Transcript Disease Management Gordon Norman, MD, MBA VP, Health Care Quality

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Disease Management
Gordon Norman, MD, MBA
VP, Health Care Quality
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Pre-CY2000 – DM Behind “Veil Of Capitation”
Pre-2000 Era
HEALTH IMPROVEMENT
DISEASE MANAGEMENT
Population-based
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Post-CY2000 – Risk Shift = Paradigm Shift
Post-2000 Era
Post-2000 Era
HEALTH IMPROVEMENT
DISEASE MANAGEMENT
HEALTH MANAGEMENT
Population-based
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Case-based
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“Disease Management” – Spectrum Of Needs
Catastrophic Care Management
Complex case management
Member Continuum
Catastrophic
Special
Populations
Chronically Ill
Acutely Ill
Well
Special Population Care
Frail members, ER frequent
users, Pre-catastrophic care,
Terminally ill members
Chronic Disease Management
CHF, CAD/stroke, COPD, ESRD
Diabetes, Depression, AMI
Acute Episode Management
In-/Out-pt. Medical Management
Transitional, Continuity of Care
Preventive Health Management
Preventive care/Risk reduction
Health improvement, Member
education
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Origins of a Bedday
Predisposition
ER
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At Risk
Chronically Ill
In-pt.
Hospitalization
Acute
Trigger
Discharge
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Classic Utilization Management – ALOS Focus
ER
In-pt.
Hospitalization
Hospitalist Interception
SNF, HH
Caregiver Resources
Onsite Nurses
Social Services
ent
on
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Discharge
Classic
BD/K Mgt.
CCR, LOS Mgt
Hospitalist Mgt
LOC Denial
Onsite RN, RMD
Discharge Planning
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Focused Acute Episode Management
• ALOS Management
– managing capitation to shared risk conversions
– change from PMG to Pareto group hospital focus
– PacifiCare as consultant and resource
– “Every Patient, Every Day” mantra
– sophisticated informatics and reporting
– onsite concurrent review coverage at outlier hospitals
– Medical Director-led regional medical teams
– Hospitalist programs increasing
– achieving Commercial and Medicare utilization results
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Daily Census – PCC, PHS
Membership-adjusted,
Seasonally-adjusted
Seasonally
Adjusted Budget ADC
Average Daily Census
Budget
Actual Average
Actual
DailyCensus:
Census
California
California
500 488
425
397
400
460 458
386
375
450
379
374 371
371 368
421 424 419
368 367
359
346
350
\
430
403
398
388
387
382
369
336
326 329
422
409
391
400
349 350 346 347
343
423
411
405
329
356
355
350
325
309
Commercial
1,800
707
713
696
700
689
5/24
5/17
5/3
5/10
4/26
4/19
4/12
4/5
3/29
3/22
1,733
1,700
1,657
687
656
652
636
650
680 675
673
662
3/8
Enterprise
733
722
3/15
Medicare
Enterprise
750
3/1
2/22
2/15
2/8
2/1
1/25
1/18
1/4
1/11
5/24
5/17
5/10
5/3
4/26
4/19
4/5
4/12
3/29
3/22
3/15
3/8
3/1
2/22
2/8
2/15
2/1
1/25
1/18
1/4
300
1/11
300
676
666 663
1,600
651
642
1,581
1,559
1,560
1,530
1,517
1,500
1,459
1,500
1,469
1,4481,435
1,4251,4321,4301,424
1,4141,414
626
606
1,400
1,338
1,314
1,314
600
1,300
5/24
5/17
5/3
5/10
4/26
4/19
4/12
4/5
3/29
3/22
3/15
3/8
3/1
2/22
2/15
2/8
2/1
1/25
1/18
1/11
5/24
5/17
5/10
5/3
4/26
4/19
4/12
4/5
3/29
3/22
3/15
3/8
3/1
2/22
2/8
2/15
2/1
1/25
1/18
1/11
1/4
8
1/4
1,200
550
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ER – Slippery Slope to Hospital Admission
Hippocratic Oath: “primum non nocere”
Division of clinical roles, responsibilities
Rescue ethos: active over passive mgt.
