Transcript Executive SummaryHealth Care Costs and Utilization

Sample Company
Integrated Health
Management Analysis
Prepared by Highmark Blue Shield
Period Ending December 31
Period ending December 31st
Introduction
Report Overview: The Integrated Health Plan Performance Review is intended to demonstrate a
holistic view of Sample Company’s health plan performance using aggregate financial, clinical and
wellness data. It offers recommendations which are aimed at helping Sample Company mitigating
cost increases by improving the health of employees and their families.
Report Time Frame: This report provides a retrospective analysis of Sample Company’s
performance based on incurred plan experience from January 1, 2005 through December 31, 2006
Incurred & Paid Claims: The data included in this report includes a comparison of claims incurred
January 2005 through December 2005 (paid through March 2006) to claims incurred January 2006
through December 2006 (paid through March 2007).
Benchmarks: In a number of the exhibits, Sample Company’s experience is compared to normative
data. This normative data is typically a national average based on claims from XX million member
lives from Highmark’s National PPO product. Several pages in the reports include external
benchmarks from various sources which are documented on each exhibit.
Period ending December 31st
2
Table of Contents
Executive Summary
Personalized Health Management
•
Overview
4
•
Highmark’s Personalized Health Management Model
20
•
Health Care Cost and Utilization Dashboard
5
•
Process Overview
21
•
Personalized Health Management Dashboard
6
•
Selected Conditions/Interventions Summary
22
•
Intensive (Case) Management
23
Cost and Utilization
•
Financial Analysis
8
•
Disease Management
24
•
Network Utilization and Discounts
9
•
Health Risk Management & Decision Support
27
•
PMPM Change Analysis
10
•
Wellness & Health Promotion
29
•
Demographics
11
Absence Management
32
•
Distribution of Members and Claims
12
Summary of Findings & Recommendations
35
•
PMPM by Type of Service
13
•
15
Appendix
36
Pharmacy Management
•
Behavior Health Management
17
Glossary
38
•
Population Health Risk
18
Period ending December 31st
3
Executive Summary
Health Care Costs and Utilization Dashboard
2005- 2006 - Incurred Basis
Claims
Medical Claims
Pharmacy Claims
Medical & Rx Claims
2005
$52,143,370
$19,701,871
$71,845,241
2006
$50,587,274
$24,323,535
$74,910,809
Benchmark
$172.52
$65.19
$237.71
$185.59
$89.23
$274.82
$158.24
$36.65
$194.89
7.6%
36.9%
15.6%
9.7%
5.4%
8.8%
Medical PMPM
Pharmacy PMPM
Medical & Pharmacy PMPM
Medical PMPM Change
Pharmacy PMPM Change
Total PMPM Change
$194.89
Medical & Pharmacy
PMPM
$274.82
$237.71
Demographics
Average Number of Subscribers
Average Contract Size
Average Member Age
2005
14,524
1.73
42.3
2006
13,644
1.66
43.2
Benchmark
Average Population Risk Score
1.67
1.62
1.04
0
0
2005
131.3
$4,314
9.8
2006
133.5
$4,724
10.8
Benchmark
42.0
$8,517
4.6
2,760
$38
3,241
$37
1,954
$36
Average Scripts per 1000 Members
Average Cost per Script
11,000
$71
14,585
$73
8,971
$61
Other Key Statistics
Average Discounts
% of Claim Dollars In-Network
2005
41.1%
98.3%
2006
41.7%
98.0%
Benchmark
N/A
N/A
Members with Claims > $50,000
Claims > $50K as % of Total Claims
106
16.7%
96
18.1%
N/A
16.1%
Member Cost Share - Medical
Member Cost Share - Pharmacy
Member Cost Share - Med & Pharm.
