CHACC Steve Wegner, MD, JD Chairman North Carolina Community Care Network 13 Sep 2012
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CHACCSteve Wegner, MD, JD
Chairman
North Carolina Community Care Network
13 Sep 2012
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Shared Savingsvs
Commercial HMO
Shared Savingsvs
Commercial HMO
Background
CCNC Primary Care Case Management
IMPACT
5% cost 54% : Who are these children and what can be saved?
Transitions
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Readmissions - Medicare
Causes of readmissions vary across and within states
Readmission rates are influenced by the local pattern of hospital utilization
Four types of readmission (relationship to initial hospitalization) related and unplanned
related and planned
unrelated and planned
unrelated and unplanned
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Readmissions – Medicare (cont.)
Factors that lead to readmissions, and potentially preventable readmissions, for Medicare beneficiaries*
inadequate relay of information to caregivers
poor compliance
inadequate follow-up
variation in hospital bed supply, and
medical errors
* Stone J, Hoffman GJ. Medicare Hospital Readmissions: Issues, Policy Options and PPACA,Congressional Research Service 2010.
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Care Transitions Intervention
6
The Four Pillars
Medication Self-
Management
Dynamic Patient-
Centered Record
Follow-Up Red Flags
Doctor to Doctor Care Plan
Referral
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Doctor to Doctor Care Plan
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Other Strategies to Reduce Readmissions
Improved discharge planning process
Patient/family activation
Telemedicine
Evidenced based practice/guidelines
Care Coordination
Post discharge follow-up visits by a Nurse Practitioner
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CCNC 3M™ Health Information System’s Clinical Risk Groups (CRG)
CRG assignment occurs in four phases
(Total of 269 categories)
(uses 9 core health status groups such as catastrophic, single/moderate chronic, and significant acute)
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Data
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Medicaid Claims Data
Limitations:
Data for services can lag care up to 6 months
Single hospitalizations can occur over multiple sites creating data headaches
Codes (e.g., Hospital & Practice Identifiers) change over time
Codes are “gamed” to maximize payments
Intricacies of data make “simple” changes in analyses not-so-simple to do
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Analysis Overview
Includes children over < 17 years old Calendar years 2009 – 2011
Medicaid claims for ≥ 3 hospitalizations in any 365-day period1
Most frequent Dx group based on all ICD9 codes in all claims records over 3 years
Primary Dx = 1st ICD9 on 1st claim
Special priority assigned for any mention of :
NICU > Cystic fib > Cancer > Sickle cell > Diabetes
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1Berry, JG, Hall, DE, Kuo, DZ et al, Hospital Utilization and Characteristics of Patients Experiencing Recurrent Readmissions Within Children’s Hopsitals, JAMA. 2011;305(7):682-690.
Months from First Admission NC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
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No. of admits in same mo.
Most Frequent by Primary GroupNC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Primary Group
No. of Patients
No. of Admits
Admits Per
Patient
Hosp Cost/
Admit
TotalHospital
Cost AMC Costs
Tertiary Costs Total Costs
NICU 1226 5323 4.3 13,212 68,597,336 52,643,205 8,322,202 719,768,329