Little time for discharge planning
Legal risks (COBRA, EMTALA)
Clinical uncertainty of dx, px
Uncertainty of patient F/U
Financial reimbursement
Family/caregiver anxiety
Discretionary gray zone
Limited clinical history
Patient expectations
Relative time, effort
Hospital economics
Patient advocacy
Malpractice risk
Convenience
Liability risk
Habit
ER
Discharge
Easy out-pt. coordination
Primary care continuity
Member disincentives
Diversion alternatives
Social work resources
Hospitalist incentives
Family expectations
Quick, easy HH svcs
Available SNF beds
24 hr. observation
Full hospital beds
Onsite RN triage
DSS, protocols
Admit
Lesson: it’s often too late by the time the member is in ER –
avoiding the slippery slope requires upstream medical management
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Upstream Medical Management – Admits/K Focus
Predisposition
Upstream
BD/K Mgt.
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At Risk
Chronically Ill
Acute
Trigger
Health
Improvement
Preventive Care
Lifestyle
Modification
Medication
Genomics
Disease
Management
Case Management
Preventive Care
Lifestyle
Modification
Primary Care
ER
eHealth Triage
Diversion Protocols
Urgent Care
24/7 Call Center
Demand
Management
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Pareto Analysis – Top 5% Most Costly Members
California 1999 S ecure Horizons Top 5% Cost Members S ummarized by Disease
% of Total
Disease
Paid
Paid PMPM
% of Paid
Cumm %
Paid
ES RD
$35,619,971
$6,407.62
26.0%
26.0%
15.1%
CHF_1
$34,020,094
$5,458.06
24.8%
50.8%
14.4%
COPD
$32,038,183
$5,142.57
23.4%
74.2%
13.6%
CAD/S TROKE
$20,660,096
$4,633.35
15.1%
89.3%
8.8%
CANCER
$3,549,138
$4,136.52
2.6%
91.8%
1.5%
RARE_DZ
$3,081,808
$5,749.64
2.2%
94.1%
1.3%
ALL OTHER
$2,219,720
$5,750.57
1.6%
95.7%
0.9%
DIABETES
$1,953,427
$3,852.91
1.4%
97.1%
0.8%
GASTROIN
$1,752,881
$3,965.79
1.3%
98.4%
0.7%
ARTHRITS
$945,890
$6,523.38
0.7%
99.1%
0.4%
DEPRESSN
$697,749
$4,333.84
0.5%
99.6%
0.3%
ASTHMA
$530,225
$4,610.65
0.4%
100.0%
0.2%
$137,069,182
Cumm %
15.1%
29.6%
43.2%
52.0%
53.5%
54.8%
55.7%
56.6%
57.3%
57.7%
58.0%
58.2%
$235,437,703
California 1999 Commercial Top 5% Cost Members S ummarized by Disease
Disease
ALL OTHER
CANCER
COPD
CAD/S TROKE
GASTROIN
ES RD
ARTHRITS
CHF_1
DEPRESSN
RARE_DZ
DIABETES
ASTHMA
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Paid
$21,704,015
$14,761,009
$13,517,550
$12,478,244
$7,816,471
$7,784,755
$4,959,525
$3,575,329
$2,678,225
$2,254,391
$1,601,938
$1,502,728
$94,634,180
Paid PMPM
% of Paid
Cumm %
$618.28
22.9%
22.9%
$1,806.95
15.6%
38.5%
$1,566.71
14.3%
52.8%
$1,208.78
13.2%
66.0%
$758.14
8.3%
74.3%
$6,969.34
8.2%
82.5%
$501.01
5.2%
87.7%
$2,019.96
3.8%
91.5%
$561.94
2.8%
94.3%
$2,314.57
2.4%
96.7%
$756.34
1.7%
98.4%
$762.42
1.6%
100.0%
% of Total
Paid
16.5%
11.2%
10.3%
9.5%
5.9%
5.9%
3.8%
2.7%
2.0%
1.7%
1.2%
1.1%
Cumm %
16.5%
27.7%
37.9%
47.4%
53.3%
59.2%
63.0%
65.7%
67.7%
69.4%
70.7%
71.8%
Disease Management – Sourcing Preferences
• Outsourcing preferred
– major focus is primary
disease driving majority of
members’ utilization/costs
– specialized skills not
easily developed or
recruited
– use of proprietary tools
– economies of scale,
scope
– performance data
available
– performance risk
accepted
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• Insourcing preferred
– major task is support,
integration of many
unmet member needs
that result in excessive
health care resource
consumption
– generalist, social mgt
more critical than
specialist skills
– integrating community
resources important
– no proprietary tools
needed
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DM Opportunity Analysis – Conclusions
