Transcript Slide 1

Telehealth Management:
Can a new paradigm in managing
chronic illness control costs and
improve quality?
presented by
Maria Lopes, MD, MS
Doreen Salek, BS, RN, CCS/CPC
October 26, 2010
Speaker Bios
Maria Lopes, MD, MS, Chief Medical Officer
Dr. Lopes is an OBGYN by training, but has been serving in senior medical management positions in
managed care since 1996. Prior to joining AMC in 2008, she spent 4 years as Senior Vice President and
Chief Medical Officer for GHI, New York State’s then largest commercial payor, and before that served in
senior positions for 7 years at Horizon Blue Cross Blue Shield of New Jersey. Dr. Lopes received her MD
from The University of Connecticut School of Medicine, and an MS in Administrative Medicine from The
University of Wisconsin.
Doreen Salek, BS, RN, CCS/CPC
Ms. Salek is the Director of Business Operations of Health Services for Geisinger Health Plan in Danville,
Pennsylvania. She is responsible for leading business planning and Health Services innovation project
teams with medical home, medical management, care coordination, quality improvement and clinical
reporting as well as strategic implementation and evaluation of outcomes. In her current role she is
focused on transitions of care across the continuum, as well as strategies around enhancing quality and
reducing readmissions, including telemonitoring. Ms. Salek earned her BS from Colorado State University
and nursing diploma from the Geisinger School of Nursing. She holds certifications as a Certified Coding
Specialist and Certified Professional Coder.
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What is TeleHealth?
Remote Telemonitoring or Telehealth:
the process of collecting daily biometric and other health-related information
from where patient is and transmitting data to clinicians who manage care
• Two forms of data collection
1. “Hard” biometric data
2. “Soft” self-reported symptom information
• “Telemedicine” has become a universal term for industry
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Evolution
•
Telemedicine has been around since early 60’s when NASA developed
monitoring methods for the space program
•
The majority of activity described as “Telemedicine” surrounds two-way
televideo for clinical consultation
•
In the last 10 years remote physiological monitoring from the home has
become a recognized and affordable component of chronic care
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How It Works: Data Collection and Integration
Data integration platform captures timely information from
patients when they cannot be physically in front of clinicians
Self-reported
symptom information
via IVR
“Live” virtual
diagnostic assessment
via televideo
Medication
compliance data via
dispensing/reporting
appliances
Biometric
information via
telemonitoring
devices
AMC collects, sorts and verifies raw data and presents it as critical,
actionable information on the secure web portal
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The Problem Telehealth Seeks to Address
• Acute exacerbation occurs outside clinical scrutiny. It is often preceded by
incremental and insidious deterioration whose expression occurs in the home,
away from clinical eyes.
• Existing information systems do not cross boundaries of care settings
• Electronic Health Records (EHR’s) illuminate what was done to patients (i.e.
tests ordered, hospitalizations, Rx written, etc.) but don’t clarify the outcome.
• “Are their biometrics improving? Are they at reduced risk because of
these actions? Are their medications having the right effect? Have
barriers to compliance been identified?”
As a result, care is often duplicated, applied too late, or in
the worst setting due to incomplete clinical information
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How TeleHealth is Advancing Patient Care
•
Knowing what is going on with a patient’s course of illness, in between
visits, when he or she cannot be physically in front of the clinician
•
Detecting pre-acute conditions early enough to bring resources to bear
before the patient clinically decompensates
•
Not waiting for the call from the ER before knowing that a patient is trending
in the wrong direction
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Not Traditional Disease Management
•
Telemonitoring uses real-time information from the patient’s home to
empower them with knowledge of how they are progressing in the
context of their personal disease progression and care plans, and how
their behaviors are indeed affecting their health
•
Thus, unlike traditional DM, which can educate a patient about what
can and usually happens, telemonitoring can tell them what is
happening, and how they—and their doctors and caregivers—can
react to these events to change course if necessary
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Value Proposition
Quality:
improve
compliance &
HEDIS metrics
Financial:
reduce rehospitalization &
optimize ROI
Clinical:
Improve
outcomes
Operational:
enhance
productivity &
care
coordination
Marketing:
differentiate
through valueadded features
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Support for Medical Home
• Empower the clinician through technology
provide critical information to electronic health records (EHR’s)
• Through daily data collection, PCP can continually monitor patient
between doctor visits
increases efficiencies in care by allowing PCP to be alerted when
intervention is most needed
• Greater frequency of targeted patient education
continual data collection provides physician with real-time quality
measures for benchmarking and improvement
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Challenges
“There is a tendency to overemphasize the technological
aspects of telehealth and indeed to equate it with its
technology … Telemedicine is not software or hardware,
although it employs both. Nor is it ‘clinicianware’ or
‘econoware’ despite its value to clinicians and administrators
and payors. When it’s all said and done, it is ‘patientware’, as it
should not be defined in terms of its technical components but
in terms of utility in reinforcing the clinician-patient bond.”
