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West Michigan

Renal Symposium: Managing CKD

NKF of Michigan Mission Statement:

Prevent kidney disease and improve the quality of life for those living with it.

Mary Cooley, RN, BSN, MS

AVP, Care Management and Operations

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Priority Health

Michigan’s second largest health plan serving more than half a million

people.

Committed to improving the health and lives of our neighbors.

Offer health plans for every stage of life –from the young to the young

at heart

Feature a network of more than 95% of health care providers in

Michigan

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Priority Health’s Core Purpose

To Improve the health and lives of the

Members we Serve.

Strategic Goal:

Attacking chronic disease to improve outcomes, lower

cost and improve members' quality of life

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Change

The way

care

is delivered

Engage

Members

In their

health

Innovate

Products

and

distribution + +

Priority Health’s Value Proposition

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The Triple Aim Population Health

Exceptional Experience

Better Care for Individuals

Lower Costs

0

5

10

15

20

25

0

1

2

3

4

5

6

7

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1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06 09

Nu

mb

er

wit

h D

iab

ete

s (

Millio

ns)

Perc

en

tag

e w

ith

Dia

bete

s

Year

Percentage with Diabetes

Number with Diabetes

Number and Percentage of U.S. Population with Diagnosed Diabetes,

1958–2010

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics

Age-Adjusted Prevalence of Diagnosed Diabetes

Among U.S. Adults

<4.5% Missing data

4.5%–5.9% 6.0%–7.4%

7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics

2010

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Although one out of three adults—about 78 million people—has hypertension, only 52.5% of adults have it controlled. With direct medical expenses estimated at $47.5 billion a year and $3.5 billion in lost productivity. This rate has not changed since 2007 with an expected rate of 37.2% by 2030.

Hypertension

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One in three Americans is at risk for

kidney disease

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Life Expectancy in the U.S.

100.00% 97.86%

91.64%

77.15%

55.56%

39.80%

22.35%

1.68%

0%

20%

40%

60%

80%

100%0 1 5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

% L

ivin

g

Age (yrs.)

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Emerging Issues in Access to

Health Services*

Access to health care services in the United States is

regarded as unreliable; many people do not receive the

appropriate and timely care they need. The U.S. health

care system, which is already strained, will face an influx

of patients in 2014, when 32 million Americans will have

health insurance for the first time. All of these issues, and

others, make the measurement and development of new

strategies and models essential.

*CDC-HealthyPeople.Gov

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Main Drivers of Total Cost of Care: Chronic Disease

•Accounts for 70% of deaths and ~75% of direct healthcare costs in

USA

•Nearly 1 of every 2 adult Americans has at least one chronic disease

•Prevalence of major contributing factors:

-adult obesity 36%

-diabetes 7-10%

-hypertension 31%

NHANES, CDC, 2011

Prevalence increases dramatically with age

# of Members Annual cost Cost/mbr

CKD w/out ESRD 2154 $3,175,776 $ 1,474.36

CKD with ESRD 504 $20,465,712 $ 40,606.57

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Social Determinants of Health

Source: Authors’ analysis and adaption from the

University of Wisconsin Population Health Institute’s

County Health Rankings model (2010)

countyhealthrankings.org/about-project/background

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Barriers to CKD Improvement:

Claims data alone is insufficient to identify mbr population with

CKD (only 32% of PH mbrs with stage 3 CKD had a renal dx).

Often patients do not know they have CKD!

CKD clinical practice guidelines are complex. PCP awareness,

time and capacity are limited. Simple, iterative intervention/solution

needed.

CKD care fragmented, Nephrologist often consulted too late, and

access/availability is inadequate.

Mortality and CV events strongly correlated with progression of

CKD

CKD complex, spans multiple chronic conditions – does not fit into

traditional disease management program structure.

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Gaps in Care

In 2005, approximately 1.2% of Medicare's 31 million

beneficiaries who had ESRD generated 6.4% of Medicare's

total costs. One of the most important aspects of CKD

diagnosis and treatment is early detection and aggressive

management of underlying causes. However, care for CKD

patients is fragmented. Primary care physicians,

cardiovascular specialists, endocrinologists, dietitians, and

pharmacists may be engaged in the patient's care early but

the nephrologist may not be approached until late, if at all.