• Most promising choices for outsourced DM
– ESRD
– cancer
– CHF
– rare complex disease medley
– CAD/stroke
– neonatal care
– COPD
– asthma
• Appealing insourced CM candidates
– End-of-life care (cancer, chronic diseases, HH services,
family support, hospice, AMDs, palliative care)
– Frail members (chronic disease, disabled, homebound)
– ER frequent utilizers (chronic disease, access,
compliance)
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Congestive Heart Failure – California
11,741
66,297
Mem Mos
10000
Paid PMPM
Days PTMPY
66,297
$2,000
8000
6000
4000
2000
11,741
$1,500
$1,000
$500
0%
-55%
-51%
1%
$0
0
Enrolled
Baseline
Not Enrolled
Intervention
Enrolled
SH
Baseline
Not Enrolled
Intervention
Net Savings $6.3M
6,408
Mem Mos
10000
$2,500
8000
$2,000
Paid PMPM
Days PTMPY
1,069
6000
4000
2000
$1,000
$500
-11%
-49%
$0
0
Enrolled
Baseline
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6,408
$1,500
-10%
-62%
1,069
Not Enrolled
Intervention
CO
Net Savings $2.3M
Enrolled
Baseline
Not Enrolled
Intervention
Baseline Period: 12/1/99 - 11/30/00 Intervention Period: 12/1/00 - 11/30/01
Chronic Obstructive Pulmonary Disease – California
15,815
Mem Mos
8000
$1,600
6000
$1,200
Paid PMPM
Days PTMPY
11,395
4000
2000
-4%
-37%
11,395
15,815
$800
$400
-3%
-28%
$0
0
Enrolled
Baseline
Enrolled
Not Enrolled
Intervention
SH
Baseline
Not Enrolled
Intervention
Net Savings $2.9M
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Baseline Period: 4/1/00 - 3/31/01 Intervention Period: 4/1/01 - 11/30/01
End Stage Renal Disease – California
4,238
Mem Mos
14000
$5,000
12000
$4,000
10000
Paid PMPM
Days PTMPY
4,238
8000
6000
4000
-26%
2000
$3,000
$2,000
-8%
$1,000
$0
0
Disease Population
Baseline
Intervention
Disease Population
SH
Baseline
Intervention
Net Savings $0.7M
875
Mem Mos
$5,000
$4,000
6000
4000
-43%
2000
Paid PMPM
Days PTMPY
8000
$3,000
$2,000
8%
$1,000
$0
0
Enrolled
Baseline
16
875
Intervention
CO
Net Savings ($0.4M)
Enrolled
Baseline
Intervention
Baseline Period: 4/1/00 - 3/31/01 Intervention Period: 4/1/01 - 11/30/01
Frail Member Care – PCC
13,654
Mem Mos
$5,000
20000
$4,000
15000
10000
-1%
-29%
Paid PMPM
Days PTMPY
5,121
25000
$2,000
-17%
$1,000
0
$0
Not Enrolled
Baseline
Intervention
13,654
$3,000
5000
Enrolled
5,121
0%
Enrolled
SH
Baseline
Not Enrolled
Intervention
Net Savings $4.8M
2,228
Mem Mos
30000
$6,000
25000
$5,000
20000
15000
10000
-10%
-8%
Paid PMPM
Days PTMPY
1,072
2,228
$4,000
$3,000
$2,000
-16%
4%
$1,000
5000
$0
0
Enrolled
Not Enrolled
Baseline
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1,072
Intervention
CO
Net Savings $0.4M
Enrolled
Baseline
Not Enrolled
Intervention
Baseline Period: 11/99 - 10/00 Intervention Period: 11/00 - 11/01
End of Life Care – PCC
579
8,241
Mem Mos
25%
20%
15%
10%
-24%
12%
$15,000
$10,000
$5,000
-6%
1%
5%
$0
0%
Enrolled
Baseline
18
8,241
$20,000
Paid per Death
% In-pt. Deathss
30%
579
Enrolled
Not Enrolled
Intervention
SH
Baseline
Not Enrolled
Intervention
Baseline Period: 1/00 - 12/00 Intervention Period: 1/01 - 11/01
Disease Management Portfolio – 2002
• Outsourced DM
– original 4 outsourced: CHF, CAD/stroke, ESRD, COPD
– launching commercial Oncology DM
– design “middle tier” diabetes pilot
– pursue pediatric asthma
– reconsider rare disease medley
– maximize appropriate, early provider referrals
– promote successful programs to capitated providers
– increase penetration in non-capitated provider groups
– implement DM programs for PPO, ASO business
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Disease Management Portfolio – 2002
• Insourced DM
– Frail members
– End of Life members
– selective catastrophic case management
– comorbid, EOL patients from outsourced DM programs