7.7%
33.5%
14.7%
8.5%
22.7%
13.1%
Plan Design Change Impact
Key Cost & Utilization Statistics
Admits per 1000 Members
Average Cost per Admit
Average Length of Stay
Office Visits per 1000 Members
Average Cost per Office Visit
2.01
33.8
$36.65
Pharmacy PMPM
$89.23
$65.19
$158.24
Medical PMPM
$185.59
$172.52
$0
$50
2005
Period ending December 31st
$100
2006
$150
$200
Benchmark
$250
$300
4
Executive Summary
Personalized Health Management Dashboard
2006 (2005 included in Chronic Condition Compliance)
Risk Distrubtion
Relative Risk Category
Low
Moderate
Elevated
High
Extreme
Disease Management Program Participation
2006
60.6%
26.2%
7.4%
3.9%
2.0%
Benchmark
65.5%
23.4%
6.4%
3.5%
1.3%
Clinical Driver Summary
Condition Category
Preventive Screenings
Hypertension
Behavioral Health Related
Diabetes
Disorders of the Vertabrae
Asthma
Coronary Artheriosclerosis
Pregnancy Related
Osteoarthritis of Hip or Knee
Cancers (Breast, Prostate, Colorectal, etc.)
Osteoarthritis of Hip or Knee
Cancers (Breast, Prostate, Colorectal, etc.)
Period ending December 31st
Rates per 1,000 Members
2006
Benchmark
% Diff
400.8
327.4
22.4%
144.1
122.2
18.0%
90.5
77.7
16.4%
47.0
43.2
8.9%
36.4
36.1
1.0%
36.0
35.5
1.2%
29.7
21.1
40.7%
16.1
17.2
-6.5%
18.6
14.4
29.3%
26.2
13.7
90.7%
14.2
12.4
14.6%
5.2
2.6
99.9%
DM Program Participation
Members
Asthma
829
Chronic Obstructive Pulmonary Disease
450
Congestive Heart Failure (CHF)
435
Coronary Arterty Disease (CAD)
1,320
Diabetes
1,788
Total
0
Prevalence
2006
Benchmark
3.2%
2.1%
1.7%
0.8%
1.7%
0.5%
5.1%
2.4%
6.9%
5.2%
0.0%
0.0%
Compliance with Recommended Practice Guidelines
Guideline
Asthma
2005
2006
Benchmark
Controller
Coronary Artery Disease
Beta Blocker
Lipid Rx
Lipid Test
Congestive Heart Failure
ACE/ARB
CHF Beta Blocker
Diabetes
Eye Exam
HbA1c
Lipid Rx
Lipid Test
Nephropathy
93%
88%
87%
69%
73%
33%
69%
70%
35%
63%
67%
70%
63%
68%
61%
69%
60%
60%
52%
47%
71%
42%
24%
53%
49%
79%
44%
25%
43%
74%
68%
69%
37%
5
Cost and Utilization
Outline
Financial Analysis
Network Utilization & Average Discounts
PMPM Change Analysis
Demographics
Distribution of Members & Claims
Medical Expense by Major Type of Service
Pharmacy Management
Behavioral Health Management
Population Health Risk
Period ending December 31st
6
Financial Analysis
Overview
Source of Payments
PMPM
2005
$554.89
$287.81
$14.31
$15.06
$237.71
Eligible Charges
Negotiated Discount
Member Cost Share
Third Party Liability
Paid Expense
2006
$667.78
$357.77
$17.28
$17.91
$274.82
Eligible Charges
Negotiated Discount
Member Cost Share
Third Party Liability
Paid Expense
2005
$167,709,160
$86,987,457
$4,324,463
$4,551,999
$71,845,241
2006
$182,026,283
$97,521,171
$4,711,139
$4,883,165
$74,910,809
2006
Key Findings
•
Blue Shield’s negotiated discounts have saved ABC
Company nearly $74 million over the past two years.
•
While ABC Company’s eligible charges increased 4.8%
PMPM from 2005 to 2006, paid expense only
increased by 3.0% due to increased member cost
sharing and improved discounts.
2005
$0
$200
$400
$600
Negotiated Discount
Member Cost Share
Third Party Liability
Paid Expense
Period ending December 31st
$800
7
Financial Analysis
Network Utilization and Average Discount
% of Network Claims
100%
98.3%
Key Findings
98.0%
•
The in-network utilization for ABC Company improved
from 2005 to 2006 and remains greater than the
Highmark PPO network average.
•
The favorable network utilization was at least in part
due to the vast Blue Cross Blue Shield network.
•
Overall discounts as a percentage of charges
increased slightly from 45.0% in 2005 to 45.2% in
2006.
•
Negotiated discounts as a percent of charges
increased for both professional and pharmacy
services while the facility discounts declined.
