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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