1 gordon norman, md, mba vp, health care quality.…a health and consumer services company making...
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Gordon Norman, MD, MBAVP, Health Care Quality
.…a health and consumer services company making people’s lives better
Disease Management
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DISEASE MANAGEMENTHEALTH IMPROVEMENT
Pre-2000 Era
Population-based
Pre-CY2000 – DM Behind “Veil Of Capitation”
.…a health and consumer services company making people’s lives better
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DISEASE MANAGEMENTHEALTH IMPROVEMENT
Post-2000 Era
HEALTH MANAGEMENT
Post-2000 Era
Population-based Case-based
Post-CY2000 – Risk Shift = Paradigm Shift
.…a health and consumer services company making people’s lives better
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Catastrophic Care Management Complex case management
Special Population CareFrail members, ER frequentusers, Pre-catastrophic care, Terminally ill members
Chronic Disease ManagementCHF, CAD/stroke, COPD, ESRDDiabetes, Depression, AMI
Acute Episode ManagementIn-/Out-pt. Medical ManagementTransitional, Continuity of Care
Preventive Health ManagementPreventive care/Risk reductionHealth improvement, Member
education
CatastrophicCatastrophic
Special Special PopulationsPopulations
Chronically Ill Chronically Ill
Acutely IllAcutely Ill
WellWell
Me
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Co
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.…a health and consumer services company making people’s lives better
“Disease Management” – Spectrum Of Needs
5 .…a health and consumer services company making people’s lives better
Origins of a Bedday
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ClassicBD/K Mgt.
.…a health and consumer services company making people’s lives better
Classic Utilization Management – ALOS Focus
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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
.…a health and consumer services company making people’s lives better
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Daily Census – PCC, PHS
.…a health and consumer services company making people’s lives better
MedicareCommercialEnterprise
606
707 713
673
652
680 675
696687
642656
666 663651
676
626
662
636
689
722733
550
600
650
700
750
1/4
1/11
1/18
1/25 2/1
2/8
2/15
2/22 3/1
3/8
3/15
3/22
3/29 4/5
4/12
4/19
4/26 5/3
5/10
5/17
5/24
California
309
326 329
346
386
374 371
343
329
371 368359
379
368 367
349 350346 347
336
397
300
325
350
375
400
425
1/4
1/11
1/18
1/25 2/1
2/8
2/15
2/22 3/1
3/8
3/15
3/22
3/29 4/5
4/12
4/19
4/26 5/3
5/10
5/17
5/24
Enterprise
1,733
1,657
1,5171,560
1,530
1,4591,500
1,5811,559
1,4481,4351,4251,4321,4301,4241,469
1,4141,414
1,3141,338
1,314
1,200
1,300
1,400
1,500
1,600
1,700
1,800
1/4
1/11
1/18
1/25 2/1
2/8
2/15
2/22 3/1
3/8
3/15
3/22
3/29 4/5
4/12
4/19
4/26 5/3
5/10
5/17
5/24
California
488
405
356
391
424 419
460 458
411423
409
388403
422430
398387
355369
382
421
300
350
400
450
500
1/4
1/11
1/18
1/25 2/1
2/8
2/15
2/22 3/1
3/8
3/15
3/22
3/29 4/5
4/12
4/19
4/26 5/3
5/10
5/17
5/24
\
Membership-adjusted, Seasonally-adjusted Average Daily Census Budget
Actual AverageDaily Census
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ERER
Hippocratic Oath: “primum non nocere”Division of clinical roles, responsibilitiesRescue ethos: active over passive mgt.Little time for discharge planningLegal risks (COBRA, EMTALA)Clinical uncertainty of dx, pxUncertainty of patient F/UFinancial reimbursementFamily/caregiver anxietyDiscretionary gray zoneLimited clinical historyPatient expectationsRelative time, effortHospital economicsPatient advocacyMalpractice riskConvenienceLiability riskHabit
Easy out-pt. coordinationPrimary care continuity
Member disincentivesDiversion alternativesSocial work resourcesHospitalist incentives
Family expectationsQuick, easy HH svcsAvailable SNF beds
24 hr. observationFull hospital beds
Onsite RN triageDSS, protocolsDischargeDischarge AdmitAdmit
Lesson: it’s often too late by the time the member is in ER – avoiding the slippery slope requires upstream medical management
Lesson: it’s often too late by the time the member is in ER – avoiding the slippery slope requires upstream medical management
.…a health and consumer services company making people’s lives better
ER – Slippery Slope to Hospital Admission
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UpstreamBD/K Mgt.
