management Model, Implementation, Process Efficiencies
• Intervene
– Care Management Programs
• Evaluate
– Conclusions
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Care Management Challenges: Understand Population Care Management Needs
• Cost distribution and trend over time– Quantitative assessment
• Population assessment– Qualitative assessment – clinical cost drivers based
on healthcare cost (direct cost)
• Total cost assessment – direct & indirect costs– Qualitative assessment – clinical cost drivers based
on healthcare cost and personnel cost (indirect cost)
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Understand Population Care Management Needs Cost Distribution and Trend Over Time Cumulative Total Healthcare Cost
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Cost Distribution and Trend Over Time Cumulative Professional and Outpatient Cost
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Cost Distribution and Trend Over Time Cumulative Pharmacy Cost
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Cost Distribution and Trend Over Time Cumulative Inpatient Cost
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Understand Population Care Management Needs Population Assessment
Population Assessment is an analysis of claims and membership data to determine characteristics of a given population (Network, Region, Group) that might affect the population’s interaction with the health care system
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Propensity to Utilize Index – The average number of episodes of illness for a member month
Episode Seriousness Index – A measure of the average cost to treat the categories of illness experienced by a population
Illness Burden – A measure of the level of illness within a group determined by multiplying the propensity to utilize index by the Episode Seriousness Index
Population Assessment Major Analysis Variables
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Provider Efficiency Index – A measure of the efficiency to treat a specific episode of illness determined by dividing the cost to treat the specific episode by the average cost for the category of illness
PMPM Cost Index – An index that measures the PMPM submitted costs for a population determined by multiplying the Illness Burden by the Provider Efficiency Index
Population Assessment Major Analysis Variables, Continued
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Population Assessment Population Profile
0
0.5
1
1.5
2
2.5
Propensity to Utilize Episode SeriousnessIndex
Provider Efficiency PMPM Cost Index
Population A Population B
0
0.5
1
1.5
2
2.5
Propensity to Utilize Episode SeriousnessIndex
Provider Efficiency PMPM Cost Index
Population A Population B
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00.020.040.060.08
0.10.120.140.16
Infectio
us Dise
ases
Endocri
nology
Hemato
logyPsy
chiat
ry
Chemica
l Dep
enden
cyNeu
rolog
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Ophthalmolo
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iology
Otolar
yngo
logy
Pulmonolo
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Gastro
enter
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Hepato
logy
Nephro
logyUro
logyObste
trics
Gynec
ologyDerm
atology
Ortho &
Rhe
umNeo
natology
Major Practice Category
Illne
ss In
dex
Population A Population B
00.020.040.060.08
0.10.120.140.16
Infectio
us Dise
ases
Endocri
nology
Hemato
logyPsy
chiat
ry
Chemica
l Dep
enden
cyNeu
rolog
y
Ophthalmolo
