www.chcs.org July 21, 2015 For Audio Dial: 866-952-1906 Passcode: 582935 Targeting Interventions for the Highest-Need, Highest-Cost Medicare-Medicaid Enrollees: Health Plan Approaches Promoting Integrated Care for Dual Eligibles (PRIDE) is supported by The Commonwealth Fund.
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www.chcs.org
July 21, 2015
For Audio Dial: 866-952-1906
Passcode: 582935
Targeting Interventions for the Highest-Need, Highest-Cost Medicare-Medicaid Enrollees:
Health Plan Approaches
Promoting Integrated Care for Dual Eligibles (PRIDE) is supported by The Commonwealth Fund.
Questions?
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Answers to questions that cannot be addressed due to time constraints will be shared after the webinar.
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About the Center for Health Care Strategies
A non-profit health
policy center
dedicated to
improving the
health of low-
income Americans
I. Welcome and Introductions
II. Identifying High-Need, High-Cost Medicare-Medicaid Enrollees through Predictive Modeling for Targeting Services and Interventions
III. Questions and Discussion
IV. Targeting Housing and Supportive Services to Promote Community Living and Independence
V. Questions and Discussion
Agenda
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Medicare-Medicaid Enrollees are a High-Need Population
65 AND OVER UNDER 65
• More likely to have been diagnosed with 3+ chronic conditions
• 25% have a behavioral health disorder• Enrollment increased 8% since 2006
• 40% have a behavioral health disorder• Enrollment increased 20% since 2006
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• 10.7 million Medicare-Medicaid enrollees
• 1 in 5 Medicare enrollees are dually eligible
• More likely than Medicare- or Medicaid-only enrollees to have multiple, chronic health conditions
• More than 40% use LTSS
• 33% are under 65
Sources: Medicare-Medicaid Coordination Office. February 2014. Data Analysis Brief Medicare-Medicaid Dual Enrollment from 2006 through 2013; and Congressional Budget Office. June 2013. Dual-Eligible Beneficiaries of Medicare and Medicaid: Characteristics, Health Care Spending, and Evolving Policies .
Promoting Integrated Care for Dual Eligibles (PRIDE)
• Supported by The Commonwealth Fund
• Brings together seven health care organizations to identify and test innovative strategies that enhance and integrate care for Medicare-Medicaid enrollees
• PRIDE participants:
- CareSource (OH) - Together4Health (IL)
- Commonwealth Care Alliance (MA) - UCare (MN)
- Health Plan of San Mateo (CA) - VNSNY CHOICE (NY)
- iCare (WI)
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Introductions
Brianna Ensslin Program OfficerCenter for Health Care Strategies
Amanda HarcusLead Financial Data AnalystIndependent Care Health Plan (iCare)
Lisa HoldenDirector of Care ManagementIndependent Care Health Plan (iCare)
Ed Ortiz
Director of Provider Network Development & Services
Health Plan of San Mateo
Chris Esguerra, MD
Deputy Chief Medical Officer
Health Plan of San Mateo
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Amanda Harcus, iCareJuly 2015
Center for Health Care Strategies
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Why Predictive Analytics?
• Focus on areas of greatest opportunity to make a difference
• Actionable information for care coordinators and aligned providers
• Member level stratification for more effective/efficient care coordination
• Strengthened ability to manage costs and quality
Why Milliman PRM Analytics?
Concerns Off-sets
• Newer (but Milliman endorsed) tool • Current machine-learning algorithms
• Narrowed information & reports • Focused and formatted information
• Middle-cost solution • Speed to deployment (90 days)
• Uncertain ROI value • Proposed 3% MLR savings estimate
• Comprehensiveness • Staff buy-in
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Evaluation
IT Perspective CM Perspectives
• Data • Data
• Standard Format • Good In = Good Out
• Automated File Production • User Interface
• Drag & Drop to File Transfer Protocol • Easy to Navigate & Filter
• User Interface • Easy to Interpret
• Straightforward • Exports to Excel (3000 lines)
• Easy to Navigate and Filter • Each User is Licensed
Requested Changes
• Make “county” a filter option
• Acquire a backend copy of the database details/results
• Incorporate the PRM information into our care management system
• Add additional chronic conditions to filtering options – current limit is 7
Description The Milliman PRM tool is predictive in determining members who would benefit from intensive care coordination
Observation PRM could be used to identify members with potentially avoidable costs compared to those members with unavoidable high costs
Goals Transfer these identified members into the iCare Specialty Services (High Risk) Team intensive pre-crisis intervention
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Profile #1
Member Female, 48, Co-Hab, DIA, CKD, Smoker
PRM Avoidable Costs $10,300 next 6 months
Prior Risk Rating Low
PRM Profile History
Findings No glucometer, no dialysis
Acton Engage in special team care
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Profile #2
Member Male, 71, Old ER Data, DIA, CHF
PRM Avoidable Costs $11,900next 6 months
Prior Risk Rating Low
PRM Profile History
Findings Member highly self-activated
Action Disengage, refer to LVAD care
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Profile #3
Member Female, 63, DIA, BH Issues
PRM Avoidable Costs $79,300next 6 months
Prior Risk Rating High
PRM Profile History
Findings Irregular dialysis, high inpatient use
Action Provider/plan surround, education
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Reasons Discussion
24-Month look-back is moving
The Milliman algorithm relies on a look-back of the most recent 24 months of claims data, updated each month
Plan interventions make a difference
Effective interventions will reduce the most recent months of costs causing a reduction in risk
Machine learning is continuous in testingpredicted results
The algorithm components are being adjusted/re-weighted for accuracy as predicted results are changed to actual
Member conditionschange
Member data available via inpatient rosters, encounters, and emergency department reports change even outside interventions
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Plan Personal Coaching Wellness Clubs Telemetrics
Description Community Health Worker/Health Coach
Community Wellness Program
24/7 monitoring of key health conditions
Observation Members respond to specialists who live in the same community, share ethnicity, a common language, socioeconomic conditions and life experiences
Members benefit, if engaged, fromWellness Programs to increase knowledge, skills and abilities necessary to better self-manage health-related behaviors
Members can adopt self-monitoring behaviors with Wi-Fi enabled assists that improve the response time of professional caregiver support
Goals Train members in how to improve their self-management of conditions and use of healthcare resources
Improve the member’s understanding and ability to self-manage their own conditions
Improve monitoring critical health conditions and accelerate response times
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In-Home Health Coaching
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Activation Signals
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Healthy Living with Diabetes -- Aurora-Sinai Medical Center
What’s in it for Me? People taking this workshop show:
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Concurrent ROI Evaluation
PRM-Related Action PlansCoach Club Tele-Monitor Investment ∑$