95%
90%
85%
2005
2006
Average Negotiated Discounts from Charges
60%
49.4% 51.8%
56.0%
48.6%
41.5% 43.8%
40%
27.5% 28.1%
20%
0%
Inpatient Facility
Outpatient Facility
2005
Professional
Pharmacy
2006
* Optional Major Medical claims excluded (if applicable)
Period ending December 31st
8
PMPM Change Analysis
Claim Payments PMPM
2005
2006
Change
Account
$160.10
$162.34
1.4%
Benchmark
$181.30
$204.69
12.9%
Components of Change
Price of Services / Unit Cost
2.7%
Inpatient
2.4%
Outpatient
7.5%
Professional
3.4%
Pharmacy
Inpatient
2.8%
6.3%
Professional
-5.4%
Pharmacy
11.8%
Total
Additional Factors/Components
Demographics
Plan Design Change
High Cost Claimants
Period ending December 31st
• ABC Company’s 2006 PMPM of $239.47 was 2.9%
below the adjusted benchmark of $246.70
• The minor change due to demographics is due to
changes in the age and gender distribution of ABC
Company from the prior year.
-6.2%
Outpatient
• ABC Company’s combined Medical/Rx claims PMPM
increased by 6.6% from 2005 to 2006. This
increase is significantly lower than the account
adjusted benchmark of 12.6% for the same time
period.
• ABC Company’s Medical only PMPM increase was
4.2% from 2005 to 2006.
23.9%
Utilization
Key Findings
5.6%
• There were no benefit design changes implemented
during the 2006 plan year.
• The 7.3% price increase was in line with the
healthcare industry’s average
N/A
N/A
16.6%
9
Demographics
Percentage of Population Male
Percentage of Population Female
2005
43.1%
56.9%
2006
42.5%
57.5%
Average Number of Subcribers
Average Number of Members
Average Contract Size
14,524
25,186
1.7
13,644
22,715
1.7
42.3
43.2
Average Member Age
% of Members & Claim Dollars by Age Range
35%
31%
30%
25%
• ABC Company’s membership grew by 21% from 2005
to 2006. Still the age and gender distribution
remained relatively stable.
• The average age of ABC Company subscribers is 41.6
years. This is 2.4 years younger than the Highmark
average. ABC Company’s average member age is
only slightly below the Highmark average.
• Despite the growth, ABC Company’s contract size
(members per subscriber) stayed the same between
2005 and 2006 at 2.0. By comparison, the Highmark
average contract size was slightly higher at 2.1.
23%
20%
20%
15%
14%
10%
20%
18%
17%
15%
10%
Key Findings
10%
11%
11%
5%
0%
0-17
18-34
35-44
%of Members
45-54
55-64
65 & Over
%of Costs
* See page 18 for Population Risk
Period ending December 31st
10
Distribution of Members
and Claims
% of Claims by Annual Member Range
60%
54%
Key Findings
51%
•
Members with claims over $100,000 accounted for
8.2% of overall claims in 2006, about the same level
as in 2005.
•
The percentage of claims incurred by members over
$50,000 increased from 14.2% in 2005 to 15.5% in
2006. This was still well below the Highmark average
of 19.6%.
•
The percent of members with claims under $10,000
declined from 96.6% to 95.0%.
40%
29%
31%
20%
8%
8.5%
7%
10.8%
0%
Less than $10K
$10K - $50K
2005
$50K - $100K
Add information from shock claim
analysis regarding program status
for members above $50,000
$100K or Greater
2006
Number of Members with Claims > $100K
Accounting for % of Total Claims
2005
2006
41
39
8.5%
10.8%
2005
2006
Payment Range
% of Claim s
% of Mem bers
% of Claim s
% of Mem bers
Less than $10,000
54.3%
95.9%
51.4%
95.3%
$10,000 - $50,000
29.0%
3.7%
30.5%
4.3%
$50,000 - $100,000
8.3%
0.3%
7.3%
0.3%
$100,000 or Greater
8.5%
0.1%
10.8%
0.1%
Aggregated claims incurred in 2006 and paid through March 31 st for each member
Period ending December 31st
11
Medical Expense
PMPM Change by Claim Type by Service Type
Inpatient Major Diagnostic Categories - PMPM
$12
$10
2005
2006
$10.64
Key Findings
$9.43
$7.30
$8
$6.11
$6
$4.62
$4.27
$4.25
$4.28
•
The biggest driver of the increase in the inpatient
PMPM was the Other Category, which includes
behavioral health, rehabilitation and skilled nursing
facilities.
