population health success at the north carolina...
TRANSCRIPT
Population Health Success at the North Carolina State Health Plan
April 15, 2015 Janet Cowell, Treasurer, State of North Carolina
Charles Saunders, M.D., Chief Executive Officer, Healthagen
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Conflict of Interest Janet Cowell and Charles Saunders, MD have no real or apparent conflicts of interest to report
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Learning Objectives 1. Explain how the North Carolina State Health Plan designed a technology-enabled population health and care management strategy that became a national model for improving health and well-being across its membership.
2. Identify the advantages of a diverse outreach strategy leveraged by the North Carolina State Health Plan including its direct impact on care quality, member engagement and costs
3. Best practices for personalized and meaningful outreach efforts
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Benefits Realized for the Value of Health IT
Satisfaction Engaged members are surveyed to assess their satisfaction with population health programs and nurse coach interaction
Treatment and Clinical
Reduction in overall, lifestyle-related risk factors
Electronic Information and Data
Clinical analytics and data give us the ability to stratify and engage our population through high-touch, highly personalized population health efforts
Prevention and Patient Education
Education through various communication channels is key to meeting our clinical and financial goals
Savings The NCSHP has recorded lower than expected net claims payments and net administrative costs
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Who We Are • We serve teachers and local school
personnel, state employees, retirees, current and former lawmakers, state university and community college faculty and staff and their dependents
• We empower members to make healthier lifestyle choices and to become partners in addressing their health care needs
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NC State Health Plan Demographics Total Membership
• 680,000 Medicare/MA, Active, COBRA and Pre-65 Retiree members • 80% are Active, COBRA and Pre-65 Retiree members
Average age is 46 11% use tobacco* 32% are obese*
Members reside in all 100 counties across the state
*Source: NC Behavioral Risk Factors Surveillance Survey 2012
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Areas of focus for today • NCSHP’s Strategic Plan • Member Health and Population Health IT • Financial Status
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48% 51%
1%
More than half of our members have a chronic illness including 1% with a catastrophic illness
Chronic Illness
Healthy/Acute
Catastrophically Ill
% of Total Population
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Source: Segal Report CRG 2013
12%
76%
12%
Chronically ill members account for 76% of annual costs
Chronic Illness
Healthy/Acute
Catastrophically Ill % of Total Claim Cost
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Source: Segal Report CRG 2013
Guiding principles for our strategic plan Mission Improve the health and health care of North Carolina teachers, state employees, retirees and their dependents in a financially sustainable manner, thereby serving as a model to the people of North Carolina for improving their health and well-being.
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Guiding Principles • Improve Affordability
• Improve Members’ Health
• Ensure Access to Quality Care
• Incent Member Engagement
• Promote Health Literacy
• Provide Member Choice
• Maintain Financial Stability
Priority Description Goal Description
Improve members’ health
PCMH Utilization Increase % of members receiving care from a NCQA recognized PCMH
Quality of Care Increase % of members with targeted high prevalence conditions receiving care according to national clinical standards
Worksite Wellness
Increase number of worksites offering worksite wellness
These goals and future targets will lead to: • Healthier and more engaged members • Better managed chronic disease • Members receiving high quality, coordinated care
Improve members’ health
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Population health programs to meet the population’s diverse needs: • Disease and case management
• Active lifestyle coaching
• 24 hour nurse-line
• Clinical decision support and health opportunity identification
• Patient Centered Medical Home practice support
• Tobacco cessation programs
Improve members’ health
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Complex Chronic
Major Chronic
Minor Chronic
At Risk
Healthy
High Impact Intensive Outpatient Care Management
Moderate Impact Care Coordination
Lower Impact Wellness & Lifestyle Enhancement
Decision Support
Improve members’ health
Catastrophic
Population health shifts from a disease focus to a care focus
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Find the right people with the right data Improve members’ health
Data Aggregation
Clinical Alerts Analytics Care Coordination Patient Engagement
Analysis and Intelligence Provider Workflow
Data Integration
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Analyze data against clinical rules and evidence-based medicine
10,000+ Clinical analytic rules