gyCard
iology
Otolar
yngo
logy
Pulmonolo
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Gastro
enter
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Hepato
logy
Nephro
logyUro
logyObste
trics
Gynec
ologyDerm
atology
Ortho &
Rhe
umNeo
natology
Major Practice Category
Illne
ss In
dex
Population A Population B
Population Assessment Illness Burden by Major Practice Category
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00.5
11.5
22.5
33.5
44.5
Infectio
us Dise
ases
Endocri
nology
Hemato
logyPsy
chiat
ry
Chemica
l Dep
enden
cyNeu
rolog
y
Ophthalmolo
gyCard
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Otolar
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logy
Pulmonolo
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Gastro
enter
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Hepato
logy
Nephro
logyUro
logyObste
trics
Gynec
ology
Dermato
logy
Ortho &
Rhe
umNeo
natology
Major Practice Category
Prov
ider
Effi
cien
cy In
dex
Population A Population B
00.5
11.5
22.5
33.5
44.5
Infectio
us Dise
ases
Endocri
nology
Hemato
logyPsy
chiat
ry
Chemica
l Dep
enden
cyNeu
rolog
y
Ophthalmolo
gyCard
iology
Otolar
yngo
logy
Pulmonolo
gy
Gastro
enter
ology
Hepato
logy
Nephro
logyUro
logyObste
trics
Gynec
ology
Dermato
logy
Ortho &
Rhe
umNeo
natology
Major Practice Category
Prov
ider
Effi
cien
cy In
dex
Population A Population B
Population Assessment Provider Efficiency by Major Practice Category
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00.05
0.10.15
0.20.25
0.30.35
Infectio
us Dise
ases
Endocri
nology
Hemato
logyPsy
chiat
ry
Chemica
l Dep
enden
cyNeu
rolog
y
Ophthalmolo
gyCard
iology
Otolar
yngo
logy
Pulmonolo
gy
Gastro
enter
ology
Hepato
logy
Nephro
logyUro
logyObste
trics
Gynec
ology
Dermato
logy
Ortho &
Rhe
umNeo
natology
Major Practice Category
Cos
t Ind
ex
Population A Population B
00.05
0.10.15
0.20.25
0.30.35
Infectio
us Dise
ases
Endocri
nology
Hemato
logyPsy
chiat
ry
Chemica
l Dep
enden
cyNeu
rolog
y
Ophthalmolo
gyCard
iology
Otolar
yngo
logy
Pulmonolo
gy
Gastro
enter
ology
Hepato
logy
Nephro
logyUro
logyObste
trics
Gynec
ology
Dermato
logy
Ortho &
Rhe
umNeo
natology
Major Practice Category
Cos
t Ind
ex
Population A Population B
Population Assessment PMPM Cost Index by Major Practice Category
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Direct costs are dollars paid out for medical treatmentIndirect costs are labor resources lost due to illness
Direct CostsDirect Costs = Inpatient + Professional/Outpatient + Pharmacy
Indirect CostsIndirect Costs = Sick Leave + Presenteeism + Family & Medical Leave + Short Term Disability + Long Term Disability + Turnover + Worker’s Compensation
Understand Population Care Management Needs Total Cost Assessment
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Total Healthcare Cost = $23,237,422Total Healthcare Cost = $23,237,422$5,631 per FTE$5,631 per FTE
Direct $ = $13,761,278$3,334 / FTE
59.2%
Indirect $ = $9,476,144
$2,296 / FTE40.8%
Inpatient
$376
6.7%
Professional/Outpatient
$2,154
38.3%
Pharmacy
$804
14.3% Sick Leave
$1,322
23.5%
Presenteeism
$318
5.7%
FMLA
$274
4.9%
STD
$220
3.9%
LTD
$4
0.1%
Turnover
$74
1.3%
Work Comp
$82
1.5%
Total Healthcare Cost = $23,237,422Total Healthcare Cost = $23,237,422$5,631 per FTE$5,631 per FTE
Direct $ = $13,761,278$3,334 / FTE
59.2%
Indirect $ = $9,476,144
$2,296 / FTE40.8%
Inpatient
$376
6.7%
Professional/Outpatient
$2,154
38.3%
Pharmacy
$804
14.3% Sick Leave
$1,322
23.5%
Presenteeism
$318
5.7%
FMLA
$274