•
The Outpatient surgery PMPM increased by 33%.
This was the big driver, along with radiology, of the
overall increase in the outpatient PMPM.
•
Many of the professional service categories
showed PMPM increases from the prior period. Of
particular note was radiation therapy, which
showed a 80% increase.
$3.97
$4
$1.62
$2
$0
Circulatory
Musculoskeletal
Respiratory
Liver / Pancreas
Nervous
Outpatient - Major Service Types - PMPM
$7
$6.59
$6.03
$5.90
$6
$5
$4.25
$3.66
$4
$3.86
$3
$2.06
$2.21
$2
$1.84
$2.03
$1
$0
Medications
Laboratory Service
Supplies
Surgical Care
Professional - Major Service Types - PMPM
$14
$12
$11.16
$11.98
$9.94
$10
$8.67
$8
$6.03
$6.44
$6
$4.97
$5.35
$4.80
$3.37
$4
$2
$0
Surgery
Period ending December 31st
Diagnostic X-Ray
Physical Therapy
Injections
12
Pharmacy Management
Key Findings
Key Pharmacy Metrics
2005
$65.19
11,000
$71.11
PMPM
Scripts / 1000
Payment / Script
2006
$89.23
14,585
$73.42
•
ABC Company’s Pharmacy PMPM decreased by 3.3%.
The 10.1% increase in utilization was more than offset
by a 4.9% decrease in the average cost per
prescription.
•
The generic utilization rate increase to 58.1% in 2006,
singificantly greater than the network average of
52.8%. This was a driver of the decrease in average
cost.
% Change
36.9%
32.6%
3.2%
Distribution of Prescriptions
Generic
Brand w/ Generic Option
Brand w/o Generic Option
2005
51.0%
3.6%
45.4%
2006
53.6%
3.3%
43.1%
Benchmark
54.1%
3.0%
42.9%
•
Mail utilization increaed modestly to 2.8% of
prescriptions, but remains well below the network
average of 8.3%.
Retail
Mail Order
83.8%
16.2%
85.5%
14.5%
87.9%
10.9%
•
Anti-infective agents accounted for 22.4% of Rx
payments for ABC Company. This was much higher than
the 8.6% network rate. This class of drugs includes X, Y,
and Z.
Top Therapeutic Classes
Class
Cardiovascular Agents
Central Nervous System
Hormones & Synthetic Subst
Gastrointestinal Drugs
Anti-Infective Agents
Period ending December 31st
2006
Pmt / Script % of Scripts
$56.85
23%
$56.79
19%
$46.34
15%
$123.62
5%
$42.99
8%
% of Pmts
21%
17%
11%
10%
6%
Benchmark
% of Scripts % of Pmts
20%
19%
22%
21%
16%
13%
5%
11%
6%
4%
13
Pharmacy Management Tools & Programs
Clinical programs
Retail Exclusivity Program
•
•
Streamlined program through which physicians can order certain
injectable drugs.
•
Program is aimed at:
◦ Enhancing integrated care and utilization management for
patients who use these drugs to help ensure that these drugs
are administered in the most appropriate and effective
manner
◦ Simplifying the precertification process for these medications
to save physicians time and members receive these
medications promptly and directly to their home
◦ Reducing cost by minimizing waste
•
Formulary
◦ List of FDA approved drugs
◦ Highmark’s independent Pharmacy and Therapeutics (P&T)
Committee
◦ Selected based on safety, efficacy, quality and cost to the
plan.
Care Management Programs
◦ Managed Rx Coverage – real-time, online, automated –
promotes appropriate dose, duration of therapy and
utilization while limiting member disruption
◦
◦
◦
•
Quantity Per Co-payment – promotes appropriate use,
prevent stockpiling
Managed Prior Authorization – promotes appropriate use of
high cost products
Concurrent/Retro DUR – promotes patient health/safety
MD Programs
◦ Profiling – educates physicians on best practices
◦
◦
MEDVANTX Point of Care Delivery Network
•
Automated dispensing system to control generic samples and
OTC products in physician office
•
Participating physicians can offer initial course of medication
therapy to all their patients free. There is no cost to either the
physician or patient.