Infection 719 2742 3.8 5,649 15,042,596 10,660,756 1,874,594 202,098,774
Respiratory 380 1661 4.4 5,495 8,885,614 5,929,410 960,270 325,941,082
Hema2 367 2432 6.6 4,617 10,914,435 7,128,787 2,453,326 469,689,617
Cancer 358 2863 8.0 9,873 26,282,035 23,141,230 2,615,672 277,227,177
Neuro 271 1335 4.9 8,689 11,034,530 8,933,634 1,092,355 313,222,627
GI 261 1243 4.8 6,993 8,391,098 6,291,441 1,156,601 166,043,874
Diabetes 211 1052 5.0 4,207 4,425,765 2,157,028 592,103 173,599,724
Kidney 96 528 5.5 6,559 3,049,938 2,728,385 115,762 63,267,472
Endocrine 73 401 5.5 7,163 2,643,083 1,977,415 355,472 90,409,594
Cystic Fibrosis 46 333 7.2 15,367 4,886,648 4,559,167 301,685 33,174,369
Cardiac 49 243 5.0 20,943 5,089,203 3,172,570 63,938 25,908,715
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Primary Diagnosis No. of PatientsAdmits Per
Patient
CostPer
Admit
TotalHospital
Cost
NICU 1,226 4.3 13,212 68,597,336
ESOPHAGEAL REFLUX 41 4.0 12,518 1,977,803
EPILEPSY NOS WO INTRACT 21 5.8 8,032 955,864 MALFUN NEURO DEVICE GRAG 17 4.9 20,391 1,712,867
FOOD/VOMIT PNEUMONITIS 17 6.6 15,411 1,710,650 OBSTRUCTIV HYDROCEPHALUS 15 3.9 20,931 1,213,969
ACUTE RESPIRATORY FAILURE 14 3.9 24,464 1,247,654 UNSPECIFIED ASTHMA, WITH ACUTE EXACERBATION 12 4.8 5,507 313,905 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY 10 8.8 8,846 769,640
HYPOPLAS LEFT HEART SYND 7 5.3 42,277 1,564,255
Most Frequent by Primary DiagnosisNC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Most Frequent by Primary DiagnosisNC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Primary Diagnosis No. of PatientsAdmits Per
Patient
CostPer
Admit
TotalHospital
Cost
Cancer 358 8.0 9,873 26,282,035 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY 184 9.9 8,848 15,041,147 ACUTE LYMPHOID LEUKEMIA W/O MENTION OF ACHIEVED REMISSION 29 5.8 12,792 2,097,943
NEUTROPENIA 30 7.8 7,837 1,833,821
Hematological 367 6.6 4,617 10,914,435
SICKLE CELL 272 7.2 4,298 8,144,444 IMMUNE THROMBOCYTOPENIC PURPURA 4 3.5 5,724 80,136
FACTOR DISEASE 4 7.3 18,652 540,907
Most Frequent by Primary DiagnosisNC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Primary DiagnosisNo. of
PatientsAdmits Per
Patient
CostPer
Admit
TotalHospital
Cost Respiratory 380 4.4 5,495 8,885,614
ASTHMA 153 4.3 2,102 1,370,633 UNSPECIFIED EPISODIC DISORDER 8 3.1 7,053 169,283
FOOD/VOMIT PNEUMONITIS 8 5.0 13,180 448,114 BIPOLAR DISORDER UNSPECIFIED 3 5.3 4,976 79,622
Neurological 271 4.9 8,689 11,034,530
EPILEPSY 90 5.0 6,286 2,816,251 MALFUN NEURO DEVICE GRAG 16 5.9 15,087 1,357,837
INFANTILE SPASMS WO INTR 10 4.0 7,633 297,693
FOOD/VOMIT PNEUMONITIS 6 7.2 11,267 484,480
CEREBRAL CYSTS 5 3.4 7,985 135,752 UNSPECIFIED EPISODIC DISORDER 4 3.8 4,729 61,471
Most Frequent by Primary DiagnosisNC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Primary Diagnosis No. of PatientsAdmits Per
Patient
CostPer
Admit
TotalHospital
Cost
GI 261 4.8 6,993 8,391,098
CONSTIPATION & IMPACTION 26 4.5 4,817 558,733
REG ENTERITIS 12 4.3 8,533 443,702
ESOPHAGEAL REFLUX 21 3.5 2,278 157,198
ACUTE PANCREATITIS 10 4.7 5,183 243,607
EPILEPSY NOS WO INTRACT 5 4.0 5,690 113,792
ESOPHAGEAL STRICTURE 4 5.5 12,237 269,204
PERSISTENT VOMITING 3 4.0 3,350 40,194
INTUSSUSCEPTION 3 3.7 21,520 236,723
HIRSCHSPRUNG'S DISEASE 3 3.7 9,081 99,893
BILIARY ATRESIA 3 8.7 15,300 397,802
Most Frequent by Primary DiagnosisNC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Primary Diagnosis No. of PatientsAdmits Per
Patient
CostPer
Admit
TotalHospital
Cost
Diabetes 211 5.0 4,207 4,425,766 DIABETES W KETOACIDOSIS & MELLITUS 86 6.3 2,811 1,515,385
ASTHMA 9 6.1 2,339 128,651
DIABETES UNCOMPL JUVEN 5 3.0 3,148 44,066 UNSPECIFIED EPISODIC DISORDER 4 4.0 4,374 69,986
