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Experience Over 25 million total subscribers
managed Medicaid among fastest growing
class of subscribers Program types
ASO Full Risk
Radiology Benefit Management
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Trend, Utilization & Cost
MedicaidUnmanaged
Modality 2004 2005 % Trend 2006 % Trend 2007 % Trend 2008 % TrendCT 44.00 49.28 12.00% 54.70 11.00% 60.17 10.00% 66.19 10.00%MRA 1.50 1.73 15.00% 1.98 15.00% 2.28 15.00% 2.53 11.00%MRI 30.00 34.20 14.00% 37.96 11.00% 41.38 9.00% 45.10 9.00%Nuc Card Prim 8.50 9.78 15.00% 11.24 15.00% 12.59 12.00% 14.10 12.00%Nuc Med 6.00 6.24 4.00% 6.49 4.00% 6.75 4.00% 7.02 4.00%PET 0.75 0.98 30.00% 1.22 25.00% 1.44 18.00% 1.68 17.00%High Tech 90.75 102.20 12.61% 113.60 11.16% 124.61 9.69% 136.63 9.64%
MedicaidManaged
Modality 2004 2005 % Trend 2006 % Trend 2007 % Trend 2008 % TrendCT 39.40 42.16 7.00% 44.69 6.00% 47.82 7.00% 50.69 6.00%MRA 1.19 1.30 9.00% 1.40 8.00% 1.52 8.00% 1.62 7.00%MRI 24.88 26.37 6.00% 27.95 6.00% 29.91 7.00% 32.00 7.00%Nuc Card Prim 6.05 6.77 12.00% 7.45 10.00% 8.04 8.00% 8.69 8.00%Nuc Med 5.20 5.30 2.00% 5.41 2.00% 5.46 1.00% 5.52 1.00%PET 0.59 0.68 15.00% 0.79 15.00% 0.89 13.00% 0.99 11.00%High Tech 77.31 82.59 6.83% 87.69 6.18% 93.64 6.78% 99.50 6.26%
Unmanaged Medicaid vs. Managed Medicaid Trend by Modality
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Relationship to Commercial RBM
Strategies used to manage Medicaid outpatient diagnostic imaging benefits are generally the same as those used for commercial and Medicare benefit programs
Key differences: Frequency and site of service Consumer knowledge and engagement Access to care Quality of care
Potential utilization management impact by Medicaid lines of business: FHP – High Impact TANF – Moderate Impact ABAD – High Impact CHP – Low Impact
Medicaid programs must address appropriateness and frequency of imaging with attention to under utilization
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Strategies for Effective Radiology Benefits Management
Key Reduction Components Impact
Prior Authorization 12%
Correct Coding 2%& Bundling
Steerage 3%
Profiling/Reporting 1%
Privileging 3%
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Nurse reviews history and findings against evidence-based criteria. If request satisfies criteria the exam is approved immediately and an authorization number is issued. If not, the case is transferred to a physician for review.
Physician reviews case and as appropriate will consult with referring physician. Case is approved, non-certified or withdrawn.
Physician seeksprior authorization & selects 1 of 3portal options:
Phone Web Fax
Physician office visit
Licensed Specialist Review
Physician evaluates clinical problem and chooses an imaging study
Prior Authorization Overview
Advanced Imaging Exams
MRI/MRA CT PET Nuclear Cardiology Nuclear Medicine
Physician Review
Criteria for radiology, cardiology and oncology can be found on the CareCore National’s website
Proprietary Clinical Criteria
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Assures ongoing performance monitoring. Componentsinclude professional practice/physician assessment, peer review, film review, equipment accreditation, equipment standards, specific performance-based privileging for complex imaging procedures, pay-for-performance, redirection and quality standards.
Quality Assurance
Professional Practice/Provider Assessment Practice and site details Ownership structure Physician information Modalities Equipment specifications Policies and procedures
Film Review Randomized targeted
film review to assess: image quality professional
interpretation Corrective actions
required if deficiencies are noted
Accreditation & Privileging Proper accreditation of
site and equipment Limit the scope of
imaging procedures that a physician, site or specialty will be authorized for payment when “self-referred.”