4.9%
STD
$220
3.9%
LTD
$4
0.1%
Turnover
$74
1.3%
Work Comp
$82
1.5%
Total Cost Assessment Account Group XYZ
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$0
$200,000
$400,000
$600,000
$800,000
$1,000,000
$1,200,000
$1,400,000
$1,600,000
$1,800,000
$2,000,000
JOIN
T DEGEN/IN
FLAM
BENIGN N
EOPLASM
GASTRO INFEC/IN
FLAM
HYPERTENSION
DEPRES & A
NXIETY DIS
ORTHO DERANGE/TRAUMA
PREG & D
ELIVERY W/ C
-SEC
MALIGNANT N
EOPLASMDIA
BETES
RHINITIS/SIN
USITIS
PREG & D
ELIV NO C
-SEC
ASTHMA
CORONARY DISEASE
OTHER CARDIA
C DIS
COND ASSOC M
ENST/INFERT
GALL BLADDER D
ISEASE
VISUAL DISTURBANCES
HYPERLIPIDEMIA
HEREDITARY/CONGEN D
IS
MINOR O
RTHO DIS
Direct Costs Indirect Costs
Total Cost Assessment Top 20 Cost Drivers
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• Identifying Members for Care Management– Referrals from
• Internal Sources• External Sources• An internally developed ICD9 Trigger list
– The ICD9 Trigger list included Asthma, Diabetes, High Risk OB, AIDs, Cancer, CHF, COPD etc
– High cost member report
• Case managers workload• 103/CM/Month
• High predicted cost member report
• Stratification index report
Care Management Challenges: Identify & Stratify Members for Care Management
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Commercial LOB 2005Allowed >= $50K
GROUP AN = 9,017 (100%)
PMPM: $9,025PMPY: $108,305
Average MM: 10.98
IP PFO Rx$4,379 $4,211 $441
$52,543 $50,534 $5,289
Experience in 2006Allowed >= $50K
GROUP B N = 1,968 (22%)
PMPM: $10,706PMPY: $128,469
Average MM: 11.12
IP PFO Rx$3,107 $6,686 $913
$37,280 $80,232 $10,957
?N = 7,049 (78%)
Eligible Members With < $50KGROUP C
N =5,180 (57%)
PMPM: $1,414PMPY: $16,966
Average MM: 10.44
MembersNot
EligibleN = 1,723 (19%)
Eligible MembersW/O Claims$N = 146 (2%)
N = 2,011,903
PMPY: $2,979
Identify & Stratify Members for Care Management Value of Working High Cost Member Report (Y1 Y2)
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Commercial LOB 2006Allowed >= $50K
GROUP AN = 10,194 (100%)
PMPM: $8,772PMPY: $105,258
Average MM: 11.09
IP PFO Rx$4,110 $4,196 $467
$49,316 $50,358 $5,608
Experience in 2005Allowed >= $50K
GROUP B N = 1,969 (19%)
PMPM: $10,155PMPY: $121,857
Average MM: 11.60
IP PFO Rx$3,285 $6,082 $761
$39,426 $72,990 $9,131
?N = 8,225 (81%)
Eligible Members With < $50KGROUP C
N =6,651 (65%)
PMPM: $1,095PMPY: $13,134
Average MM: 11.14
MembersNot
EligibleN = 1,166 (11%)
Eligible MembersW/O Claims$N = 408 (5%)
N = 2,091,256
PMPY: $2,995
Identify & Stratify Members for Care Management Value of Working High Cost Member Report (Y2 Y1)
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Year 2004
Commercial LOB 2004N = 1,837,214PMPY: $2,836
Allowed >= $50KN = 7,404 (100%)
PMPM: $8,910PMPY: $ 106,921
Average MM: 10.94
Year 2005
Allowed >= $50KN = 1,635 (22%)
PMPM: $10,251PMPY: $ 123,006
Average MM: 11.47
Year 2006
Allowed >= $50KGROUP DN = 650 (9%)
PMPM: $9,493PMPY: $ 113,915
Average MM: 11.24
Identify & Stratify Members for Care Management Value of Working High Cost Member Report (Y1 Y2 Y3)
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ETGCode ETG Description Allw
%TotalAllw
ETGCode ETG Description Allowed
% TotalAllw
553 Chronic Renal Failure, w ith ESRD $47,923,994 5.4 553 Chronic Renal Failure, w ith ESRD $38,761,827 16.1721 Joint Degeneration, Local, w / Surgery $35,771,711 4.0 656 Malignant Neoplasm of Breast w /o Surgery $10,600,438 4.4786 Other major Neonatal d/o perinatal origin $30,891,125 3.5 75 Non-Neoplastic Blood Disease, Major $9,977,285 4.173 Neoplastics Disorder Blood & Ly mph, Ex Leu $30,658,775 3.4 73 Neoplastic Disorder Blood & Ly mph, Ex Leuk $9,880,412 4.1