Dose Optimization – simplifies dosage regimens and
increases compliance
Generic Sampling – increases utilization of generic
medication
Period ending December 31st
14
Behavioral Health Management
Condition Category
Depression
Major Depressive, Bipolar & Paranoid Disorder
Anxiety Disorder
Reactive and Unpecified Psychosis
Personality Disorder
Schizophrenia
Drug/Alcohol Abuse, w/o Dependence
Drug/Alcohol Dependence
Drug/Alcohol Psychosis
2006
Members
442
399
247
13
19
10
205
36
8
2006
Benchmark
Mbrs/1,000 Mbrs/1,000
29.7
30.8
26.8
18.3
16.6
12.7
0.9
0.8
1.3
0.8
0.7
0.5
13.8
19.0
2.4
2.8
0.5
0.8
Behavioral Health Referral
and Management Model
Medical
Case
Management
•
Client ABC’s average cost per prescription of $29.77 was 13% lower
than the network average of $34.46 as a result of:
 Increased generic utilization
 Lower per script prices
 Higher employee cost sharing
A large percentage (7.9%) of Rx costs were part of the Miscellaneous
Endocrine class of drugs, the majority of which were infertility drugs.
Period ending December 31st
BH Continued
Stay IP
Reviews
Referral
Distribution
Checklist
 Key Findings
•
Surveys –
Inpatient &
Outpatient
Complex
Case
Management
(Maximum of
90 days)
Outreach
(Brief telephonic
outreach)
Depression
Management
Program
(Maximum of
1 year)
15
Population Health Risk
Concurrent Risk Scores and Risk Distribution
Low
Moderate
Elevated
High
Extreme
2005
Risk Score
1.67
2006
Risk Score
PMPM
1.62
$218
Benchmark
Risk Score
PMPM
1.36
$207
2005
% of Mbrs
61.4%
25.4%
7.1%
4.0%
2.1%
2006
% of Mbrs
60.6%
26.2%
7.4%
3.9%
2.0%
Benchmark
% of Mbrs
PMPM
65.5%
$36
23.4%
$211
6.4%
$495
3.5%
$1,030
1.3%
$3,798
PMPM
$45
$204
$439
$825
$3,174
Something like this: DxCG has developed a rigorous
methodology for assigning weights to relative health risks
of a member or population. Each medical diagnosis is
assigned a relative weight, or risk score. A risk score is
calculated for each member based on the diagnoses
incurred during the specified time period. The overall risk
score for ABC Company is the average of all member
scores. Please see the Appendix for additional explanation
of the DxCG methodology.
 Key Findings
•
ABC Company’s aggregate risk score declined
from 2005 to 2006. This reflects a relative
improvement in the health of the ABC company
population.
•
Similarly the ABC Company risk score for 2006
was below the Highmark average. This is
consistent with the claims PMPM also being
lower than the Highmark average.
% of Members by Risk Category
70%
61% 61%
65%
60%
50%
40%
25% 26% 23%
30%
20%
7% 7% 6%
10%
4% 4% 3%
2.1%2.0%1.3%
High
Extreme
0%
Low
Moderate
2005
Period ending December 31st
Elevated
2006
Benchmark
16
Personalized Health Management
Outline
 Highmark’s Personalized Health Management Model: Continuum of
Care
 Clinical Cost Drivers and Intervention Summary
 Highmark Patient Identification and Stratification Process
 Wellness and Health Promotion
 Health Risk Management & Decision Support and Advocacy
 Disease Management
 Intensive Management
Highmark’s Personalized Health Management program objectives:
• Keep healthy people healthy and productive – actively involve members
• Provides support to making health-related decisions
• Reduces health risk over time
• Actively manages those with chronic conditions to avoid costly complications
• Coordinates care for intensive-case patients
Period ending December 31st
17
Highmark’s Personalized Health Management Model
Continuum of Health
Healthy
(Risk)
Low
Health Promotion
and Disease
Prevention
Health Risk
Assessment
Lifestyle
Improvement
Interventions
Screenings
Wellness Coaching
At Risk
Acute Condition
Chronic Disease
Complex/Disabling
Moderate
Elevated
High
Extreme
Health Risk
Management
Decision Support
& Advocacy
Disease
Management
Intensive
Management
Symptom Support
Episodic Case
Management
Chronic Condition
Management
Case Management
Evidence-based
Criteria and
Guidelines
Management of
Co-morbidities