ESOPHAGEAL REFLUX 3 3.3 1,913 19,130
Cardiac 49 5.0 20,943 5,089,203
CONGENITAL OTHER 14 5.2 24,927 1,819,662
CONGESTIVE HEART FAILURE 5 3.8 25,847 336,010
PAROX VENTRIC TACHYCARD 2 4.5 48,781 439,029 CARDIAC DYSRHYTHMIAS NEC 2 5.5 6,344 69,783
AMC Admissions/CostsNC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Primary Condition
Total Hospital
CostECU
Admits ECU
Costs Duke
Admits Duke Costs
UNC Admits
UNC Costs
WFB Admits WFB Costs
NICU 68,597,336 407 6,566,106 559 12,364,734 689 14,136,120 661 10,147,718
Infection 13,906,960 113 839,951 132 2,985,675 181 2,412,782 166 1,849,145
Respiratory 10,232,347 73 1,000,707 197 2,606,489 113 1,472,998 93 797,697
Hema2 10,925,191 222 925,749 211 1,901,895 111 1,536,395 328 1,305,327
Cancer 26,282,035 305 3,034,428 520 6,539,482 378 4,367,551 546 4,297,371
Neuro 12,944,543 88 846,396 284 2,992,139 213 2,638,879 228 2,136,756
GI 8,900,613 51 289,387 146 1,610,659 237 2,125,127 117 716,120
Diabetes 4,279,750 49 356,800 53 285,879 50 335,930 43 164,429
Kidney 3,420,272 36 191,194 54 355,368 117 1,026,640 82 573,528
Cardiac 7,458,008 22 396,142 109 2,617,977 48 1,125,066 79 1,913,426
Endocrine 2,475,159 10 63,648 20 124,401 93 1,095,216 48 403,600
Cystic Fibrosis 4,886,648 2 7,809 75 2,006,282 135 1,959,353 12 74,060
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Tertiary Ref Centers - CostNC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Primary Condition
Total Hospital
Cost Wake Med Mission CMC NE Presby
Moses Cone Cape Fear New Han
NICU 68,597,336 2,064,948 710,969 2,214,651 392,690 1,333,986
Infection 13,906,960 311,336 486,926 419,128 136,527 254,454
Respiratory 10,232,347 164,954 75,856 246,853 75,244 173,627
Hema2 10,925,191 256,823 86,932 1,059,800 419,930 199,939
Cancer 26,282,035 1,228,097 18,054 1,238,461 18,943 69,374
Neuro 12,944,543 301,456 160,145 433,898 176,864 239,264
GI 8,900,613 286,410 196,305 307,539 86,156 139,734
Diabetes 4,279,750 209,725 52,151 35,013 45,655 77,759
Kidney 3,420,272 14,191 13,370 52,672 6,586 7,294
Cardiac 7,458,008 81,796 35,482 24,034 12,330 11,170
Endocrine 2,475,159 189,692 11,488 7,841 13,455 14,244
Cystic Fibrosis 4,886,648 266,444 11,472 17,901 5,868
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Repeat AdmissionsNC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Higher Frequency Repeat Admissions
Repeat Admissions
Count
Count(Y-axis has changed to show lower
counts)
Admission after initial hospitalization
Patients* with Infection as Most Frequent Primary Diagnosis – continued next slide
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Primary Condition All Pts
Pts* w Infection
% with Infection
Infection 700 534 76%
Cystic_Fibrosis 46 25 54%
NICU 1226 582 47%
Newborn 190 75 39%
Respiratory 406 132 33%
Skin 71 22 31%
Cardiac 92 24 26%
GI 280 72 26%
Injury 50 12 24%
Endocrine 66 14 21%
Neuro 330 69 21%
Kidney 108 20 19%
Musculo_Skel 38 7 18%
Pregnancy 249 34 14%
Hema2 368 45 12%
Diabetes 208 22 11%
Cancer 358 26 7%
MHDD 990 11 1%
Integrated Care for Physical and Emotional Disorders
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Patients with a mental health grouping with a primary medical diagnosis
DISEASE CATEGORYTOTAL UNIQUE
PATIENTS HOSPITAL COST
PER ADMIT AVERAGE NUMBER
OF ADMITS TOTAL COSTS
CANCER 23 23,924 4.3 1,770,392
ENDOCRINE 42 15,612 6.1 3,980,997
GI 12 11,029 6.2 816,153
HEMATOLOGIC 1 3,138 4.0 12,553
HIV 2 9,038 3.5 63,263
KIDNEY 8 3,575 5.1 146,590
NEURO 45 8,363 4.9 1,856,677
RESP 48 18,564 5.9 5,272,219
SICKLE CELL 9 8,045 8.6 619,474
NICU/PREG 12 13,952 4.8 795,271
202 $13,703 5.5 $15,333,590
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