Enterprise Data Management as a Health Plan Quality Improvement Strategy The Quality Colloquium, Harvard University August 21, 2007 Tariq Abu-Jaber, MA, MPH, Staff VP.
Download ReportTranscript Enterprise Data Management as a Health Plan Quality Improvement Strategy The Quality Colloquium, Harvard University August 21, 2007 Tariq Abu-Jaber, MA, MPH, Staff VP.
Enterprise Data Management as a Health Plan Quality Improvement Strategy The Quality Colloquium, Harvard University August 21, 2007 Tariq Abu-Jaber, MA, MPH, Staff VP Clinical Informatics, EIM, WellPoint, Inc. Praveen Soti, MD, MBA, Principal, Healthcare Consulting, Infosys Technologies Data Management to Improve Care Quality Thesis: Enterprise Data Management Enables Integrated Care Coordination Across Products, Time and Services, Leading to Better Quality of Care and Therefore Health Outcomes • • • • • Value Proposition Industry Experience Measuring Outcomes Implementation Challenges Recommendations 2 Value Proposition Value Proposition for Data Integration For Groups/Members … For Health Plans … “Direct” Improvements Revenue & Membership Growth • Medical, pharmacy and specialty cost reduction • Coordinated prevention, diagnosis and treatment of conditions “Indirect” Benefits • Absenteeism, disability, family med leave, worker’s comp, “presenteeism” • Intangible (pain, psychosocial costs, etc.) • Increased penetration through integrated medical, behavioral health, specialty and clinical programs • Lower cost of care Industry Leadership • Meets customer needs to manage overall expense • Sets improved standard for quality of care Note: Productivity Costs usually 13x Direct Medical Costs 4 Industry Experience Cost of Care Establishing the “Cost Burden” of Poor Health Median HPM Costs Per Eligible Employee (1998 $) Medstat/IHPM/APQC Benchmarking Study Group Health $4,666 47% Turnover $3,693 37% NonOccupational Workers’ Unscheduled Disability Compensation Absence $513 $310 $810 5% 3% 8% The sum of median 1998 HPM costs across programs was $9,992 per eligible employee From: “Steps to a Healthier US Workforce”, Goetzel R., NIOSH background paper, 2004 6 Integration Opportunity Median HPM Opportunity Per Eligible Employee for All Survey Participants Turnover $1,247 49% Group Health $617 24% Unscheduled Workers’ NonAbsence Occupational Compensation $435 $120 Disability 17% 4% $143 6% The sum of the 1998 HPM costs opportunity costs The summedian of the median 1998 HPM opportunity across programs was $2,562 across programs per eligible employee, a 26% reduction opportunity in total per employee HPM costs was $2,562 per eligible employee, a 26% reduction opportunity in total per employee HPM costs From: “Steps to a Healthier US Workforce”, Goetzel R., NIOSH background paper, 2004 7 Savings Opportunity From Integrating Medical & Short-Term Disability Data & Care Disease Prevalence (%) Differential Medical Costs Differential STD Costs Potential Opportunity /1000 ee’s Arthritis 9-22% $1,382 $616 $435,477 Asthma 4-7% $1,117 $373 $73,001 Cancer 1-2% $4,210 $558 $52,457 Depression 2-5% $2,453 $539 $83,785 Diabetes 4-7% $3,346 $971 $258,996 Cardiac 2-7% $4,372 $1,029 $334,888 Migraines 4-18% $1,510 $366 $84,441 From: Musich, Schultz, Burton and Edington, Disease Management and Health Outcomes, 2004 8 8 WellPoint: 360º Health® Program Integration Integrated program to manage the whole member and every member, across all levels of illness/risk, across all WellPoint health programs, via integrated database: • • • • • • • • • • • Health Coaching Condition Care (DM): • Asthma 24/7 Nurseline • Diabetes Worksite Wellness • CAD Healthy Lifestyle • CHF Future Moms • COPD • 4 Vascular at Risk programs ComplexCare • Low Back Pain NICU • Musculoskeletal Pharmacy • Oncology Behavioral Health • ESRD Integrated Disability Management MyHealth Advantage (therapeutic alerts) 9 : Comprehensive Suite of Services Health Resources Health Extras Health Guidance Health & Wellness Health Incentives Tools & Discounts Health Support/ Advocacy Health Portals Drug Interaction Alerts Special Offers Discount programs Daily Health Tips Health Portals Condition Centers Physician Pre-visit Questionnaire Health Quotient Nutrition Center Alternative Medicine Prevention Reminders Children’s Health Men’s Health Women’s Health Audio Tape Library Immunizations Online Preventive Guideline Cancer Screenings InTune Living Health Management and Coordination Health Management 24/7 Nurseline Pre-Certification Predictive Modeling Utilization Management Condition-Specific Education Decision Support ComplexCare Catastrophic Care Management Centers of Clinical Excellence • Transplants • Bariatric • Cardiac • Oncology/Radiology Condition Care • Asthma, Diabetes, CAD, COPD, CHF • Low Back Pain, Oncology, Musculoskeletal, Vascular, Depression Advanced Care Management MyHealth Advantage Early Risk Management Therapeutic Alerts Neonatal Intensive Care Unit Hospital Quality Comparison Tool Procedure Decision Support Tool MyHealth Record Pre-populated personal health record (PHR) Health Coaching Wellness incentive program Member/Family advocate Dedicated RN’s Worksite Wellness OnSite Screening and Seminar Programs High Engagement Future Moms Maternity Management 10 Advantages of Enterprise Data Integration Consolidated, integrated data: • 1 member = 1 record across time, providers, events • “Single source of truth” – clinical and financial • Facilitates coordination of care, avoids errors • Improves predictive modeling across data sources • Allows health plan to personalize member experience • Enables member <> plan <> provider communications • One face to the customer • Administrative efficiencies • Comprehensive ROI assessment resulting from integration of