![Page 1: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/1.jpg)
1
2.05 Predictive Modeling P4P and Physician Engagement
Pay for Performance Summit February 7, 2006
2.05 Predictive Modeling P4P and Physician Engagement
Pay for Performance Summit February 7, 2006
![Page 2: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/2.jpg)
2
Agenda
• Three Key Healthcare Trends
• About “Predictive Modeling”
• About “Reporting”
• Business and Clinical Outcomes
![Page 3: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/3.jpg)
3
Healthcare Costs…
![Page 4: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/4.jpg)
4
Fragmented Information
![Page 5: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/5.jpg)
5
Quality ‘Gaps’ in Care
* Source: www.NCQA.org/communications/somc/sohc2004.pdf
“Our results indicate that, on average, Americans receive about half of recommended care processes.” - McGlynn, et.al,
NEJM; June 26, 2003
“Poor quality care leads to 65.5M avoidable sick days and $1.8B in Excess Medical costs eachyear…”- State of Healthcare Quality: 2004*
![Page 6: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/6.jpg)
6
Challenge: Chronic Disease• Chronic Disease – 50-75% of
US health care spend
• Chronic Diseases – 125mm Americans with at least 1 chronic disease, 45mm with >2 chronic conditions
• Patients with chronic medical conditions account for:
– 76% of inpatient admissions
– 88% of prescription drug use
– 96% of home care visits
– 72% of physician visits
Source: Chronic Conditions: Making the Case for Ongoing Care; December 2002; Partnership for Solutions, Johns Hopkins University, for The Robert Wood Johnson Foundation
![Page 7: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/7.jpg)
7
Population Contribution to Total Health Care Costs
28%
95%
45%
27%
1%4%
Membership Medical Costs
Source: AC Monheit, “Persistence in Health Expenditures in the Short Run: Prevalence and Consequences,” Medical Care 41, supplement 7 (2003): III53–III64.
Opportunity: Chronic Disease
45%45%
28%28%
27%27%
![Page 8: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/8.jpg)
8
Case Management
Role for Medical Management
1%
9%
90%
1/3
1/3
1/3
Specialty Pharmacy
Rare chronic (Hemophilia,
Hepatitis C, MS, RSV, Growth
Hormone)
$71,600
Retail and Mail Order
Prevalent chronic (Asthma, Diabetes)
Procedures (Childbirth,Surgery)
$6,600
Retail
AcuteLow-Grade
ChronicHealthy
$1,200
Distribution ChannelsParticipants
Avg. AnnualCost/Case
Covered Population
Total Drug Spend
Source: JP Morgan Industry Update, “Specialty Pharmacy: Conduit of Growth for Biotechnology,” March 14, 2003.
Emerging Management
Disease Management
Demand Management
![Page 9: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/9.jpg)
9
Success Formula “Musts”
1) Aggregate records of health care services2) Measure effectiveness of care:
– Benchmark the process of care against medical evidence-based metrics
– Benchmark the outcome of care against what is valued3) Establish valid economic correlates to the care
– Use case-severity adjusted measures4) Use data mining and statistical analysis to predict which
individuals will most benefit from proactive delivery of services
5) Convey timely and accurate reporting to physicians6) Align financial incentives of stakeholders
![Page 10: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/10.jpg)
10
Objectives
1. Understand uses of predictive modeling as an applied science in health care delivery
2. Cite how predictive modeling can advance disease management
3. Review how predictive modeling can be can be applied to pay for performance programs
4. Cite specific steps for implementation
![Page 11: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/11.jpg)
11
Predictive Modeling: Definition
• The process of using predictive analytics to identify a set of variables that can be combined and used to forecast probabilities of an event with an acceptable level of reliability.
• Steps in creating a predictive model:1) Data is collected2) A statistical model is formulated3) Predictions are made 4) Model is validated (or revised) as additional data becomes
available.
