Using Patient Cohorts to Drive System Transformation

Objectives

• Recognize that chronic disease management is a critical driver of excess

healthcare utilization and cost

• Learn best practice approaches to identify high risk patient cohorts

• Identify high risk patients via patient cohorts in Lightbeam

• Be prepared to enroll patients in your Chronic Care Management Program

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The Burden of Chronic Disease


The Pandemic of the 21st Century

One of the greatest challenges that will face health systems globally in the twenty-first century will be the increasing burden

of chronic diseases.- WHO 2002

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“ “

Chronic Disease

5

60-70%of deaths in US are due to

Chronic Disease – many of

which are preventable or

at least treatable.

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Leading Causes of Death 65+

Heart disease, 25.3

Cancer, 21.1

CLRD, 6.5

Stroke, 6.1Alzheimer's disease,

5.7

Diabetes, 2.8

Unintentional injuries, 2.7

Influenza and pneumonia, 2.1

Kidney disease, 2.1

Septicemia, 1.5

Other, 24.1


1. Heart Disease

2. Cancer

3. Chronic Lung Disease

4. Stroke

5. Alzheimer’s

6. Diabetes

7. Injuries

8. Influenza and Pneumonia

9. Kidney Disease

10. Septicemia

We Have Room to Improve

of people with Chronic

Disease in the US are

under control

7

50-60%

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Only

A Significant Change in Per Capita Spending on Medicare Beneficiaries Occurred in 2005


Cutler et al. “Explaining The Slowdown In Medical Spending Growth Among The Elderly, 1999–2012.” Health Affairs 2019 38:2, 222-229

Real per capita health care spending for the elderly, 1992-2015

The Reason Might Surprise You


Per capita spending slowdown by major medical condition, 1999-2012

Cutler et al. “Explaining The Slowdown In Medical Spending Growth Among The Elderly, 1999–2012.” Health Affairs 2019 38:2, 222-229

Chronic Disease Matters

Together, these two groups of conditions:

accounted for 56%of the spending slowdown.


Cardiovascular and Cerebrovascular Disease

Cardiovascular Risk Factors

Cardiovascular Disease Culprits

The decline in spending on Cardiovascular Disease was

attributable to three cardiovascular disease risk factors:


Hypertension

Hyperlipidemia

Diabetes

Prevention Matters

The majority of the slowdown in the combined

cardiovascular disease risk factor category was

due to a slowdown in spending on people with

hypertension alone.


Better Medication Management!


Impact of medications to treat various cardiovascular diseases and risk factors on overall

spending for cardiovascular disease, 1999-2012

Better Medication Management!


It is not that new therapies to treat

cardiovascular disease risk were developed during this period. Rather, the therapies that were previously available are now

used much more frequently.

Source - Health Affairs – Explaining the Slowdown in Medical Spending Growth FEB 2019 - 38:2

“ “Cutler et al. “Explaining The Slowdown In Medical Spending Growth Among The Elderly, 1999–2012.” Health Affairs 2019 38:2, 222-229

Source: Cutler et al., Health Affairs 2019

The Impact of Better Disease Management is Real

Hospital Admissions for

Ischemic Heart Disease

Admissions for Stroke


56%

41%

Risk Stratification: Where to Start?


The Majority of Patients Qualify for CCM


32% 32%

23%

14%

0%

5%

10%

15%

20%

25%

30%

35%

0 to 1 2 to 3 4 to 5 6+

Percentage of Medicare FFS Beneficiaries by Number of Chronic Conditions, 2010

Number of Chronic Conditions

Focusing on the Riskiest Patients Matters in an ACO 2016 Medicare Data Source: AHRQ


Source: AHRQ, 2014 MEPS #455

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Enrollees Expenditures

Top 5 Percentile use 50% Resources

Top 1 Percentile use 23% Resources

Bottom 50 Percentile use 2.7% Resources

You Must “Shrink the Goal”

National Academy of Medicine and others have

highlighted the importance of recognizing that

all High-Need & High-Cost patients are not alike,

and recommend segmentation of patients

according to risk criteria.