Maternity Program
Shared Decision
Making
Depression
Management
Physician
Involvement in
assessment &
planning
Targeted Behavior
Modificaition
Discharge
Planning
Self Management
Skills
Educational Resources
such as Healthwise
Knowledgebase
Audiotapes &
Literature
Address clinical,
psychosocial, and
financial issues
Pharmacy Benefit Management
Utilization Management
Integrated Absence Management
Health Advocacy and Wellness and Lifestyle Behavior Modification Programs
Personal Health Records
Period ending December 31st
18
Highmark Patient Identification & Stratification Process
Program Process Overview
Healthy
Period ending December 31st
Identification
Stratification
• Medical and Rx claims
• Readiness to change (HRA)
• Authorizations
• Health Coach case findings
• Likelihood of hospitalization
• High Cost Claimants
• Financial risk
• Clinical risk
• Predictive modeling
• Predicted clinical risks
• Predicted financial risks
• Health Risk Assessment
At Risk
Acute Condition
Chronic Disease
Complex/Disabling
19
Selected Clinical Conditions and Intervention Summary
Condition Category
Preventive Screenings
2006
Members
5973
2006
Benchmark
Mbrs/1,000 Mbrs/1,000
400.8
327.4
% Diff
22%
Hypertension
2147
144.1
122.2
18%
Behavioral Health Related
1348
90.5
77.7
16%
Diabetes
701
47.0
43.2
9%
Disorders of the Vertabrae
543
36.4
36.1
1%
Asthma
536
36.0
35.5
1%
Coronary Artheriosclerosis
443
29.7
21.1
41%
Pregnancy Related
240
16.1
17.2
-6%
Osteoarthritis of Hip or Knee
277
18.6
14.4
29%
Cancers (Breast, Prostate, Colorectal, etc.)
390
26.2
13.7
91%
COPD
211
14.2
12.4
15%
77
5.2
2.6
100%
Renal Failure
Period ending December 31st
Interventions
24/7 Nurse Call Line, Relax T M, BalanceT M, 10,000 Step Challenge,
CAM Affinity Netw ork, HealthWise Know ledge Base
Behavioral Health Case Management, Depression Management
Program, 24/7 Nurse Call Line, Shared Decision-Making Topics,
Relax T M, CAM Affinity Netw ork
Chronic Condition Management, 24/7 Nurse Call Line, Care for
Your HealthT M, NourishT M, BalanceT M, CAM Affinity Netw ork,
HealthWise Know ledge Base, 10,000 Step Challenge
24/7 Nurse Call Line, Shared Decision-Making Topics, Care for
Your BackT M, BalanceT M, CAM Affinity Netw ork, HealthWise
Know ledge Base
Chronic Condition Management, 24/7 Nurse Call Line, BreatheT M,
CAM Affinity Netw ork, HealthWise Know ledge Base
Chronic Condition Management, 24/7 Nurse Call Line, Shared
Decision-Making Topics, BalanceT M, 10,000 Step Challenge,
Bands on the Run, CAM Affinity Netw ork, HealthWise Know ledge
Base
Maternity Program, Specialty Maternity Complex Case
Management, 24/7 Nurse Call Line, NourishT M, HealthWise
Know ledge Base
24/7 Nurse Call Line, BalanceT M, Shared Decision-Making Topics,
CAM Affinity Netw ork, HealthWise Know ledge Base
Case Management, 24/7 Nurse Call Line, Shared Decision-Making
Topics, HealthWise Know ledge Base, CAM Affinity Netw ork
Chronic Condition Management, 24/7 Nurse Call Line, BreatheT M,
NourishT M, CAM Affinity Netw ork, HealthWise Know ledge Base,
Case Management, 24/7 Nurse Call Line, NourishT M, CAM Affinity
Netw ork, HealthWise Know ledge Base
20
Intensive Management Summary
Case Management Activity
Description of Care Management Program
Who?: Provided to members who require in-depth care
coordination, community service, education and advocacy due
to major illness, injury, or certain types of surgery
How?: Case managers work with members, their families,
physicians and hospitals to provide proactive, comprehensive
assessment, issue identification, goals setting, and targeted
interventions to guide members to appropriate health care
services (e.g., home health services, community resources, or
Employee Assistance Programs
Why?: The goal is to enable the member to reach optimum
recovery in a timely manner
Intensive Management
Case Management Activity
Medical Cases Targeted
Medical Cases Closed
Closed Unable to Reach
Closed Member Refusal to Participate