Based on standards from American Heart Association, National Institute of Health, CDC, BMJ, American Academy of Pediatrics, American Diabetes Association, and more
1,453 Care considerations (CCs)
250+ Unique conditions
100+ Care management assessments
200+ Quality measures*
Evidence-based Medicine Claims evaluation based on EBM rules**
Health opportunity identification
Health opportunity communication to patients and providers
Clinically Validated Rules
*ActiveHealth, NQF, PQRS, Meaningful Use, HEDIS, Medicare Stars and 21 measures endorsed by NQF **Rules are reviewed and endorsed by Harvard
Improve members’ health
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Risk stratification – population level
Healthy At Risk Minor Chronic
Major Chronic
Catastrophic and End of
Life
Preventative care
Isolated lifestyle issues
At risk for diabetes
At risk for CAD
At risk for stroke
At risk for cancer
Pre-hypertension
Overweight
Smoking
Asthma
Hypertension
Obesity
Diabetes
Heart disease
COPD
Cancer
Chronic kidney disease
Late-stage diseases
Long term care
Hospice care
Patients at risk and opportunities to close gaps in care are identified, so resources can be tailored to the unique needs of sub-populations
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Improve members’ health
Poorly-controlled congestive heart failure
Poly-chronic conditions Frequent/High utilizers Advanced illness
Diabetic - Blind (retinopathy) - End-stage kidney
(nephropathy) Regimen well-titrated
- HbA1c well-controlled (<7.0)
Hypertension - Single medication, marginal
BP control Borderline hyperlipidemia Pre-diabetes
- Metabolic syndrome pattern
Risk stratification – individual level To focus resources, individuals are prioritized by risk and the ability to impact
Improve members’ health
*Expanded Outreach: High Cost Claimants High ED Utilization High Hospital Utilization
Frequent Ambulance Rider High Number of Prescriptions Cystic Fibrosis
CHF Diabetes Asthma
IVIG
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Platform Technology
Segment • Groups members by
common needs, desires and behaviors
Stratify • Represents the
opportunity to impact clinical outcomes
Wherever the member is on the spectrum of health, the Clinical Rules Engine monitors his or her health condition
Engagement Personalization Insights
Recommend and Communicate
• Tailors program recommendations by taking into account member profile and opportunity score
• Messages opportunities to the member and physician via various channels based on segment
Collect and Synchronize • Sorts and organizes
large volumes of data
Identify • Assesses member’s
risk for disease and validates presence of conditions
Improve members’ health
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Platform Technology Collect and Synchronize
Large volumes of data are ingested from a variety of sources: Medical, Rx, and
behavioral claims Member
self-report Physician and inpatient EMR
Labs and biometrics
Care team via ActiveAdvice
Physician feedback
Engage • Individualized • Prioritized
• Clinically robust • Motivational
• Health literate • “Snackable”
Engagement modes vary by opportunity:
And use consistent content across all services:
high-tech digital
high-touch one-on-one
to
Segment and communicate
Members are grouped by needs, behaviors and preferences
Communications are tailored and modes of engagement are promoted
Stratify Individuals are assessed for impactability:
Acute or complex
Moderate to high risk Low risk Healthy,
no risks
Recommend Individuals are referred to available programs:
Decision support
Lifestyle coaching
Condition management
Maternity support
Transitions of care
Compassionate care
Case management
General wellness
Identify Clinical Rules Engine identifies opportunities for health improvement using:
Evidence-based algorithms
Predictive analytics
Improve members’ health
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Asthma Step 2 Therapy
“Your patient has evidence for asthma and for multiple refills of short-acting beta agonists…”
Doctor version
Ask about Inhaled Steroids
“Our data shows that you have asthma that may not be well controlled. Ask your doctor…”
Patient version
Alert patients and providers of opportunities to improve care through preferred communication channel
Improve members’ health
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Engage and recruit practices
Evaluate $ Build Support Coordinate
Develop payment model along value-
based spectrum
Maximize Patient Centered Medical Home effectiveness • Patient centered care coordination model designed to support physicians and
practices and increase member engagement • Use provider facing care management application to integrate various sources
of clinical and member derived data including real time ADT data • Exploring HIE partnerships and provider EMR workflow access/integration
Evaluate effectiveness
using independent third party consultant
Improve coordination by using a combination of
embedded care managers and
telephonic support
Improve members’ health
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Improvement in 23 of 28 measured clinical outcomes since inception
2.4% 2.9% 2.7% 3.0% 2.7% 3.3%
0%1%2%3%4%
Diabetes:Nephropathy
Asthma:Appropriate Meds
Breast CancerScreening
Cervical CancerScreening
CHF: ACE/ARB CHF: LVEF Eval
8.8% 7.4% 7.9%
16.4% 17.1%
0%2%4%6%8%
10%12%14%16%18%
Asthma: β-agonist overuse reduction
Diabetes: HbA1c Diabetes: LDL Colon CancerScreening