data, programs and products 11 Industry Experiences – Cigna Illustration Around $6,000 Actual Cost Per Employee Per Year Averages 15% Of Payroll Employer Costs of Lost Productivity (% of Payroll) Direct Indirect Total AON 4-6% 8-12% 12-18% Towers Perrin 8-12% 4-6% 12-18% Watson Wyatt 6.1% 2-4 x direct costs 12-30% Mercer 4.4% ½-4 x direct costs 7-22% Premium Costs = Only 1-2% of payroll Inefficiencies largely driven by non-integration of data, services 12 Key Cigna Findings • Most top cost drivers are the same for disability & medical • Disability claimants with chronic conditions experience longer durations whether or not the disability was primarily due to the chronic condition • Claimants involved in integrated STD and Healthcare management (having both Disability and Healthcare coverage) have 12% Shorter STD Durations and 6% Higher Return to Work Rates • Behavioral health conditions associated with a medically related disability result in poorer outcomes (durations 28% longer; incidence rate 7% greater) • Employees engaged in Cardiovascular Disease and Low Back Pain disease management programs experience shorter disability durations & lower incidence of STD 13 Aetna’s Integrated Health and Disability (IHD) • Common Platform Real-time, shared data enables improved outcomes Service efficiencies from availability of information • Real-time data integration Enables predictive modeling for medical events and disabilities to facilitate coordinated care management Combined reporting helps customers recognize total cost of conditions, provides focus for prevention efforts • Proactive case management Data availability provides opportunities for early intervention Earlier member outreach and program referral may reduce disability risk IHD Results: Reduced STD Duration 53 52 52.5 Days 51 Aetna’s IHD STD claims were 4.5 days shorter than those with only Disability coverage 50 49 48 48.0 47 46 45 Aetna Disability Only Aetna Medical + Disability Source: March 2006 Aetna Integrated Informatics ® study of claims incurred between 4/1/2003–1/31/2005. A group of 5,546 claimants were split evenly between members with Aetna disability only and members with Aetna medical and disability (IHD). Claims include members who returned consent and those who did not. Other Results in the Literature • Johnson & Johnson: After integrating health and disability management with a common data store and common processes, Johnson & Johnson realized medical cost savings of $225 per employee per year. • Pitney Bowes: After integrating disease and disability data and management, Pitney Bowes found a 32% decrease in average duration of disability, and an 11% reduction in absenteeism. From: “Integrating Disease Management and Disability Programs Results in Great Rewards,” Managed Health Care Executive, Sept. 2003. 16 Measuring Outcomes Measurement Components Establishing benchmarks across all programs, products and interventions is essential to measuring comprehensive effectiveness Target Acceptable Questionable = Actual Unscheduled Non-occup Turnover Disability Absence Disease & Workers’ Employee Health Comp Satisfaction Demand Mgmt. Insurance 18 Criteria Used to Track Improvements Direct Medical Cost Reductions Group Health Costs Occupational Disability Costs Workers Compensation Costs Disease Management Savings Indirect Productivity Improvements Unscheduled Absentee Rates Paid Sick Leave Employee Turnover Rates Employee Assistance Occupational Safety Claims Employee Satisfaction Non-occupational Disability Worker's Compensation Short Term/Long Term Disability 19 Recommendations Process of Building an EDM as Quality Strategy - Based on our Scars and Stars Define data domains across time, members, providers, events products and services: Involve all the operational departments Have Enterprise Information Management group become a facilitator for this program Define a robust Data Model (Dimensional &/or Relational) to support analytics and decision making and integrate it with Enterprise Warehouses Define a common vocabulary, infrastructure, analytical tool set and robust analytics processes to identify deviations from standard thresholds Pilot the program in 1 region with 1 employer group with 1 product Gather learnings and then define an Enterprise wide roll-out Enable a single distribution point for Organizational information: internally and externally 2 The Basis of Improved Outcomes In an article on the evolution of care management programs, Al Lewis stated that a newly emerging model “works because it is vastly more inclusive… doesn’t just involve chronic diseases… combines wellness, 24/7 nurse line, preference-sensitive conditions, complex case management and care coordination…” How does the new model achieve its results? 1. Consolidation of data in a common store 2. Touching more people by combining programs 3. Coordinating care by combining intervention data 4. Measuring results across all members & products 22 Sample Illustration Claims Ops Systems Laboratories UM/CM Ops Systems External PBM Plans and Purchasers Member Portals Pharmacy/PBM Warehouses Providers Source Data from different feeder systems from healthcare entities Patient’s Condition Medical History & Examination Laboratory Results data Utilization & Adverse Effect Reporting Comprehensive services provided elsewhere Complete Medication history EIM Repository serves as the source of Information for Business Functions EIM Repository Clinical Information Based Business Services Clinical Informatics – Reporting & Extracts Accounts and External Reporting Pay for Performance Refining Medical Policy Clinical Informatics – Care-Based Use Disease and Care Management Health IT Initiatives Personal Health Record, EPrescribing 23