260 Coronary Disease w /o AMI w / CABG $27,081,959 3.0 72 Leukemia w /o Splenectomy $7,787,074 3.2655 Malignant Neoplasm Breast, w / Surgery not B $21,565,875 2.4 76 Non-Neoplastic Blood Disease, Minor $7,526,867 3.1251 Coronary Disease w / AMI w /CABG $21,287,899 2.4 991 Orphan Drug Record $5,929,881 2.5401 Malignant Pulmonary Neoplasm, w /o Surgery $20,113,568 2.2 401 Malignant Pulmonary Neoplasm, w /o Surgery $5,921,153 2.572 Leukemia w /o Splenectomy $19,282,495 2.2 478 Malignant Neoplasm Rectum/Anus, w /o Surg $4,566,464 1.975 Non-Neoplastic Blood Disease, Major $17,920,993 2.0 721 Joint Degeneration, Local, w / Surgery $3,616,225 1.5
253 Coronary Disease w /o AMI w / Angioplasty $16,713,020 1.9 373 Bacterial Lung Infection w ith Comorbidity $3,494,225 1.4477 Malignant Neoplasm Rectum/Anus w /Surgery $16,288,401 1.8 51 Other Metabolic Disorder $3,339,403 1.4656 Malignant Neoplasm of Breast w /o Surgery $16,052,116 1.8 655 Malignant Neoplasm Breast, w / Surgery not B $3,310,015 1.4262 Coronary Disease w /o AMI w /Angioplasty $15,814,419 1.8 810 Late Effects and Late Complications $3,206,696 1.3373 Bacterial Lung Infection w ith Comorbidity $11,639,075 1.3 454 Malignant Neoplasm Intest/Abdom w /o Surge $3,178,822 1.3264 Coronary Disease w /o AMI w /Cardiac Cath $10,862,902 1.2 477 Malignant Neoplasm Rectum/Anus w /Surgery $2,985,750 1.2153 Malignant Neoplasm of CNS w /Surgery $10,366,887 1.2 262 Coronary Disease w /o AMI w /Angioplasty $2,352,321 1.0282 Cardiac Congenital Disorder w /Surgery $10,178,199 1.1 452 Inflam of Intestines/Abdomen w /o Surgery $2,293,327 1.076 Non-Neoplastic Blood Disease, Minor $9,999,538 1.1 282 Cardiac Congenital Disorder w /Surgery $2,103,403 0.9
162 Major Brain Trauma w /o Surgery $9,938,655 1.1 153 Malignant Neoplasm of CNS w /Surgery $2,011,666 0.8Total For Top 20 ETGs $400,351,606 45.0 Total For Top 20 ETGs $132,843,254 55.0
Grand Total = $893,294,617 Grand Total = $241,542,404
GROUP B: >=$50K in 2005 and 2006 GROUP A: >=$50K in 2005
Commercial LOB: TOP 20 ETGs
Identify & Stratify Members for Care Management Value of Working High Cost Member Report: Cost Drivers
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ETGCode ETG Description Allowed
%TotalAllw
ETGCode ETG Description Allowed
%TotalAllw
722 Joint Degeneration, Local, w /o Surgery $2,592,627 3.3 553 Chronic Renal Failure, w ith ESRD $20,649,142 23.273 Neoplastic Disorder Blood & Ly mph, Ex Leuk $2,297,356 2.9 75 Non-Neoplastic Blood Disease, Major $5,249,796 5.9
656 Malignant Neoplasm of Breast w /o Surgery $1,887,226 2.4 76 Non-Neoplastic Blood Disease, Minor $4,212,880 4.7721 Joint Degeneration, Local, w / Surgery $1,873,126 2.4 656 Malignant Neoplasm of Breast w /o Surgery $4,192,427 4.7401 Malignant Pulmonary Neoplasm, w /o Surgery $1,736,043 2.2 73 Neoplastic Disorder Blood & Ly mph, Ex Leuk $3,544,421 4.0265 Ischemic Heart Disese, Ex , CHF w /o AMI $1,718,398 2.2 991 Orphan Drug Record $3,063,321 3.4553 Chronic Renal Failure, w ith ESRD $1,589,758 2.0 72 Leukemia w /o splenectomy $2,571,613 2.9655 Malignant Neoplasm Breast, w / Surgery not B $1,465,064 1.9 51 Other Metabolic Disorder $1,810,990 2.0262 Coronary Disease w /o AMI w / Angioplasty $1,409,685 1.8 478 Malignant Neoplasm Rectum/Anus w /o Surge $1,748,250 1.929 Non-Insulin Dependent Diabetes w / Comorbidi $1,352,197 1.7 454 Malignant Neoplasm Intest/Abdom w /o Surge $1,380,751 1.5