– maximize appropriate, early provider referrals
– integrate workflow with outsourced vendors
– pre-catastrophic case management as predictive
modeling allows (DCG, RxGroups, ACG, CRG, CRxG,
Ingenix, Medical Scientists, M&R, RxSols)
– combine predictive modeling with HRA stratification
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Disease Management Portfolio – 2002
• Apply DM learnings to other outsourced service
providers
– Hospitalist contracting for in-pt. care management,
ER intervention
– neonatal/NICU management
• Improve integration – across comorbidities, vendors
and PHS, providers
• Subject our DM performance to rigorous challenges
– CMS Disease Management Demonstration Program
– CMS PPO Demonstration Program
– external validation of savings methodology
– external audits of DM capabilities, effectiveness
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Double-Barreled Approach – CAD
CAD Programs
Lower Risk
Population-based
Case-based
Taking Charge of Your
Heart HealthSM
DM vendor
Includes all members
with CAD
Evidence-based
management of CAD
Member and Provider
Interventions
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Higher Risk
Member Testing, Provider
Intervention
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Triple-Barreled Approach – Diabetes
Diabetes Programs
Low Risk
Population-based
Moderate Risk
High Risk
Case-based*
Case-based
Taking Charge of
DiabetesSM
1 DM vendor
4 DM vendors
Includes all members
with diabetes
Diabetics with worst
control, highest risk,
readiness to change
Manage diabetesrelated end-organ
conditions
Member and Provider
Interventions
Intensive Member
Case Management
Coronary artery disease
Congestive heart failure
End-stage renal disease
*pilot program in negotiation
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Newest DM Program – Cancer
• Why cancer?
– Shortage of medical oncologists (cancer doctors), all
“too busy”
– MDs unfamiliar with oversight of total patient care
– Technical, sophisticated treatment emphasized over
education, empathy, preparation for end of life
– MDs tend to use most convenient setting for them, not
the patient
– Difficulty discussing, dealing with death
– Futile and unwanted treatment not uncommon within
commercial populations
– Preparation for end of life is variable, late, or neglected
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What’s Different about Cancer DM?
< 1 Month
Diagnosis
Traditional
Practice
Primary Treatment
(Futile Treatment)
(Unwanted Treatment)
Curative Anticancer Treatment
End-of-Life
Palliative Care
Pain
Management
Diagnosis
Cancer DM
Approach
End-of-Life
Curative
Anticancer
Treatment
Anticancer
Treatment
Psychosocial
Counseling
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Primary
Treatment
Hospice
Referral
Palliative
Care Care
Palliative
Pain
Cancer
Advanced
Management
Rehabilitation
Care
Planning
Nutrition
Fatigue
Services
Management
Hospice
Referral
Ongoing
Symptom
Management
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Today – Full Service Health Management
HEALTH IMPROVEMENT


DISEASE MANAGEMENT







HEALTH MANAGEMENT
Population-based
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Case-based
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Member Continuum
Disease Management – “Baked Into” Our...
• Brand Promise
• Quality Initiatives
• HEDIS Performance
• NCQA Accreditation
• Medical Management
Catastrophic
Special
Populations
Chronically Ill
Acutely Ill
Well
• Member, Provider Satisfaction
• Competence/Achievement Culture
• Financial Performance & Membership Growth
27
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