Managed Care Models for ABD

Populations: Identification,

Stratification and Care

Coleen Kivlahan, MD, MSPH

Schaller Anderson, Inc.

CHCS Medicaid Best Buys Webcast

Tuesday, May 29, 2007

1

SA’s Complex and ABD Members

Arizona: 8,524 LTC; 41,000 ABD; 11,000

HCG (high risk pool); 13,000 SNP

California: 66,000 TANF and ABD children

Delaware: 9,000 ABD

Maryland: 12,300 ABD

Total = More than 100,000 members (March

2007 data)

2

Annual Claim Costs by Percentile(Medicare vs. Commercial vs. Medicaid)

3

$-

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

Percentile of Medicaid Members

Pe

r C

ap

ita C

osts

Medicare Medicaid-ABD Commercial Medicaid-TANF

Avg. Medicare Avg. Medicaid-TANF Avg. Comm

ABD High Utilizer

in the Traditional Insurance Model

1. No PCP or medical home

2. Uses ER for primary care

3. Little to no information passing between ER, inpatient setting and care manager

4. No way to identify her as high utilizer and inform interventions

5. No concurrent review, only retrospective review

6. No prior authorization for key procedures

7. Lack of integration of pharmacy, lab or BH data

8. Limited intensive care management

4

More than Half of People with Serious Chronic

Conditions* Have Three or More Physicians

No Physicians 3%

1 Physician 6%

2 Physicians 26%

3 Physicians 23%

4 Physicians 5%

5 Physicians 6%

6+ Physicians 11%

• People with serious chronic conditions have a condition that is expected to last a year or more, requires ongoing medical attention, and limits what one can do. Serious chronic conditions are a subset of chronic conditions, which are also expected to last a year or more but limit what one can do, and/or may require ongoing medical care. Source: Serious Chronic Illness Survey, conducted by the Gallup Organization, 2002.

5

Physicians Believe that Poor Care

Coordination Produces Poor Outcomes

6

24%

34%

34%

36%

44%

49%

54%

0% 10% 20% 30% 40% 50% 60%

Unnecessary Nursing Home

Placement

Experience of Unnecessary Pain

Patients Not Functioning to

Potential

Unnecessary Hospitalization

Adverse Drug Interactions

Unattended Emotional Problems

Receipt of Contradictory

Information

Percent of Physicians Who Believe That Poor Outcomes Result From Poor Care Coordination

Source: National Public Engagement Campaign on Chronic Illness—Physician

Survey, conducted by Mathematica Policy Research, Inc., 2001.

Our Predictive Modeling tool includes:

Predictive Risk Score – Multiple factors, including the Medicaid Rx, a pharmacy based

risk adjustment tool, are used.

Chronic Care Risk Stratification -- Members are stratified on the basis of their

compliance or adherence to program goals and outcomes, and ranked by the risk of future

avoidable costs that each enrollee represents.

Co-morbidity -- Each member is assigned additional algorithm weight if a significant co-

morbid condition is identified. Predictive Pathways uses the Charlson Index to identify and

apply additional diagnostic weight for those conditions having significant morbidity

implications.

Impact Rating -- A member’s primary condition is assessed and scored based on the

possible level of impact from care management on the member’s financial and clinical

outcomes.

12-Month Claims Cost -- A rolling 12 months of claims cost (pharmacy, medical, DME,

procedures, lab, etc) (excluding trauma and maternity) is calculated. Cost is stratified into

high-cost, moderate and low-cost enrollees, with higher weights given to those members

having higher accumulated costs.

Care Gaps -- The presence or absence of evidence-based effective interventions for each

of the four conditions in disease management: CHF, COPD, Diabetes and asthma.

7

It should also include:

Self-report data (HRA)

Functional status

QOL indicators

Social and behavioral indicators

Cognitive markers

Biomarkers

Pharmacy adherence measures for key

meds

8

Predictive Modeling Ranks for all Members:

sorted by ABD population

9

47-year-old with CHF, diabetes,

schizophrenia: 23 ER visits, no PCP

10

11

12

14

The Levels of Care in Schaller Anderson’s Pathways to Integrated Care™

Prevention and Wellness

Disease Management – Low Risk

Disease Management – High Risk

Care Coordination

Perinatal Case Management

Short-Term Case Management

Intensive Case Management

Catastrophic and End of Life Care

COMPLEX DM:

Cluster: CHF, Diabetes, HTN, lipids, depression, sleep apnea

Member ID – CHF & Diabetes

Assessments

Awareness of Diseases

Medication Adherence

Aspirin

Barriers

Labs & Procedures History

Blood Pressure

Social Factors (Diet, Smoke, EtOH)

Sleepiness / OSA

Depression / Anxiety

ER & Hospital IP

Goals & Plans

Next contact

15

Use of Clusters and Evidence-Based Guidelines to spot

care gaps

16

Member Name:

Carrier Member Id:

Age:

Rate Description:

Primary Comorbidity:

ECHOCARD Flu VacPneum

Vac

Beta

Blockers

Aldo-

sterone

ARB/ACE

TherapyNitrates

Anti-

coagulants

Stress

Test

SF

Survey

ACE

Test

CHF

Compliance

Risk

Strat

Y N N Y N Y N N Y N N Low

Status MarkersTreatment MarkersClinical & Preventive Markers

CHF Compliance Risk Stratification

Spirometry Flu VacPneum

Vac

Steroid

Therapy

Anti-Coag/B-

Agonist

L-T

B-Agonist

Oxygen

TherapySF Survey ACE Test

COPD

Compliance

Rist Strat

N N N N N N N N N High

Clinical & Preventive

Markers

Treatment Markers Status Markers

COPD Compliance Risk Stratification

A1C

Test

A1C

Level

LDL

Test

LDL

Level

Retinal

ExamFlu Vac

Pneum

Vac

Insulin

Therapy

Oral

Antidiabetic

Therapy

Statin

Therapy

SF

Survey

ACE

Test

Diabetes

Compliance

Risk Strat

Y Y Y Y N N N N Y Y N N Low

Diabetes Compliance Risk Stratification

Clinical & Preventive Markers Treatment Markers Status Markers

Quick view of the

complex

member’s gaps in

evidence-based

care

TOP 5 KEYS TO MAXIMIZE IMPACT

Impact members by:

1. Link key data (claims, pharmacy, lab, procedures, DME, BH, referrals, PCP use, care management tool)

2. Integrate with self-report, functional status and QOL indicators, social, behavioral and cognitive indicators

3. Use predictive modeling to target care management interventions (SA uses 50% standard), but leave opportunity for self and community referral as well as assessment data to influence who gets CM

4. Measure pharmacy adherence for key meds

5. Make care plans accessible to members and their community of providers