– Jay Sanders, MD, former President, American Telemedicine Association
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Challenges
(continued)
It can never be about the technology:
•
This has to be about putting accurate and meaningful information
in front of the clinician, regardless of the means of collection
•
Must be seamlessly embedded into a care management workflow
to maximize efficiency
•
Data must be timely, meaningful and actionable and not simply
contribute to the ‘noise’
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AMC-Geisinger Strategic Partnership
PCMH & Telehealth Platform Evolution
Geisinger:
Subject Matter
Expertise for
Predictive Analytics
Clinical Content &
Decision Support
AMC Health:
Telemonitoring
And IVR Services
Real-time Data &
Clinical Decision
Support Tools
A mutual investment to strategically impact and enhance each other’s
core competencies and business models
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Geisinger Health Plan Outcomes
AMC’s Telehealth program doubled the ratio of CHF Patients that
Geisinger Case Managers were able to cover in complex case
management:
1.
2.
3.
4.
Track patients in real-time
Uncover proactive intervention opportunities
Receive unbiased, reliable patient data
Reduce the need for clinicians to initiate outreach
96% of Geisinger Case
85% of Geisinger Case
Managers reported AMC
technology improved efficiency
in monitoring HF patients
Managers reported telehealth
solution prevented patient
hospitalization
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Looking Forward
New technologies are constantly being assessed for integration potential
Motion Analysis and Access
Detection Technologies
Wearable Sensors for
Recording Events Over Time
GPS Tracking and
Communications
Bringing the Lab Home
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Exercise Monitoring
Smart Bandages and Clothing
Synthesis with New HIT Priorities
Data Mining and
Population Analytics
Data Collection
Technologies
Thread telehealth technology
unobtrusively into best-of-breed
care coordination models that best
fit each unique structure, including:
• Comprehensive, cross-setting,
interdisciplinary care coordination models
that utilize Extended Care Pathways
• ACO models
Webportal for Shared
Reporting & Analytics
Patient at Home
• Less comprehensive care management
models housed within the payor or
community-based care entity
Telecare Management
Nurse Call Center
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The Goal: Open-Ended Integration
PBM & Other Pharma Data
External Care Management Data
Universally-Accessible Webportal
with Decision-Support Analytics
Telehealth Data
Claims
EHR’s
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Outcomes
Impact of Telecare Management (TCM) on Medicare Advantage (MA)
Members after 8 months:
Study Parameters:
Results:
•TCM Intervention Group N=69
Cost
•8 Month Period
•Random Selection
• Intervention and control cohorts had
Total
similar claims histories
•CHF, Hypertension, Diabetes,
Inpatient
COPD, CAD , Atrial Fibrillation
•66% >3 diagnoses
Outpatient
ER
Intervention
Group
Control
Group
↓ 23%
↑ 6%
↓ 20%
↑ 16%
↓64%
↓17%
↓14%
↓8%
ROI 3:1
If ESRD is included, 43% reduction in total costs compared to control
represents ROI 6:1
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Outcomes
Impact of Telecare Management (TCM) on MA Members after 8 months
(continued):
Comparison of Total Costs (8 Months)
Care Management vs. Care Management + Telemonitoring*
$3,000
$2,608
PMPM
$2,500
$2,457
$2,378
$2,000
$1,839
control group (n=641)
$1,500
telemonitored patients (n=69)
$1,000
$500
$0
High-Risk Pre-Intervention
High-Risk Post-Intervention
* MEMBER MONTHS: Control Group – pre: 5,106, post: 4,698 , Telemonitored Group - pre: 538, post: 543
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Outcomes
Impact of Telecare Management (TCM) on MA Members after 8 months
(continued):
• Majority of non-diabetics reached BP goals, as did nearly half the
diabetics
• Improvement in BP translates into 29% reduction in risk of
cardiac events and 21% reduction in risk of stroke
• 83% of diabetics reached blood glucose targets
• Average blood sugar reduction equates to a 1.7 point drop in
HbA1c:
63% reduction in risk of microvascular complications
73% reduction in risk of peripheral vascular disease
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Outcomes
Impact of Telemonitoring Combined with Home Care
Case Management (Medicare Advantage Plan):
Study Parameters
• N = 47,
• Intervention period > 12 months
• Longitudinal
• Primary Dx CAD, CHF, COPD
or DM
• Control members in Case
Management without
Telemonitoring
Results
TM Group
Control
Group
Hospital
Admissions
↓ 50%
↑ 8%
Total Costs
↓ 55%
↑ 6%
Total Claims
Savings
TM Group > Control
Group for All Diagnosis
CHF
↓ 37%
↑ 43%
COPD
↓ 70%
↓ 16%
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Outcomes
Comparison of Acute Care Admissions (12 Months):
Case Management vs. Case Management + Telemonitoring*
3000
Admissions per 1000 Members per Year
Impact of
Telemonitoring
Combined with
Home Care
(cont.)
2500
2000
1500
1000
500
0
control group (n=132)
telemonitored pts (n=47)
High Risk - Pre Intervention
1920
2396
High Risk - Post Intervention
2068
1205
* MEMBER MONTHS: Control Group - pre 1644, post 853 , Telemed Group - pre 586, tele 219
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Outcomes
Impact of
Telemonitoring
Combined with
Home Care
(cont.)