Source: Commonwealth ACO – Pt Segmentation article

“ “

There are Multiple Risk Stratification Tools

Haas et al., “Risk-Stratification Methods for Identifying Patients for Care Coordination.” The American Journal of Managed Care 2013;19(9):725-732


Adjusted Clinical Groups - ACG

Hierarchical Condition Categories - HCC

Minnesota Tiering

Elder Risk Assessment Index

Chronic Condition Count

Charlson Morbidity Index

Hospital-Affiliated ACO Care Coordination Approaches


81%↑

21%↓17%

13%

65%↑

57%↓

42%↓ 40%37%

50%↑

32%29% 28%

10% 12%8%

Reduce avoidable

emergencydepartment

visits and avoidable

inpatient admissions

Preventreadmissions

through better care

transitions

Active management of

high-need high-cost

patients

Manage/reduce

post-acute-care

spendingand quality

Reduceavoidable/

unnecessary care

Increase referrals to

ACO- based

providers/reduce

network leakage

Integrate behavioral Palliative care/ hospice

health care into primary

care settings

Top Priorities for Improving Efficiency, Reducing Cost

A physician group n =77 Both (hospital and physician group equally) + Ahospital n =86

Accountable Care Learning Collaborative, Western Governors University

Care Coordination Varies in Time and Intensity

Very High Risk 1%

Care Transitions

Complex Chronic Care Management

Chronic Disease Management


Higher Intensity and Effort

Lower Intensity and Effort

Shrink the Goal in Order to Start

• Preventing avoidable emergency visits and inpatient

admissions via better chronic care management


LEVEL 1 Practice Level Interventions

• Manage or reduce post-acute care spending

• End of life palliative care and hospice

• Network utilization

• Clinical episodes cost Analysis

LEVEL 2 System Level Interventions

Level 1 Interventions: Avoiding High Cost Care


Common High-Risk Selection Considerations

Focus on high yield Dx – HTN, CHF, COPD, DM,

Behavioral Health Dx


Disease Based

Event Based

Socioeconomics

Focus on high cost utilization – ED, Hospital,

Post-Acute

Focus on patient barriers/limitations

Caravan Health High Risk PatientsInpatient and Emergency Room Utilization Impact


CohortAverage

Total Cost of Care

CountPercent of

Total

Attributed Medicare Population $10,872 509,991 100%

3+ Chronic Conditions $21,047 92,062 18%

3+ Chronic Conditions plus 1+ Inpatient or ED visit

$30,840 50,501 11%

Impact of Avoidable ED Visits


37.4%of all

Caravan

ED visits

are low

acuityED Level ED Visits Percent of Total

ACO Percent

of Total

Caravan Percent

of Total

Level 1: Minor 32 2.0% 2.6% 1.5%

Level 2: Low 144 8.8% 7.4% 8.0%

Level 3: Moderate 240 14.6% 29.0% 27.9%

Level 4: High 719 43.8% 34.6% 34.4%

Level 5: Very High 477 29.1% 25.1% 26.9%

Critical Care 29 1.8% 1.3% 1.2%

ED Utilization by Severity Level

The High Cost of Chronic Care in the ED

What is the average cost of an Emergency Room

visit in Caravan Health Patients?


$2,491

Cost Effective Chronic Care


What is the cost of an

average outpatient office

visit for management of

Hypertension, Diabetes,

COPD, CHF, Depression?

$47.50

$315.40

$121.45

Overcoming Patient CCM Cost Sharing Barrier


A single ED visit

copay for patients

is 10x the cost of

6 months CCM

and 5x the cost

of 6 months

Complex CCM$498

$48

$108

$0 $100 $200 $300 $400 $500 $600

Single ED Visit

CCM x 6 mo

Complex CCM x 6 mo

Level 1 – Practice-Level Interventions: Lightbeam Demo



Lightbeam Training Resources

Types of reports• Patient Cohorts

• Johns Hopkins

Lightbeam Cohorts


• Five cohort options

• Workbook explains

data fieldsNew! New!


Cohort Training Video


Lightbeam Training Resources

Your workbook provides more information about these

reports via video and instruction sheets.

Level 2 – System-Level Interventions: Compass Analytics


Caravan Compass is a good place to Explore Health System Level Opportunities

Familiar Content:

• Key Performance Indicators

New Content:

• Network Utilization

• End-of-Life Analysis

• Post-Acute Care Analysis

• Clinical Episodes Cost Analysis


Key Performance

Indicators

Network Utilization

End-of-Life Analysis

Post-Acute Care

Analysis

Clinical Episodes

Cost Analysis

Discussion


Preparing for Success in CCM

1. Which of the 5 Pre-identified Lightbeam cohorts will you start with?

2. Who on your team will “own” care coordination efforts for your identified list of

patients to keep on track ?

3. How many patients do you think you can enroll today to test processes?

4. How will you engage your ACO Physician Leaders and providers?

5. Who will reach out to Emergency Room and/or Inpatient Discharge planner to

start working together as a larger team?



Getting Your Program Off the Ground

What is the first thing you will do when you go home

(on this list or not) to get your program off the ground?

Thank Youbringing population health to life

www.caravanhealth.com | [email protected] | 916.542.4582

Using Patient Cohorts to Drive System Transformation · One of the greatest challenges that will...

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