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Network Management
Factors driving cost: 60% of all Medicaid outpatient imaging is provided at
hospital outpatient departments 40% of the balance is self-referred Need adequate access to quality free-standing imaging
centers
MODALITY Office HospitalCT SCAN 242.56$ 375.06$ MRA 301.16$ 563.42$ MRI 327.48$ 725.71$ NUC CARD PRIMARY (BUNDLED) 536.90$ 1,568.90$ NUC MED 119.09$ 447.71$ PET SCAN 1,955.12$ 4,712.71$
MEDICAID Avg Paid Amount
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Quality & Privileging
Quality considerations: Medicaid recipients are entitled access
to quality services Equipment and performance standards
are essential Balance quality and cost
Privileging considerations Focus on limiting self-referred imaging Impose universal equipment and
performance standards Monitor utilization profiles
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Experience Over 5.5 million subscribers under
management Program types
ASO Full Risk
Diagnostic imaging & implantable devices
Cardiology Benefit Management
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Cardiology Facts
10%
20%
30%
40%
50%
60%
0%
Pacemakers ICD
$11.8 Billion Implantable Device Cost
10%
20%
30%
40%
50%
60%
0%0%
Pacemakers ICDICD
$11.8 Billion Implantable Device Cost
10%
20%
30%
40%
50%
60%
0%
Pacemakers ICD
$11.8 Billion Implantable Device Cost
10%
20%
30%
40%
50%
60%
0%0%
Pacemakers ICDICD
$11.8 Billion Implantable Device Cost$25 Billion Imaging Costs
2%
28%
34%
8%
3%
26%
Cardiac PET/MRI EchocardiographyNuclear Stress Test Coronary CT AngiographyEcho Stress Test Left Heart Catheterization
Modality Trend (yearly) Volume (2006) Cost
Nuclear stress 13% 19 million $600-$1200
Echo stress 10% 3 million $300
Echocardiography 8.5% 26 million $350
2006 Cardiology Spending
Nuclear Medicine
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Diagnostic Studies Nuclear stress test Echo stress test Echocardiography Cardiac PET Cardiac MRI Coronary CT angiography (CCTA) Diagnostic left heart catheterization
Implantable Devices Pacemakers Implantable cardioverter defibrillator
(ICD) Biventricular pacemakers
A Comprehensive Approach
Cardiology Program Components
Cardiology Program Impact
MODALITY Approvals /1000
Non Certs /1000
% Approved
% Non-Cert
% Withdrawn
Cardiac Catheterization 2.92 0.36 79.7% 9.77% 10.53%
Cardiac CT/CCTA 0.06 0.18 20.0% 65.0% 15.0%Cardiac MRI 0.23 0.03 53.33% 6.67% 40.0%Echo Stress 1.86 1.75 46.08% 43.34% 10.58%Echocardiography 32.32 0.52 94.99% 1.54% 3.48%Nuclear Stress 18.60 4.48 75.83% 18.28% 5.89%
MEDICAID 2007
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Oncology Benefit Management
Experience Over 24 million lives under
management ASO Program
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MedPORTAL™
A highly customizable, web-based medical and medication management tool, designed to meet the demands of managing injectable and specialty drug programs across all platforms
Features Drug coverage mapping Medical pharmacy guidelines Online Prior Authorization Therapeutic reimbursement
management Clinical protocol mapping Provider education Dose calculator Patient drug education leaflets
Optional Online drug and administration
claims adjudication Online medication ordering with
contracted pharmacies
MedPORTALTM
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Clinical & Utilization Overview of the BioMANAGE™ ESA Program
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FMVTM: Therapeutic Class Reimbursement
Reimburse “lower cost alternative” at a “higher profit margin” then costlier drugs
Name Indications Dosage Physician’s Physician’s Cost toCost Profit Insurer
Zometa Hypercalcemia of malignancy 4 mg q 3-4 weeks $840.00 $84.00 $924.00
Aredia Hypercalcemia of malignancy 90 mg q 3-4 weeks $118.00 $11.80 $129.80
Appropriate utilization management: A prior authorization is required on Zometa
Proposed Physician Margin
Zometa $80.00 (9.5%) $920.00Aredia $80.00 (68%) $198.00
Savings to Insurer $722.00Per Treatment
Lower-cost Drugs Higher-cost Drugs
Paid Drug Claim Prior Authorization Approved or Denied
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RadCareTM
As an essential component of oncology treatment, radiation oncology is bringing new technology and more treatment options to members with cancer than ever before.
Recent enhancements since 2001 have represented triple digit growth in IMRT.
Future advances such as proton therapy will contribute even more to this rising cost trend.1
CareCore Oncology, under the guidance ofnationally recognized medical experts in radiationoncology have developed a series of radiationoncology pathways focusing on appropriatemanagement and billing of radiation oncologyservices.1NY Times article, “Hospitals Look to Nuclear Tool to Fight Cancer,” Dec. 26, 2007
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Cyber Knife
$55,000 to$70,000 per Treatment
The Rising Cost of Prostate Cancer Treatment
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RadCARETM Pathways Pathways developed by nationally recognized radiation oncologists RadCARE™ Pathways developed for:
Low denial rate, bundling of appropriate radiotherapy CPT codes Reimbursement and preparation of radiopharmaceuticals Anticipated savings between 12% to 15%
RadCARETM Pathways
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LabMANAGE™
With the movement towards individualized medicine in its infancy, the current and forthcoming lab studies in:
Genetics Genomics Cytopathology Cytogentics Pharmacogenomics Chemogenomics
necessitates the appropriate identification andmanagement of these costly tests
In conjunction with the University of Washington, Dept. of Laboratory Medicine, CareCore National has produced:1. Evidenced-based lab study review criteria 2. Diagnosis appropriate lab study guidelines 3. Treatment-specific lab management tools
This process identifies appropriate studies resulting in improved treatment outcomes while reducing the cost associated to unnecessary and/or inappropriate lab studies.