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Soyal Momin MS, MBA
December 14th, 2007
Maximizing the Value of Predictive Modeling: The BlueCross BlueShield of
Tennessee Experience
2
Outline• Understanding Population Needs
• Historical View: Care Management at BCBST
• Concept: Next Generation Care Management (NGCM)
• Implementation of NGCM
– Improving the
• Process Efficiency
• Information Shared with CM
• Using Predictive Modeling to Evaluate Care Mgmt. ROI
• Conclusions
3
Understanding Population Needs
• Utilization distribution– Total healthcare cost and its components
• Population assessment
• Total cost assessment – direct & indirect costs
4
Cumulative Total Healthcare Cost
5
Cumulative Professional and Outpatient Cost
6
Cumulative Pharmacy Cost
7
Cumulative Inpatient Cost
8
Population Assessment
Population Assessment is an analysis of claims and membership data to determine characteristics of a given population (Network, Region, Group) that might affect the population’s interaction with the health care system
9
Propensity to Utilize Index – The average number of episodes of illness for a member month
Episode Seriousness Index – A measure of the average cost to treat the categories of illness experienced by a population
Illness Burden – A measure of the level of illness within a group determined by multiplying the propensity to utilize index by the Episode Seriousness Index
Major Analysis Variables
10
Provider Efficiency Index – A measure of the efficiency to treat a specific episode of illness determined by dividing the cost to treat the specific episode by the average cost for the category of illness
PMPM Cost Index – An index that measures the PMPM submitted costs for a population determined by multiplying the Illness Burden by the Provider Efficiency Index
Major Analysis Variables, Continued
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Population Profile
0
0.5
1
1.5
2
2.5
Propensity to Utilize Episode SeriousnessIndex
Provider Efficiency PMPM Cost Index
Population A Population B
0
0.5
1
1.5
2
2.5
Propensity to Utilize Episode SeriousnessIndex
Provider Efficiency PMPM Cost Index
Population A Population B
12
Illness Burden by Major Practice Category
00.020.040.060.08
0.10.120.140.16
Infe
ctio
us Dis
ease
s
Endocr
inolo
gy
Hemat
ology
Psych
iatry
Chem
ical
Dep
enden
cy
Neuro
logy
Ophthal
mol
ogy
Cardi
ology
Otola
ryngo
logy
Pulm
onology
Gastro
ente
rolo
gy
Hepat
ology
Nephro
logy
Urolo
gy
Obstet
rics
Gynec
ology
Derm
atolo
gy
Ortho &
Rhe
um
Neonat
ology
Major Practice Category
Illn
es
s In
de
x
Population A Population B
00.020.040.060.08
0.10.120.140.16
Infe
ctio
us Dis
ease
s
Endocr
inolo
gy
Hemat
ology
Psych
iatry
Chem
ical
Dep
enden
cy
Neuro
logy
Ophthal
mol
ogy
Cardi
ology
Otola
ryngo
logy
Pulm
onology
Gastro
ente
rolo
gy
Hepat
ology
Nephro
logy
Urolo
gy
Obstet
rics
Gynec
ology
Derm
atolo
gy
Ortho &
Rhe
um
Neonat
ology
Major Practice Category
Illn
es
s In
de
x
Population A Population B
13
00.5
11.5
22.5
33.5
44.5
Major Practice Category
Pro
vid
er
Eff
icie
nc
y In
de
x
Population A Population B
00.5
11.5
22.5
33.5
44.5
Major Practice Category
Pro
vid
er
Eff
icie
nc
y In
de
x
Population A Population B
Provider Efficiency by Major Practice Category
14
PMPM Cost Index by Major Practice Category
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
Infe
ctio
us Dis
ease
s
Endocr
inolo
gy
Hemat
ology
Psych
iatry
Chem
ical
Dep
enden
cy
Neuro
logy
Ophthal
mol
ogy
Cardi
ology
Otola
ryngo
logy
Pulm
onology
Gastro
ente
rolo
gy
Hepat
ology
Nephro
logy
Urolo
gy
Obstet
rics
Gynec
ology
Derm
atolo
gy
Ortho &
Rhe
um
Neonat
ology
Major Practice Category
Co
st
Ind
ex
Population A Population B
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
Infe
ctio
us Dis
ease
s
Endocr
inolo
gy
Hemat
ology
Psych
iatry
Chem
ical
Dep
enden
cy
Neuro
logy
Ophthal
mol
ogy
Cardi
ology
Otola
ryngo
logy
Pulm
onology
Gastro
ente
rolo
gy
Hepat
ology
Nephro
logy
Urolo
gy
Obstet
rics
Gynec
ology
Derm
atolo
gy
Ortho &
Rhe
um
Neonat
ology
Major Practice Category
Co
st
Ind
ex
Population A Population B
15
Total Cost Assessment
Direct costs are dollars paid out for medical treatment Indirect costs are labor resources lost due to illness
Direct CostsDirect Costs = Inpatient + Professional/Outpatient + Pharmacy
Indirect CostsIndirect Costs = Sick Leave + Presenteeism + Family & Medical Leave + Short Term Disability + Long Term Disability
+ Turnover + Worker’s Compensation
16
Total Cost Assessment: Company XYZ
Total Healthcare Cost = $23,237,422Total Healthcare Cost = $23,237,422
$5,631 per FTE$5,631 per FTE
Direct $ = $13,761,278