786 Other Major Neonatal D/O Perinatal Origin $1,194,070 1.5 373 Bacterial Lung Infection w ith Comorbidity $1,350,668 1.5999 Orphan Record $1,145,019 1.5 401 Malignant Pulmonary Neoplasm $1,174,693 1.3991 Orphan Drug Record $1,090,253 1.4 394 Emphy sema w ith Chronic Bronchitis $1,053,345 1.2433 Inflammation of Esophagus w /o Surgery $1,018,298 1.3 262 Coronary Disease w /o AMI w /Angioplasty $985,902 1.1160 Cereb Vasc Accident w /o Surgery $981,220 1.3 810 Late Effects and Late Complications $861,726 1.051 Other Metabolic Disorder $908,220 1.2 27 Insulin Dependent Diabetes w /Comorbidity $846,994 1.075 Non-Neoplastic Blood Disease Major $888,965 1.1 452 Inflam of Intestines/Abdomen w /o Surgery $754,833 0.947 Hy perlipidemia $887,798 1.1 280 Benign Hy pertension w /Comorbidity $723,403 0.872 Leukemia w /o Splenectomy $856,636 1.1 167 Hered/Degen Dis CNS w /o Surgery $708,984 0.8
253 Coronary Disease w /o AMI w / Angioplasty $792,093 1.0 266 Pulmonary Hear Disease w /o AMI $698,100 0.7Total For Top 20 ETGs $27,684,052 35.0 Total For Top 20 ETGs $57,582,239 71.0
GROUP C: >=$50K in 2005 and <$50K in 2006 GROUP D: >=$50K in 2004, 2005 and 2006
Grand Total = $78,098,373 Grand Total = $81,451,176
Commercial LOB: TOP 20 ETGs
Identify & Stratify Members for Care Management Value of Working High Cost Member Report: Cost Drivers
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• Why?
• 1) To reliably identify higher cost, highly impactable members
• 2) To enhance prioritization of members for nurse-intervention management
• How?• Use predictive output from MEDai
• Select key MEDai measures to construct a composite score
• Use the composite score as an index to stratify members
Focus on members with the highest index scoresFocus on members with the highest index scores
Identify & Stratify Members for Care Management Developing a Stratification Index (SI)
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0%
20%
40%
60%
80%
100%
0 10 80-85 86-90 91-95 96-100
Chronic Impact Level
Perc
ent o
f Mem
bers
High Index ScoresModerate Index ScoresLow Index Scores
Validating SI Score Chronic & Acute Impact: Break Down by SI Score
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-50 51-70 71-85 86-95 96-100
Acute Index Level
Perc
ent o
f Mem
bers
High Index ScoresModerate Index ScoresLow Index Scores
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0%
10%20%
30%40%
50%
60%70%
80%90%
100%
0 1 - 2 3 - 4 > = 5
Number of Chronic Gaps
Perc
ent o
f Mem
bers
High Index ScoresModerate Index ScoresLow Index Scores
Validating SI Score Chronic & Preventative Gaps: Break Down by SI Score
0%10%20%30%40%50%60%70%80%90%
100%
0 1 - 2 > = 3
Number of Preventative Gaps
Perc
ent o
f Mem
bers
High Index ScoresModerate Index ScoresLow Index Scores
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0%
20%
40%
60%
80%
100%
$0-999 $1000-4999 $5000-9999 $10000-24999
>$25000
Forecasted Cost Level
Perc
ent o
f Mem
bers
High Index ScoresModerate Index ScoresLow Index Scores
Validating SI Score Forecasted Cost Risk: Break Down by SI Score
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• Movers are members who are likely to make the transition from low or moderate to high risk
• Movers can be identified by comparing current vs. forecasted cost risk level
• if a member’s current cost is less than $1,000 (Risk Level I) and is predicted to cost more than $25,000 (Risk Level V)
• Do movers have higher index scores?