CHF ReadmissionReduction
*Clinical measures 2010-2013
Improve members’ health
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Notify members of program eligibility through targeted communications
Diversify outreach: Leverage multiple communication channels, including print, digital and telephonic
High volumes: 3.9 million touches through portals, webinars, mailers, calls and alerts – average of 7.3 touches per member
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Improve members’ health
Priority Description Goal Description
Improve members’ experience
Customer Satisfaction
Maintain/improve overall customer satisfaction score
Annual Enrollment Service Level Agreements
Improve customer service SLAs
Member Engagement
Increase in # of active members registered on TPA site, usage of provider search and transparency tools, and attendance at educational roadshows
These goals and future targets will lead to: • Increased member engagement • Higher level of trust • More informed members empowered in their decision making
Improve members’ experience
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• Increased awareness of member health status by engaging members in 2014
– Incent members through premium reduction to for complete Health Assessment
– Member portal provides each member with immediate feedback on personalized Health Assessment report with a detailed plan to take action
– Health Assessment completions increased from 10,919 in January 2013 to 233,368 in November 2014
– Generated 40+% increase in identified health opportunities across the population
Incent members to complete Health Assessment to be more aware
Improve members’ experience
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Improve the members’ experience
85% engaged from
those contacted
14% total population
engaged
93% member
satisfaction
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Priority Description Goal Description
Ensure a financially stable state health plan
Net Income/Loss Actual at or above budget for plan year
PMPM Claims Expenditures
At or below budget for plan year
Member Cost-Sharing
% of total claims cost paid by members through copays, deductibles and coinsurance at or below benchmark
These goals and future targets will lead to: • Reduced costs for members and the Plan • Reduced fraud, waste, abuse and overuse • Delivery of appropriate care in the appropriate setting • Payment for quality and value rather than quantity
Ensure financial stability
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Savings from Population Health Improvement
*Validated by independent 3rd party actuarial consultants
Ensure financial stability
Actual vs. Expected Trend
Period Total Savings PMPM Savings
2010-2011 $149,676,520* $22.69 2011-2012 $142,701,928* $21.86 2012-2013 $148,817,452 $23.08
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ROI analysis showed the following annual changes: 2011-2012 2012-2013
Medical IP admissions 1.8% -0.6%
Surgical IP admissions -9.4% -6.7%
Ambulatory surgery services -6.5% -2.9%
Brand name medication utilization -18.9% -13.3%
ED visits -2.4%
Every 1% decrease in chronic disease = $90 million saved annually
Ensure financial stability
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Utilization Annual Changes
Ensure financial stability
0
10
20
30
40
50
Nov '10 - Oct '11 Nov '11 - Oct '12 Nov '12 - Oct '13 Mar '13-Feb '14
Total MIH/1000
Total Non-MIH/1000
Utilization Outcomes
0
10
20
30
40
50
60
70
2010 2011 2012 2013 Q2 2014
ED Use per K mbrs withasthma/yrHospital Use per Kmbrs with asthma /yr
0
50
100
150
200
250
300
2010 2011 2012 2013 Q2 2014
Hospitalizations per Kmbrs with CHF/yrReadmission Rates(denom is admissions)
Most Impactable Hospitalizations
Asthma
Heart Failure
MIH
E
D/H
ospi
tal U
se
Hos
pita
l/Rea
dmits
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The North Carolina State Health Plan saved the state $23 million by foregoing premium increases for the 2015 benefit year based on savings generated
Ensure financial stability
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Recent Historical Financial Results Revenues and Expenses
$2.273
$2.676
$2.490
$2.798 $2.852
$2.960 $3.020
$2.290
$2.625
$2.559 $2.650 $2.620
$2.679
$2.845
$2.0
$2.2
$2.4
$2.6
$2.8
$3.0
$3.2
FY 2008 FY 2009* FY 2010 FY 2011 FY 2012 FY 2013 FY 2014
$ Billions
Revenues Expenses
*FY 2009 revenues include a $250 million general fund appropriation from the State.
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Ensure financial stability
Recent Historical Financial Results Net Income/(Loss) & Ending Cash Balance
($17)
$51
($69)
$148 $232 $281
$175 $140 $190
$122
$270
$502
$784
$959
-$200
$0
$200
$400
$600
$800
$1,000
$1,200
FY 2008 FY 2009* FY 2010 FY 2011 FY 2012 FY 2013 FY 2014
$ Millions
Plan Income/(Loss)
Ending Cash Balance
*The Plan received a $250 million general fund appropriation from the State in FY 2009.
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Ensure financial stability
Recent Historical Financial Results Expenditures (Claims + Administrative) PMPM
$298.84
$330.91 $321.93 $332.85
$328.60 $334.90
$352.30
$290.00
$333.48
$317.36
$347.49
$361.56 $358.70
$374.75
$280
$300
$320
$340
$360
$380
$400
FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014
PMPM Expenditures
Actual Expenses
Budgeted Expenses
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Ensure financial stability