Managed Care Models for ABD Populations

16 Pages·2007·1.84 MB·English

Managed Care Models for ABD
Populations: Identification,
Stratification and Care
Coleen Kivlahan, MD, MSPH
Schaller Anderson, Inc.
CHCS Medicaid Best Buys Webcast
Tuesday, May 29, 2007
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SA’s Complex and ABD Members
Arizona: 8,524 LTC; 41,000 ABD; 11,000

HCG (high risk pool); 13,000 SNP
California: 66,000 TANF and ABD children

Delaware: 9,000 ABD

Maryland: 12,300 ABD

Total = More than 100,000 members
 (March
2007 data)
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Annual Claim Costs by Percentile
(Medicare vs. Commercial vs. Medicaid)
$70,000
$60,000
$50,000
s
t
s
o
C
$40,000
a
t
i
p
a
C

re $30,000
P
$20,000
$10,000
$-
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%
Percentile of Medicaid Members
Medicare Medicaid-ABD Commercial Medicaid-TANF
Avg. Medicare Avg. Medicaid-TANF Avg. Comm 3
ABD High Utilizer
in the Traditional Insurance Model
No PCP or medical home
1.
Uses ER for primary care
2.
Little to no information passing between ER, inpatient
3.
setting and care manager
No way to identify her as high utilizer and inform
4.
interventions
No concurrent review, only retrospective review
5.
No prior authorization for key procedures
6.
Lack of integration of pharmacy, lab or BH data
7.
Limited intensive care management
8.
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More than Half of People with Serious Chronic
Conditions* Have Three or More Physicians
No Physicians 3%

1 Physician 6%

2 Physicians 26%

3 Physicians 23%

4 Physicians 5%

5 Physicians 6%

6+ Physicians 11%

• People with serious chronic conditions have a condition that is expected to last a year or more,
requires ongoing medical attention, and limits what one can do. Serious chronic conditions are a
subset of chronic conditions, which are also expected to last a year or more but limit what one can do,
and/or may require ongoing medical care. Source: Serious Chronic Illness Survey, conducted by the
Gallup Organization, 2002.
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Physicians Believe that Poor Care
Coordination Produces Poor Outcomes
Percent of Physicians Who Believe That Poor Outcomes Result From Poor Care Coordination
Receipt of Contradictory
Information 54%
Unattended Emotional Problems
49%
Adverse Drug Interactions
44%
Unnecessary Hospitalization
36%
Patients Not Functioning to
Potential 34%
Experience of Unnecessary Pain
34%
Unnecessary Nursing Home
Placement 24%
0% 10% 20% 30% 40% 50% 60%
Source: National Public Engagement Campaign on Chronic Illness—Physician
Survey, conducted by Mathematica Policy Research, Inc., 2001. 6
Our Predictive Modeling tool includes:
 Predictive Risk Score – Multiple factors, including the Medicaid Rx, a pharmacy based
risk adjustment tool, are used.
 Chronic Care Risk Stratification -- Members are stratified on the basis of their
compliance or adherence to program goals and outcomes, and ranked by the risk of future
avoidable costs that each enrollee represents.
 Co-morbidity -- Each member is assigned additional algorithm weight if a significant co-
morbid condition is identified. Predictive Pathways uses the Charlson Index to identify and
apply additional diagnostic weight for those conditions having significant morbidity
implications.
 Impact Rating -- A member’s primary condition is assessed and scored based on the
possible level of impact from care management on the member’s financial and clinical
outcomes.
 12-Month Claims Cost -- A rolling 12 months of claims cost (pharmacy, medical, DME,
procedures, lab, etc) (excluding trauma and maternity) is calculated. Cost is stratified into
high-cost, moderate and low-cost enrollees, with higher weights given to those members
having higher accumulated costs.
 Care Gaps -- The presence or absence of evidence-based effective interventions for each
of the four conditions in disease management: CHF, COPD, Diabetes and asthma.
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It should also include:
Self-report data (HRA)

Functional status

QOL indicators

Social and behavioral indicators

Cognitive markers

Biomarkers

Pharmacy adherence measures for key

meds
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Predictive Modeling Ranks for all Members:
sorted by ABD population
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47-year-old with CHF, diabetes,
schizophrenia: 23 ER visits, no PCP
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