Tariq Abu-Jaber, MA, MPH, Staff VP Clinical Informatics, EIM, WellPoint, Inc.

Praveen Soti, MD, MBA, Principal, Healthcare Consulting, Infosys Technologies

Enterprise Data Management as a Health Plan Quality Improvement Strategy

The Quality Colloquium, Harvard University August 21, 2007

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Data Management to Improve Care Quality

Thesis: Enterprise Data Management Enables Integrated Care Coordination Across Products, Time and Services, Leading to Better Quality of Care and Therefore Health Outcomes

• Value Proposition• Industry Experience• Measuring Outcomes• Implementation Challenges• Recommendations

Value Proposition

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Value Proposition for Data Integration

For Health Plans …For Groups/Members …

“Direct” Improvements• Medical, pharmacy and

specialty cost reduction• Coordinated prevention,

diagnosis and treatment of conditions

“Indirect” Benefits• Absenteeism, disability,

family med leave, worker’s comp, “presenteeism”

• Intangible (pain, psychosocial costs, etc.)

Note: Productivity Costs usually 1- 3x Direct Medical Costs

Revenue & Membership Growth

• Increased penetration through integrated medical, behavioral health, specialty and clinical programs

• Lower cost of careIndustry Leadership

• Meets customer needs to manage overall expense

• Sets improved standard for quality of care

Industry Experience

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Cost of Care

Establishing the “Cost Burden” of Poor HealthMedian HPM Costs Per Eligible Employee (1998 $) Medstat/IHPM/APQC Benchmarking Study

The sum of median 1998 HPM costs across programs was $9,992 per eligible employee

Workers’ Compensation

$3103%

Group Health$4,666

47%

Non-Occupational

Disability$513

5%

Turnover$3,693

37%Unscheduled

Absence$810

8%

From: “Steps to a Healthier US Workforce”, Goetzel R., NIOSH background paper, 2004

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Median HPM Opportunity Per Eligible Employee for All Survey Participants

The sum of the median 1998 HPM opportunity costs across programs was $2,562 per eligible employee, a 26% reduction opportunity in total per employee HPM costs

Group Health$61724%

Unscheduled Absence

$43517%

Workers’ Compensation

$1204%

Turnover$1,247

49%

Non-Occupational

Disability$143

6%

Integration Opportunity

From: “Steps to a Healthier US Workforce”, Goetzel R., NIOSH background paper, 2004

The sum of the median 1998 HPM opportunity costs across programs was $2,562 per eligible employee, a 26% reduction opportunity in total

per employee HPM costs

88

Savings Opportunity From Integrating Medical & Short-Term Disability Data & Care

Disease Prevalence (%)

Differential Medical Costs

Differential STD Costs

Potential Opportunity /1000 ee’s

Arthritis 9-22% $1,382 $616 $435,477

Asthma 4-7% $1,117 $373 $73,001

Cancer 1-2% $4,210 $558 $52,457

Depression 2-5% $2,453 $539 $83,785

Diabetes 4-7% $3,346 $971 $258,996

Cardiac 2-7% $4,372 $1,029 $334,888

Migraines 4-18% $1,510 $366 $84,441

From: Musich, Schultz, Burton and Edington, Disease Management and Health Outcomes, 2004

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WellPoint: 360º Health® Program Integration

Integrated program to manage the whole member and every member, across all levels of illness/risk, across all WellPoint health programs, via integrated database:

• Health Coaching• 24/7 Nurseline• Worksite Wellness• Healthy Lifestyle• Future Moms• ComplexCare• NICU• Pharmacy• Behavioral Health• Integrated Disability Management• MyHealth Advantage (therapeutic alerts)

Condition Care (DM): • Asthma• Diabetes• CAD• CHF• COPD• 4 Vascular at Risk programs• Low Back Pain• Musculoskeletal• Oncology• ESRD

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: Comprehensive Suite of Services

Pre-Certification

Utilization Management

ComplexCare Catastrophic Care Management

Centers of Clinical Excellence• Transplants• Bariatric• Cardiac• Oncology/Radiology

Condition Care• Asthma, Diabetes,

CAD, COPD, CHF• Low Back Pain,

Oncology, Musculoskeletal, Vascular, Depression

Advanced Care Management

MyHealth Advantage Early Risk Management Therapeutic Alerts

Neonatal Intensive Care Unit

Health Management

Health Management and Coordination

24/7 Nurseline

Predictive Modeling

Condition-Specific Education

Decision SupportHospital Quality Comparison Tool

Procedure Decision Support Tool

MyHealth Record

Pre-populated personal health record (PHR)

Health Coaching

Member/Family advocate

Dedicated RN’s

High Engagement

Future Moms Maternity Management

Special Offers Discount programs

Health PortalsCondition CentersPhysician Pre-visit QuestionnaireHealth QuotientNutrition Center

Prevention Reminders

Immunizations

Cancer Screenings

InTune Living

Wellness incentive program

Worksite Wellness On-Site Screening and Seminar Programs

Health Portals

Drug Interaction Alerts

Children’s Health

Men’s Health

Women’s Health

Daily Health Tips

Alternative Medicine

Audio Tape Library

Online Preventive Guideline

Health Resources

Health & Wellness

Health Extras Health GuidanceHealth Support/

AdvocacyHealth Incentives Tools & Discounts

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Advantages of Enterprise Data Integration