$3,334 / FTE
59.2%
Indirect $ = $9,476,144
$2,296 / FTE
40.8%
Inpatient
$376
6.7%
Professional/Outpatient
$2,154
38.3%
Pharmacy
$804
14.3% Sick Leave
$1,322
23.5%
Presenteeism
$318
5.7%
FMLA
$274
4.9%
STD
$220
3.9%
LTD
$4
0.1%
Turnover
$74
1.3%
Work Comp
$82
1.5%
Total Healthcare Cost = $23,237,422Total Healthcare Cost = $23,237,422
$5,631 per FTE$5,631 per FTE
Direct $ = $13,761,278
$3,334 / FTE
59.2%
Indirect $ = $9,476,144
$2,296 / FTE
40.8%
Inpatient
$376
6.7%
Professional/Outpatient
$2,154
38.3%
Pharmacy
$804
14.3% Sick Leave
$1,322
23.5%
Presenteeism
$318
5.7%
FMLA
$274
4.9%
STD
$220
3.9%
LTD
$4
0.1%
Turnover
$74
1.3%
Work Comp
$82
1.5%
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$0
$200,000
$400,000
$600,000
$800,000
$1,000,000
$1,200,000
$1,400,000
$1,600,000
$1,800,000
$2,000,000
JOIN
T DEGEN/IN
FLAM
BENIGN N
EOPLASM
GASTRO INFEC/IN
FLAM
HYPERTENSION
DEPRES & A
NXIETY D
IS
ORTHO DERANGE/T
RAUMA
PREG & D
ELIVERY W
/ C-S
EC
MALIG
NANT NEOPLASM
DIABETES
RHINIT
IS/S
INUSIT
IS
PREG & D
ELIV N
O C-S
EC
ASTHMA
CORONARY DIS
EASE
OTHER CARDIA
C DIS
COND ASSOC M
ENST/INFERT
GALL BLADDER D
ISEASE
VISUAL D
ISTURBANCES
HYPERLIPID
EMIA
HEREDITARY/C
ONGEN DIS
MIN
OR ORTHO D
IS
Direct Costs Indirect Costs
Top 20 Cost Drivers
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History
• Identifying Members for Case Management – Referrals from
• Internal Sources• External Sources• An internally developed ICD9 Trigger list
– The ICD9 Trigger list included Asthma, Diabetes, High Risk OB, AIDs, Cancer, CHF, COPD etc
• Case managers workload– 103/CM/Month
• PM implementation validation revealed missed opportunities for case management
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Next Generation Care Management:Triage Guidelines
Segmentation DxCG Risk Level
Management Type
Healthy Group; Worried Well
1 – 2
Lifestyle/Health
Counseling
Chronically Ill 3 – 4 Refer to Care Coordination Unit
Catastrophic
5
Refer to Catastrophic Case Management
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Lifestyle/Health Counseling for Healthy and Worried Well
• Information on disease/condition– Web resources– Pamphlets– Telephonic health library
• Encouragement to take more active role/accountability
21
Care Coordinationfor Chronically Ill
• Telephonic coordination with members and their providers
• Ensures appropriate treatments and pharmaceuticals
• Five different programs included in this model
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Care Coordination Programs
• Pharmacy Care Management
• Emergency Room (ER) Visits Mgmt.
• Transition of Care
• Condition Specific Care Coordination
• Disease Management
23
Catastrophic Case Management
• Directed to members with– Terminal illness– Major trauma– Cognitive/physical disability– High-risk condition– Complicated care needs
• Systematic process of assessing, planning, coordinating, implementing, and evaluation of care
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Next Generation Care Management:Implementation
• Predictive Modeling Using– DCG
– ETG
• Rolling 12 Months DCG Explanation Prospective Model
• ETG Cost to Supplement DCG Prediction
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Next Generation Care Management:Process Enhancements
• Developed SQL database containing DCG and ETG information
– Improved processes/workflow– Easy and continuous access– Better documentation
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Next Generation Care Management:Process Enhancements
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Next Generation Care Management:Process Enhancements
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• Under prediction at all risk levels
• Use pharmacy data for prediction
– NDCs
• Prediction of utilization
• Provide information to help prioritize
members for interventions
• Evidence-based guideline gaps
Care Management Staff Feedback
29
MEDai RNC
Prediction of utilization
Evidence-based guideline gaps
Use pharmacy data for prediction
Provide information to help prioritize members for interventions
• Forecasted cost–Overall–Pharmacy
• ER and IP LOS prediction
• Mover identification• Impact index
–Acute–Chronic
• Risk drivers
• Gaps in care
30
Improving the Information Shared with Care Management Staff
• Enhancing SQL database with RNC information
ETG Low/Med/High Amount
MEDai forecasted costs (total and Rx)ER and IP LOS prediction Impact indexCare management historyActive PCP
- Risk drivers - Latest Rx data
- Gaps in Care - Risk History
31
32
33
34
35
36
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• Why?