![Page 12: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/12.jpg)
12
Modeling ProcessIdentify segments & select best drivers/variables
Segments: Diseases, Enrollment Groups, Users, Benefit Class, Product Line Via Classification Methods
Best Variables via: Decision Networks, Nearest Neighbor Pairing….,Select model for optimum training of each segment
Linear & Nonlinear / Regression, Neural Networks….,
Apply model on out-of-sample set for validationSensitivity/specificity, R2Content experts evaluate results by reviewing variables across risk categories
Each Client’s Population is evaluated against population parameters to determine Universal Model to deploy & whether optimization ofmodel is required
![Page 13: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/13.jpg)
13
Creating a Predictive Model
• Episodes of care – Symmetry ETG
• Drug Groupings - First Databank
• MEDai clinical groupings
• Service timing/frequency Inpt/ER/Phys
• Patient characteristics
• Evidence Based Risk Markers
Forecasted Costs for
each member
Risk Score 1-5
Relative Risk Index
Medical Claims
Rx Claims
Member Eligibility
Optional DataLab resultsHRAUM/Auth
Raw DataTransformed Variables
Output - Risk
MITCH ENGINE
![Page 14: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/14.jpg)
14
Validation Set $ Paid PM Predicted vs. Actual
Each data point represents a single group of members within a range of predicted paid amount fromthe lowest predicted group to the highest predicted group (100 groups each with 1100+ members)
0
200
400
600
800
1000
1200
1400
1600
1800
1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97
$Pai
d P
M
Actual$Predicted$
Use Year1 data to predict Year 2 cost
![Page 15: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/15.jpg)
15
Validation Set by Age Grouping$ Paid PM Predicted vs. Actual
0
50
100
150
200
250
300
350
400
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75
AGE
PM
PM
$
ACTUAL
PREDICTED
![Page 16: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/16.jpg)
16
Engage Physicians
Providers need:Providers need:Incentives – Pay For Performance
Single point of accessComplete patient historyMember / Risk / Impact ProfileAccess to Evidence based guidelines & referencesIdentify “gaps” in care for all patientsStratification of prospective risk for all patientsIdentify where to spend resource
No disruption of day to day work flow
![Page 17: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/17.jpg)
17
![Page 18: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/18.jpg)
18
![Page 19: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/19.jpg)
19
![Page 20: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/20.jpg)
20
Q
![Page 21: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/21.jpg)
21
![Page 22: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/22.jpg)
22
![Page 23: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/23.jpg)
23
![Page 24: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/24.jpg)
24
SELECT
![Page 25: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/25.jpg)
25
![Page 26: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/26.jpg)
26
![Page 27: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/27.jpg)
27
![Page 28: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/28.jpg)
28
![Page 29: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/29.jpg)
29
![Page 30: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/30.jpg)
30
![Page 31: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/31.jpg)
31
![Page 32: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/32.jpg)
32
![Page 33: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/33.jpg)
33
![Page 34: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/34.jpg)
34
What Does this Capability Mean for You?Physicians can focus on the proactive delivery of services that will have a predictable impact on quality and cost
No disruption to existing workflow
An EMR or e-Prescribing software is not required to be in place
Revolutionizes physician access to information: View of ALL the care services irrespective of provider
Better coordination of care between Health Plan and entire provider network as well as between providers
IPAs “at risk” are able to: Improve financial performance under the ‘cap’ in real timeValidate actuarial fairness of their capitation agreements
![Page 35: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/35.jpg)
35
Predictive Modeling & P4P
• Predictive modeling can be thought of as the “entry level” HIT system that can be adopted by any practicing physician with computer in the office
• Reporting is evidence based, transparent • Enables P4P to connect the “process of care” to
the “clinical impact on outcomes”• Ability to align incentives fairly and equitably
irrespective of the condition or severity of illness
![Page 36: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/36.jpg)
36
P4P Programs: Future Predictions
Predictive modeling will be used to administer “high-impact” P4P:• Multi-payer reporting
– Ability to address a physician’s entire practice• Simultaneous, multi-cohort disease management
with unified criteria (payer, QIO, CMS)• Automated P4P, QIO & CMS reporting of outcomes• Substantial financial incentives tied to “Quality”• Automated “dash-board” reporting in real time • Can be used to administer a more sophisticated
physician payment system which reimburses for proactive care in both FFS and capitated plans
![Page 37: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/37.jpg)
37
Caveats
• Seldom involves more than one payer in a practice
• Enables multiple conditions to be tracked and managed simultaneously and “at scale”
• Can be solely “payer driven”
• Needs to involve reporting from all payers
• Need for payer coordination of the clinical goals in collaboration with physicians
• Recommend collaborative approach with physicians and/or IPA governance and consideration of positions of organizations such as American College of Physicians and others
Today Near Term
![Page 38: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/38.jpg)
38
Summary
Medical claims, pharmacy utilization and clinical laboratory information, can serve as valuable ‘inputs’ into a predictive modeling engine to automate reporting which will:
• Identify patients most likely to require medical services over the prospective benefit period
• Segregate of those with “impactable” risk • Determine the most effective clinical course of
action to mitigate acuity and cost of illness • Support fair and equitable management of P4P
initiatives “at scale”
![Page 39: 2.05 Predictive Modeling · MedPlus, a Quest Diagnostics Company 4690 Parkway Dr. Mason, OH 45040 513.229.5500 ptellez@medplus.com Rebecca Hellmann Payer Services MedPlus, a Quest](https://reader033.vdocuments.us/reader033/viewer/2022042921/5f6ab9bd09d1bd656e1e3257/html5/thumbnails/39.jpg)
39
Thank you….Contacts:Patrick Tellez, MD, MPH, MSHAVice President, Medical AffairsMedPlus, a Quest Diagnostics Company4690 Parkway Dr.Mason, OH [email protected]
Rebecca HellmannPayer ServicesMedPlus, a Quest Diagnostics Company4690 Parkway Dr.Mason, OH [email protected]
Further Reading: 1) Predictive modeling: www.medai.com
2) P4P Program Design:
a) “Linking Physician Payments to Quality Care” American College of
Physicians Position Paper 2005; www.acponline.org/hpp/link_pay.pdf
b) American Assn. Family Practice: http://www.aafp.org/x30307.xml