Consolidated, integrated data:• 1 member = 1 record across time, providers, events• “Single source of truth” – clinical and financial• Facilitates coordination of care, avoids errors• Improves predictive modeling across data sources• Allows health plan to personalize member experience• Enables member <> plan <> provider communications• One face to the customer• Administrative efficiencies• Comprehensive ROI assessment resulting from

integration of data, programs and products

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Employer Costs of Lost (% of Payroll)Productivity Direct Indirect Total

AON 4-6% 8-12% 12-18%

Towers Perrin 8-12% 4-6% 12-18%

Watson Wyatt 6.1% 2-4 x direct costs 12-30%

Mercer 4.4% ½-4 x direct costs 7-22%

Industry Experiences – Cigna Illustration

Around $6,000 Actual Cost Per Employee Per YearAverages 15% Of Payroll

Premium Costs = Only 1-2% of payrollInefficiencies largely driven by non-integration of data, services

Illustration

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Key Cigna Findings

• Most top cost drivers are the same for disability & medical

• Disability claimants with chronic conditions experience longer durations whether or not the disability was primarily due to the chronic condition

• Claimants involved in integrated STD and Healthcare management (having both Disability and Healthcare coverage) have 12% Shorter STD Durations and 6% Higher Return to Work Rates

• Behavioral health conditions associated with a medically related disability result in poorer outcomes (durations 28% longer; incidence rate 7% greater)

• Employees engaged in Cardiovascular Disease and Low Back Pain disease management programs experience shorter disability durations & lower incidence of STD

Illustration

Aetna’s Integrated Health and Disability (IHD)

• Common Platform Real-time, shared data enables improved outcomes Service efficiencies from availability of information

• Real-time data integrationEnables predictive modeling for medical events and disabilities to facilitate coordinated care managementCombined reporting helps customers recognize total cost of conditions, provides focus for prevention efforts

• Proactive case management Data availability provides opportunities for early intervention Earlier member outreach and program referral may reduce disability risk

Illustration

IHD Results: Reduced STD Duration

Source: March 2006 Aetna Integrated Informatics® study of claims incurred between 4/1/2003–1/31/2005. A group of 5,546 claimants were split evenly between members with Aetna disability only and members with Aetna medical and disability (IHD). Claims include members who returned consent and those who did not.

454647484950515253

Aetna Disability Only Aetna Medical + Disability

Day

s

52.5

48.0

Aetna’s IHD STD claims were 4.5 days shorter than those with only Disability coverage

Illustration

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Other Results in the Literature

• Johnson & Johnson: After integrating health and disability management with a common data store and common processes, Johnson & Johnson realized medical cost savings of $225 per employee per year.

• Pitney Bowes: After integrating disease and disability data and management, Pitney Bowes found a 32% decrease in average duration of disability, and an 11% reduction in absenteeism.From: “Integrating Disease Management and Disability Programs Results in Great Rewards,” Managed Health Care Executive, Sept. 2003.

Illustration

Measuring Outcomes

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Measurement Components

TargetAcceptableQuestionable

= Actual

Health Insurance

Unscheduled Absence

EmployeeSatisfaction

Non-occupDisabilityTurnover Workers’

CompDisease &

Demand Mgmt.

Establishing benchmarks across all programs, products and interventions is essential to measuring comprehensive effectiveness

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Criteria Used to Track Improvements

Direct Medical Cost ReductionsGroup Health Costs Occupational Disability CostsWorkers Compensation CostsDisease Management Savings

Indirect Productivity ImprovementsUnscheduled Absentee RatesPaid Sick LeaveEmployee Turnover RatesEmployee Assistance Occupational Safety ClaimsEmployee SatisfactionNon-occupational DisabilityWorker's CompensationShort Term/Long Term Disability

Recommendations

Process of Building an EDM as Quality Strategy - Based on our Scars and Stars

Define data domains across time, members, providers, events products and services: Involve all the operational departments

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Define a robust Data Model (Dimensional &/or Relational) to support analytics and decision making and integrate it with Enterprise Warehouses

Gather learnings and then define an Enterprise wide roll-out

Define a common vocabulary, infrastructure, analytical tool set and robust analytics processes to identify deviations from standard thresholds

Pilot the program in 1 region with 1 employer group with 1 product

Have Enterprise Information Management group become a facilitator for this program

Enable a single distribution point for Organizational information: internally and externally

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The Basis of Improved Outcomes

In an article on the evolution of care management programs, Al Lewis stated that a newly emerging model “works because it is vastly more inclusive… doesn’t just involve chronic diseases… combines wellness, 24/7 nurse line, preference-sensitive conditions, complex case management and care coordination…”

How does the new model achieve its results?1. Consolidation of data in a common store2. Touching more people by combining programs3. Coordinating care by combining intervention data4. Measuring results across all members & products

Sample Illustration

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Clinical Informatics – Care-Based UseClinical Informatics – Reporting & Extracts

Warehouses

Laboratories

Pharmacy/PBM

Plans and Purchasers

Member Portals

Source Data from different feeder systems from healthcare entities

Accounts and External

Reporting

Pay for Performance

Refining Medical Policy

Disease and Care

Management

Health IT Initiatives

Personal Health

Record, EPrescribing

External PBM

UM/CM Ops Systems

EIM Repository

Clinical Information Based Business Services

EIM Repository serves as the source ofInformation for Business Functions

Claims Ops Systems Providers

Patient’s Condition Comprehensive services provided elsewhere

Complete Medication history

Utilization & Adverse Effect Reporting

Laboratory Results data

Medical History & Examination