2006 Mbrs
113
101
16
21
2006 Cases
121
109
17
22
Behavioral Health Cases Targeted
Behavioral Health Cases Closed
Closed Unable to Reach
Closed Member Refusal to Participate
15
16
6
3
16
17
6
3
Account
128
Highmark
24,441
CM Participant
7%
0%
CM Opt Out
11%
11%
Total Membership Under CM
Case Management Measures
Readmissions Rate
ER Visit Rate (per Case)
Key Findings
• Client XYZ currently has 1.2% of its population under some form of case management compared to 1.0% for Highmark’s
book-of-business average
• Readmission rates and ER visit rates are 4 times higher for those who patients who were targets, but opted out of Highmark’s
case management programs
* See Appendix XX for more detailed metrics on Case Management program
Period ending December 31st
21
Disease Management
Disease
Management
Prevalence and Outreach Activity
Disease Management Outreach: Highmark’s Disease Management programs assist members with specific chronic diseases to better
understand their conditions, including the risks, complications and co-morbidities that can create potential unfavorable outcomes if not
monitored and treated appropriately. DM support is provided by licensed professionals trained specifically for each managed
condition. These professionals provide education and counseling through targeted outreach and condition monitoring.
Disease Management Program Participation
DM Program
Asthma
COPD
CHF
CAD
Diabetes
Totals
Members
829
450
435
1,320
1,788
4,822
% Prevalence
3.2%
1.7%
1.7%
5.1%
6.9%
18.6%
Benchmark
2.1%
0.8%
0.5%
2.4%
5.2%
11.0%
Chronic Condition Targeted Member Outreach Statistics
Total Membership
Identified
Unable to Contact
Contact Attempted
Reached
Engaged
% Reached/Engaged
Period ending December 31st
Members
25,966
3,663
70
3,345
3,336
561
% Prevalence
Benchmark
14.1%
1.9%
91.3%
91.1%
15.3%
9.1%
7.5%
81.2%
80.9%
11.1%
16.8%
13.7%
Key Findings
•
ABC Company’s aggregate risk score
declined from 2005 to 2006. This reflects a
relative improvement in the health of the ABC
company population.
•
Similarly the ABC Company risk score for
2006 was below the Highmark average. This
is consistent with the claims PMPM also being
lower than the Highmark average.
22
Health Risk Management and Decision
Support & Advocacy
Symptom Support and Outreach
Decision Support &
Advocacy
Blues on Call is a component of Highmark’s integrated care management solution. Through Blues on Call, members have access
to a range of programs and services providing education, advocacy and support with the goal of improving the quality of care.
Resources and services include the following:
• Health coaching (registered nurses) available 24 hours per day to answer questions and provide educational materials
regarding medical conditions, symptoms, treatment options, and medications
• Pre-admission and post-discharge counseling
• Targeted outreach to at-risk or newly diagnosed members
• On-demand audio and video materials targeted to specific medical conditions and treatment decisions
• Healthwise Knowledgebase, on online source for information on diagnoses, symptoms, medications and the latest medical
technologies
Acute Condition - Targeted Member Outreach Statistics
Total Membership
Identified
Unable to Contact
Contact Attempted
Reached
Engaged
% Reached/Engaged
Period ending December 31st
Members
25,966
22,303
4
434
428
350
% of Total
85.9%
0.0%
1.9%
1.9%
1.6%
81.8%
Key Findings
•
Only 54 members attempted calls to a Health Coach. This
represents only 2.7% of members and is well below the
4.9% Highmark average. Better communication of this
service to members would provide opportunities for
improved decision making for members of ABC company
•
35 out of the 135 members identified for targeted
member outreach were not available. Typical reasons
include outdated phone numbers or addresses. This
information should be kept up to date with Highmark to
maximize the value of the Blues on Call resources.