• 1) To reliably identify higher cost, highly impactable members
• 2) To enhance prioritization of members for nurse-intervention management
• How?• Use predictive output from MEDai
• Select key MEDai measures to construct a composite score
• Use the composite score as an index to stratify members
Focus on members with the highest index scoresFocus on members with the highest index scores
Developing a Stratification Index (SI)
38
0%
20%
40%
60%
80%
100%
0 10 80-85 86-90 91-95 96-100
Chronic Impact Level
Pe
rce
nt
of
Me
mb
ers
High Index Scores
Moderate Index Scores
Low Index Scores
Chronic Impact: Break Down by SI Score
39
Acute Impact: Break Down by SI Score
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-50 51-70 71-85 86-95 96-100
Acute Index Level
Pe
rce
nt
of
Me
mb
ers
High Index Scores
Moderate Index Scores
Low Index Scores
40
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 1 - 2 3 - 4 > = 5
Number of Chronic Gaps
Per
cen
t o
f M
emb
ers
High Index Scores
Moderate Index Scores
Low Index Scores
Chronic Gaps: Break Down by SI Score
41
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 1 - 2 > = 3
Number of Preventative Gaps
Per
cen
t o
f M
emb
ers
High Index Scores
Moderate Index Scores
Low Index Scores
Preventative Gaps: Break Down by SI Score
42
0%
20%
40%
60%
80%
100%
$0-999 $1000-4999 $5000-9999 $10000-24999
>$25000
Forecasted Cost Level
Per
cen
t o
f M
emb
ers
High Index Scores
Moderate Index Scores
Low Index Scores
NGCM Risk Levels: Break Down by SI Score
43
• Movers are members who are likely to make the transition from low or moderate to high risk
• Movers can be identified by comparing current vs. forecasted NGCM risk level
• if a member’s current cost is less than $1,000 (Risk Level I) and is predicted to cost more than $25,000 (Risk Level V)
• Do movers have higher index scores?
Mover Identification
44
Current Risk Level
Forecasted Risk Level
FrequencyMean Index
Score
I II 430,312 4.52
I III 11,370 9.87
I IV 451 12.75
I V 2 11.00
II III 96,352 10.26
II IV 7,737 13.03
II V 51 13.04
III IV 22,492 13.47
III V 225 13.95
IV V 2,142 14.85
Index Scores for Movers
45
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Commercial LOB 10/2005
High Scores: >=11(10.2%)
Moderate Scores: 6-10(18.4%)
Low Scores: <=5(71.4%)
Distribution of Index Scores
46
• Basic research problem: measuring what would have happened vs. what actually happened
• Methodologies:• Randomized Control Group• Population-Based Pre-Post Methodology• Predictive Modeling• Control Group Matching • Combination
How Do We Measure Care Management (CM) Impact?
47
Predictive Modeling
Predictive Modeling with Inflation FactorsYr1 Yr2
Net Savings 12,606$ 72,811$ ROI 1.43 3.72
Group's Inflation Factor 5% 7%
CM Mbrs Actual PMPM 574$ 542$ CM Mbrs Predictive Modeling PMPM 629$ 638$ Inflated CM Mbrs Predictive Modeling PMPM 659$ 682$
CM Savings PMPM 85$
140$
Total CM Savings 42,005$ 99,560$ Admin Cost 29,399$ 26,749$
48
Predictive Modeling w/Adjustments
Predictive Modeling w/Inflation Factors and AdjustmentsYr1 Yr2
Non CM Mbrs Actual PMPM 225$ 217$ Non CM Mbrs PMPM Predictive Modeling 205$ 232$ Inflation Adjusted Non CM Mbrs PMPM Predictive Modeling 214$ 248$ Adjustment for Actual to Predictive Modeling 5% -13%
CM Mbrs Actual PMPM 574$ 542$ CM Mbrs Predictive Modeling PMPM 629$ 638$ Inflated CM Mbrs Predictive Modeling PMPM 659$ 682$ Adjusted Predictive Model 692$ 597$
Adjusted CM Savings PMPM $ 117 $ 55 Adjusted CM Savings $ 57,819 $ 39,113 Admin Cost 29,399 26,749$$
Adjusted Net Savings 28,296$ 12,364$ Adjusted ROI 1.96 1.46
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Conclusions of DM Evaluations
• A statistically valid predictive model should be incorporated in lieu of randomized control group
• Adjustments (inflation factors, inaccuracy of predictive models, etc.) should be made to the model information
50
Conclusions
• More scientific/standardized approach• Able to touch more lives efficiently• Well accepted by our case managers• NGCM has helped
– Streamline our processes– Better manage case managers case load
• Provide “Peace of Mind” to our members and clients