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Why is this important and what are

our next steps?

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The

The

Priority Health

Difference

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Triple Aim Goals of CKD Workgroup

Progression of CKD reduced as a result of improvement in

evidence-based medicine accelerated by provider incentive

program:

•Improved screening/identification of members with CKD

•Improved provider adherence to CKD clinical practice guidelines

(care tailored to CKD stage)

•Improved management of key risk factors

BP <130/80

HbA1c < 7%

Persistence of Ace/Arb therapy, >75% MPR

•Care management for patients in Stage 3 and beyond

•Improvement in QOL/Functional status for members with CKD

•Reduction in cost/mbr with CKD as incidence of ESRD

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Improvement in e-GFR Screening Rate

33%

78%

2010 2012

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Medical Cost Avoided - Diabetes

Potentially Avoidable Complications (PAC) – lower is better

High quality and better management reduces avoidable cost

0%

5%

10%

15%

20%

25%

30%

35%

Diabetes

PH PAC Cost Percent

MI Avg PAC Cost Percent

US Avg PAC Cost Percent

US Minimum

PAC

Percent

of Costs

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Diabetes ACE/ARB

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Diabetes

60%

65%

70%

75%

80%

85%

90%

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Priority Health Average 90th percentile Benchmark Plan

A1c testing and outcome

LDL testing and outcome

BP outcome

Eye exams

Nephropathy screening

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Cardiovascular

40%

50%

60%

70%

80%

90%

100%

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Priority Health Average 90th percentile Benchmark Plan National Average

Hypertension BP control

Cholesterol testing and outcome, with CV disease

Beta Blocker after AMI

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Dialysis

- no change in dialysis rates from 2012 to 2013

- an approximate 1.5% decrease in average costs for members on dialysis,

primarily due to significant per-member cost decreases for patients on a

peritoneal modality for the year- more than offsetting increases in average

hemodialysis costs.

2012 2013

Dialysis rates

avg cost

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The Role of Care Management

Care Management Influences Patient Engagement:

More activated members have more positive and supportive

health care experiences.

• Successful navigation of the complex and confusing

health care system

• patients with chronic conditions get significant

support from their health care team

• patients experience fewer problems with access to needed

care

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Population Segmentation Makes It Feasible to Measure and

Manage the Population Health Management Value Equation

How good is

our aim? Right members,

Right timing,

Right allocation

of effort

How well do

we connect? People, program

offerings, and

outreach that

inspire members

towards active

participation to

goal completion

How much

difference

does it

make? Effect of

intervention on

the intervened

How quickly do

we achieve

results? Progress rate,

time to successful

completion

$$$

Program Inputs (cost of

staff, other resources)

= ROI

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Care Management is a pivotal component

of team based care

Team-based health care is the provision of health

services to individuals, families, and/or their

communities by at least two health providers who work

collaboratively with patients and their caregivers—to the

extent preferred by each patient—to accomplish shared

goals within and across settings to achieve coordinated,

high-quality care.

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Additional Programmatic Interventions Via

Community Partnerships:

Diabetes prevention program, in partnership with the NKF of Michigan

•Building awareness of the importance of diabetes prevention.

•Free to our members!

•200 members enrolled

•A total of 1,904 pounds lost!

•An average activity level of 160 minutes/member/week!

The research and evaluation of studies on DPP reveal that for every 100

participants:

•15 cases of type 2 DM are prevented.

•162 missed work days are avoided.

•11 patients will not require lipid lowering rx.

•Avoid $91,400 in (avoidable) healthcare costs.

•Adds the equivalent of 20 years of perfect health!

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Interventions

Partnership with Davita

•Individual Counseling

•Group Classes

•Kidney Smart Program

THRIVE (Personal Action Toward Health)

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Interventions

Clinical Decision Support Tools

EMMI – Communication solutions that empower patients to take action

around a healthcare event or condition.

Patient Empowerment

EMMI has an entire suite of programs dedicated to educating people about

renal related conditions and circumstances.

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Guiding Principles

• Patient Centered

• Integrated, holistic model

• Multidisciplinary approach to

patient care

• Partnership with providers

• Adherence to evidence based

standards of practice

• Engaged patient with input into

clinical decision support

• Promotes safe, timely care

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Alone we can do so little; together we can do so much

-Helen Keller