23
Wellness and Health Promotion
Preventive Screening Tests
Wellness & Health
Promotion
Health Risk
Management
Program Premise
•
•
Evidence exists to prove that people who get preventive healthcare - screening
tests, immunizations, and health counseling and advice - enjoy better health
overall
Many studies have substantiated that preventive care helps people live longer
and improve their quality of life
74%
68%
70%
68%
58%
60%
50% 49% 51%
50%
45%
40%
35%
30%
20%
25%
18%
0%
0%
Mammograms
2005
Period ending December 31st
• The mammogram screening rate for ABC
Company compares favorably to the
benchmark
• The Highmark Blue Shield preventive
schedule can be found at
highmarkbcbs.com.
10%
Physicial Exams
• In general, preventive screening for XYZ
Company improved from 2005 to 2006
and compared favorably with the
benchmark
• Because of the relatively low rate of
prostate screening and the low
percentage of males in the ABC
Company population this may be a
target area for education. Prostate
cancer is an extremely preventable
cancer with early detection.
Compliance with Recommended Screening Guidelines
80%
Key Findings
2006
Prostate Screenings
Colorectal Cancer
Screenings
Benchmark
24
Productivity Management
Presenteeism and Indirect Health-Related Costs
Productivity
Management
Presenteeism is defined as lost productivity occurring when an employee is present for work, but is not performing at full capacity. Unlike
absenteeism, the costs of presenteeism can be difficult to quantify, but the costs of health-related presenteeism are significant. Recent
studies1 have shown that medical costs account for only a portion of total health and productivity-related expenditures that employers face.
Presenteeism costs, along with the indirect health-related costs of absenteeism and disability, highlight the need for broad and proactive
management of employee health risk factors as well as chronic and disabling conditions.
Highmark Productivity Management
Distribution of Indirect / Direct Health Costs for Select Conditions
1, 2
•
Highmark experts collaborate with Company ABC on
management of the risks and financial exposure associated with
health-related absenteeism and presenteeism.
•
Productivity management specialists analyze your existing and
future risks and will develop appropriate interventions to alter
the course of anticipated health risk and disease progressions.
•
Highmark Productivity Management provides an outsourced
corporate medical department which can be used by Company
ABC in setting key HR policies and procedures, as well
coordinating medical services for executives and other personnel.
•
Physicians are on call 24 hours per day, 365 days per year to
provide support and intervention for any health-related issue.
•
“First Report of Absence” intervention is provided for work and
non-work related issues. Physicians will work directly with
providers through closure.
100%
80%
60%
40%
82%
77%
89%
73%
71%
53%
20%
63%
62%
19%
25%
ep
re
C
ss
an
io
ce
n/
r
M
en
ta
lI
ll n
es
s
D
ia
be
te
H
s
ea
rt
D
is e
as
e
H
yp
er
te
M
ns
ig
io
ra
n
in
e/
H
R
ea
es
da
pi
ra
ch
to
e
ry
D
i so
rd
er
s
D
As
th
m
a
Ar
th
rit
is
Al
le
rg
y
0%
Presenteeism
Absence & STD
Direct Medical / Pharmacy
1 Goetzel,
2
Ron et al. Health and Productivity Cost Estimates. Journal of Occupational and Environmental Medecine. April 2004: 398-412
Presenteeism cost estimates assume average wage of $23.15 per hour.
Period ending December 31st
25
Recommendation Summary
Opportunity Areas
Based on Highmark’s analysis, below is a three-pronged integrated strategy to address ABC Company’s overall health
care costs through targeted communication and program investment. Additionally, ABC Company should monitor
previous plan design changes to ensure intended results.
Theme
Recommendations
•

Prevention & Wellness: Continue to focus on preventive
care and healthy lifestyle changes through Highmark’s
extensive suite of prevention and wellness programs
•
•
•
•



Employee Engagement: Engage consumers through an
enhanced communications campaign focused on prudent
utilization of health care services
Plan Design: Continue to implement plan design
modifications consistent with ABC Company’s overall benefits
management strategy and employee cost sharing objectives
Period ending December 31st
Promote Living Healthy Babies program to better manage neonatal
costs
Promote nutrition education program
Promote stress management program
Promote fitness programs
Promote screenings and smoking cessations programs


Communicate on-line programs
-- Promote PHA participation
Promote Blue Care Line and Healthwise
Hold worksite consumerism workshops


Develop communications roll-out plan for benefit design changes
Consider the introduction of Consumer Driven Health Plan option.
26