Comparison of Total Costs (12 Months)
Case Management vs. Case Management +
$2,500
Costs PMPM
$2,000
$1,500
$1,000
$500
$0
control group (n=132)
telemonitored pts (n=47)
High Risk - Pre Intervention
$2,291
$2,344
High Risk - Post Intervention
$2,161
$969
* MEMBER MONTHS: Control Group - pre 1644, post 853 , Telemed Group - pre 586, tele 219
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Outcomes
Impact of
Telemonitoring
Combined with
Home Care
(cont.) 3000
Results sustainable for up to
6 months post-telemonitoring*
Telemonitoring Period
After Discharge from Telemonitoring
2500
2000
Pre-Intervention Levels
1500
1205
1000
$969
$1,109
1234
500
0
Costs PMPM
Admits per 1000 Members per Year
* MEMBER MONTHS:
Telemed
Group tele
219, post
107
* MEMBER
MONTHS:
Telemed
Group
tele 219, post 107
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Outcomes
Value of Telemonitoring in Achieving A1c and Blood Pressure
Goals in Medicaid Managed Care Population
• N= 440 on telehealth for a minimum of 40 days
• Identified through outpatient clinics
Results
79% sustained
improvement
Glycemic Control
% hypertensive at baseline
who improved BP
69% improved by an
average of 6mmHg
diastolic
Reduction of cardiac risk
25%
Reduction of risk of stroke
18%
• For the 21% with no glycemic improvement, 66% of those hypertensive at
baseline improved by an average of 5mmHg diastolic
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Outcomes
Value of Telemonitoring in Achieving A1c and Blood Pressure
Goals in Medicaid Managed Care Population (cont.)
Of the group with improvement, the higher the baseline HgA1c, the greater the
improvement:
Those with Improvement (79%)
Baseline
HbA1c
Mean
Latest
HbA1c
Mean
Point
Improvement
< 7.0 (n=13)
7.0 to 8.9 (n=129)
9.0 to 9.9 (n=60)
10.0 to 11.9 (n=91)
6.4
8.0
9.4
10.9
5.8
7.0
7.6
8.3
0.6
1.0
1.8
2.6
12.0 (n=53)
14.0
9.3
4.7
Baseline HbA1c Tier
For the subset of members with a minimum of 12 mos of claims both pre-telemonitoring and
for 12 mos of telemonitoring (n=77):
• 36% reduction in hospitalization
• 47% reduction in emergency room visits
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Outcomes
Impact of Telemonitoring (TM) Post-Discharge from Acute Care Setting
Fee-for-Service Medicare Home Care:
Study Parameters
• Pre/Post intervention study
• N = 1,451 for 2 years
Results:
60-day
Readmission Rate
Pre-TM
Post TM
27%
11%
RN Weekly Visits ↓50%
Cost/ Home Care Episode ↓ $750
ER Visits ↓ 40%
Subsequent Controlled Study:
• N= 510 for 18 months
• Result: ↓34% reduction in 30-day readmission compared to control
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Outcomes
Impact of Telecare Management on Biometric Outcomes – 1st 90 Days
Medicaid (SSI, non-Medicare Eligible) Diabetes Pilot
 Average PMPM costs prior to pilot: $1,943
Goals
Reached
Average Blood Glucose
67%
Systolic BP
26%
Diastolic BP
39%
 Reductions in average blood pressure:
17% reduction in risk of cardiac events
12% reduction in stroke risk
 Blood sugar reductions for 25% most severe at baseline = 2 pt reduction in HbA1c:
10% reduction in overall health care costs
80% reduction in risk of eye, kidney and nerve disease complications*
* Source: National Diabetes Clearinghouse
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Outcomes
Impact of Telecare Management on Biometric Outcomes – 1st 120 Days
Medicaid (SSI, ABD & Medicare Eligible) Telehealth Pilot
 Average PMPM costs prior to pilot:
$2,893
:
 High risk, rural population
 COPD, Diabetes, Heart Failure,
Hypertension, Renal Failure
Goals
Reached
Systolic
BP
Diastolic Blood
BP
Glucose
Nondiabetics
60%
82%
N/A
Diabetics
40%
54%
70%
 Reductions in average blood pressure for 25% most severe non-diabetics:
43% reduction in risk of cardiac events
27% reduction in stroke
 Blood sugar reductions for 25% most severe at baseline = >1.2 pt reduction in HbA1c:
24% reduction in overall health risk
 for Sources: Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Prospective Studies Collaboration. Age-specific relevance of
usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet.
2002;360:1903-1913 and Heart Disease and Stroke Statistics – 2007 Update Dallas, TX: American Heart Association 2007. e million
adults in
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Case Study
Patient
• 54 year old female
• TIA, CAD; Hx of palpitations, dizziness
Intervention
•Telehealth initiated 7/15/09
•RN monitoring daily B/P and pulse
•Pulse above 100 daily as
high as 120 bpm
•BP within normal range.
•Started Metoprolol
•RN notified physician and
presented data
Outcome
•Pulse average 98 bpm
•Continue to follow medication effects
Metoprolol
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