Validating SI Score Mover Identification
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Current Risk Level
Forecasted Risk Level Frequency Mean Index
ScoreI II 430,312 4.52I III 11,370 9.87I IV 451 12.75I V 2 11.00II III 96,352 10.26II IV 7,737 13.03II V 51 13.04III IV 22,492 13.47III V 225 13.95IV V 2,142 14.85
Validating SI Score Index Scores for Movers
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Commercial LOB 10/2005
High Scores: >=11(10.2%)
Moderate Scores: 6-10(18.4%)
Low Scores: <=5(71.4%)
Validating SI Score Distribution of Index Scores
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Segmentation Risk Level Management Type
Healthy Group; Worried Well
Low
Lifestyle/Health
Counseling
Chronically Ill Moderate Refer to Care Coordination Unit
Catastrophic
High
Refer to Catastrophic Case Management
Care Management Challenges: Triage & Intervene Members for Care Management Needs Care Management Model
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• Information on disease/condition– Web resources– Pamphlets– Telephonic health library– 24/7 Nurse Line– HRA/PHR
• Encouragement to take more active role/accountability
Care Management Model Lifestyle/Health Counseling for Healthy and Worried Well
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• Telephonic coordination with members and their providers
• Ensures appropriate treatments and pharmaceuticals
• Five different programs included in this model
Care Management Model Care Coordination for Chronically Ill
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• Pharmacy Care Management
• Emergency Room (ER) Visits Mgmt.
• Transition of Care
• Condition Specific Care Coordination
• Disease Management
Care Management Model Care Coordination Programs
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• Directed to members with– Terminal illness (HOPE)– Major trauma– Cognitive/physical disability– High-risk condition– Complicated care needs
• Systematic process of assessing, planning, coordinating, implementing, and evaluation of care
Care Management Model Catastrophic Case Management
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Triage & Intervene Members for Care Management Needs Implementation
• Predictive modeling using– MEDai, DCG, ETG
• Rolling 12 months DCG explanation prospective model
• ETG cost to supplement MEDai prediction• Developed SQL database containing MEDai,
DCG, and ETG information• Improved processes/workflow• Easy and continuous access
• Better documentation
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39
40
41
42
43
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Triage & Intervene Members for Care Management Needs Implementation: Future Enhancements
• Accreditation Analytics • Member non-compliance for HEDIS measures• Satisfaction profile
• Geo-spatial Analytics (imputed race, vicinity to Centers of Excellence (COE) or efficient/quality providers)
• Data Mining Analytics• Probability of engagement, segmentation profile
• Psychosocial Profile
• Speech Analytics
• Indirect Cost Profile
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• Basic research problem: measuring what would have happened vs. what actually happened
• Methodologies:• Randomized Control Group• Population-Based Pre-Post Methodology• Predictive Modeling• Control Group Matching • Combination
Care Management Challenges: Evaluate Care Management Interventions
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Predictive Modeling with Inflation FactorsYr1 Yr2
Net Savings 12,606$ 72,811$ ROI 1.43 3.72
Group's Inflation Factor 5% 7%
CM Mbrs Actual PMPM 574$ 542$ CM Mbrs Predictive Modeling PMPM 629$ 638$ Inflated CM Mbrs Predictive Modeling PMPM 659$ 682$
CM Savings PMPM 85$ 140$
Total CM Savings 42,005$ 99,560$ Admin Cost 29,399$ 26,749$
Evaluate Care Management Interventions Predictive Modeling
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Predictive Modeling w/Inflation Factors and AdjustmentsYr1 Yr2
Non CM Mbrs Actual PMPM 225$ 217$ Non CM Mbrs PMPM Predictive Modeling 205$ 232$
Inflation Adjusted Non CM Mbrs PMPM Predictive Modeling 214$ 248$ Adjustment for Actual to Predictive Modeling 5% -13%
CM Mbrs Actual PMPM 574$ 542$ CM Mbrs Predictive Modeling PMPM 629$ 638$ Inflated CM Mbrs Predictive Modeling PMPM 659$ 682$ Adjusted Predictive Model 692$ 597$
Adjusted CM Savings PMPM $ 117 $ 55 Adjusted CM Savings $ 57,819 $ 39,113 Admin Cost 29,399 26,749$$
Adjusted Net Savings 28,296$ 12,364$ Adjusted ROI 1.96 1.46
Evaluate Care Management Interventions Predictive Modeling w/Adjustments
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Evaluate Care Management Interventions Total Cost Approach
Direct CostsDirect Costs by SI Score – 2007 Commercial Subscribers
Median 2007 Direct Costs by SI Score -Commercial Subscribers Enrolled in 2007
0
10,000
20,000
30,000
40,000
50,000
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score
Num
ber o
f Sub
scrib
ers
$0
$6,000
$12,000
$18,000
$24,000
$30,000
$36,000
Med
ian
Dire
ct C
osts
Number of Subscribers Median 2007 Direct $
Percent of Direct Costs & Commercial Subscribers by SI Score - Subscribers Enrolled in 2007
0%
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16%
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score
% of Total Subscribers % of Direct $ in 2007
80% of Members 20% of Members
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Evaluate Care Management Interventions Total Cost Approach
Indirect CostsIndirect Costs by SI Score – 2007 Commercial Subscribers
Median 2007 Indirect Costs by SI Score -Commercial Subscribers Enrolled in 2007
0
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30,000
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Num
ber o
f Sub
scrib
ers
$0
$4,000
$8,000
$12,000
$16,000
$20,000
Med
ian
Indi
rect
Cos
ts
Number of Subscribers Median 2007 Indirect $
Percent of Indirect Costs & Commercial Subscribers by SI Score Subscribers Enrolled in 2007
0%
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4%
6%
8%
10%
12%
14%
16%
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score
% of Total Subscribers % of Indirect $ in 2007
80% of Members 20% of Members
50
Evaluate Care Management Interventions Total Cost Approach
Total CostsTotal Costs by SI Score – 2007 Commercial Subscribers
Median 2007 Total Healthcare Costs by SI Score -Commercial Subscribers Enrolled in 2007
0
10,000
20,000
30,000
40,000
50,000
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score
Num
ber o
f Sub
scrib
ers
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
Med
ian
Tota
l Hea
lthca
re C
osts
Number of Subscribers Median 2007 THC $
Percent of Total Healthcare Costs & Commercial Subscribers by SI Score - Subscribers Enrolled in 2007
0%
2%
4%
6%
8%
10%
12%
14%
16%
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score
% of Total Subscribers % of THC $ in 2007
80% of Members 20% of Members
51
Evaluate Care Management Interventions Total Cost Approach
-$14,000
-$12,000
-$10,000
-$8,000
-$6,000
-$4,000
-$2,000
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10
EBI Score Change From December 2006 to 2007
Median Change in Indirect $ (06 vs. 07)Median Change in Direct $ (06 vs. 07)
Change in SI Score vs. Change in Median THC Change in SI Score vs. Change in Median THC for Commercial Subscribers in 2006 & 2007for Commercial Subscribers in 2006 & 2007
SI Score Reduced
SI Score Increased
Each 1 point reduction in Score = $775 in THC savings PMPY
Each 1 point increase in Score = $750 THC increase PMPY
Med
ian
Chan
ge in
Cos
ts
SI Score Change From December 2006 to 2007
52
Conclusions
• More scientific/standardized approach• Able to touch more lives efficiently• Well accepted by our care managers• PM approach has helped
– Streamline our processes– Better manage case managers case load
• Provide “Peace of Mind” to our members and clients