.…a health and consumer services company making people’s lives better
Upstream Medical Management – Admits/K Focus
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California 1999 Commercial Top 5% Cost Members Summarized by Disease
Disease Paid Paid PMPM % of Paid Cumm %% of Total
Paid Cumm %ALL OTHER $21,704,015 $618.28 22.9% 22.9% 16.5% 16.5%CANCER $14,761,009 $1,806.95 15.6% 38.5% 11.2% 27.7%COPD $13,517,550 $1,566.71 14.3% 52.8% 10.3% 37.9%CAD/STROKE $12,478,244 $1,208.78 13.2% 66.0% 9.5% 47.4%GASTROIN $7,816,471 $758.14 8.3% 74.3% 5.9% 53.3%ESRD $7,784,755 $6,969.34 8.2% 82.5% 5.9% 59.2%ARTHRITS $4,959,525 $501.01 5.2% 87.7% 3.8% 63.0%CHF_1 $3,575,329 $2,019.96 3.8% 91.5% 2.7% 65.7%DEPRESSN $2,678,225 $561.94 2.8% 94.3% 2.0% 67.7%RARE_DZ $2,254,391 $2,314.57 2.4% 96.7% 1.7% 69.4%DIABETES $1,601,938 $756.34 1.7% 98.4% 1.2% 70.7%ASTHMA $1,502,728 $762.42 1.6% 100.0% 1.1% 71.8%
$94,634,180
Pareto Analysis – Top 5% Most Costly Members
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• 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
• 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
.…a health and consumer services company making people’s lives better
Disease Management – Sourcing Preferences
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• 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)
DM Opportunity Analysis – Conclusions
.…a health and consumer services company making people’s lives better
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$0
$500
$1,000
$1,500
$2,000
$2,500
Pai
d P
MP
M
Enrolled Not Enrolled
Baseline Intervention
Congestive Heart Failure – California
0
2000
4000
6000
8000
10000
Day
s P
TM
PY
Enrolled Not Enrolled
Baseline Intervention
$0
$500
$1,000
$1,500
$2,000
Pai
d P
MP
M
Enrolled Not Enrolled
Baseline Intervention
0
2000
4000
6000
8000
10000
Day
s P
TM
PY
Enrolled Not Enrolled
Baseline Intervention
SHNet Savings $6.3M
CONet Savings $2.3M
-55% 0%
-62% -10%
-51% 1%
-49% -11%
Baseline Period: 12/1/99 - 11/30/00 Intervention Period: 12/1/00 - 11/30/01
Mem Mos11,741 66,297
1,069 6,408 Mem Mos
11,741 66,297
1,069 6,408
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Chronic Obstructive Pulmonary Disease – California
0
2000
4000
6000
8000
Day
s P
TM
PY
Enrolled Not Enrolled
Baseline Intervention
$0
$400
$800
$1,200
$1,600
Pai
d P
MP
M
Enrolled Not Enrolled
Baseline Intervention
-37% -4% -28% -3%
Baseline Period: 4/1/00 - 3/31/01 Intervention Period: 4/1/01 - 11/30/01
SHNet Savings $2.9M
Mem Mos11,395 15,815 11,395 15,815
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End Stage Renal Disease – California
0
2000
4000
6000
8000
10000
12000
14000
Day
s P
TM
PY
Disease Population
Baseline Intervention
$0
$1,000
$2,000
$3,000
$4,000
$5,000
Pa
id P
MP
M
Disease Population
Baseline Intervention
0
2000
4000
6000
8000
Da
ys
PT
MP
Y
Enrolled
Baseline Intervention
$0
$1,000
$2,000
$3,000
$4,000
$5,000
Pa
id P
MP
M
Enrolled
Baseline Intervention
-26% -8%
-43% 8%
Baseline Period: 4/1/00 - 3/31/01 Intervention Period: 4/1/01 - 11/30/01
SHNet Savings $0.7M
CONet Savings ($0.4M)
Mem Mos4,238
Mem Mos875
4,238
875
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0
5000
10000
15000
20000
25000
Day
s P
TM
PY
Enrolled Not Enrolled
Baseline Intervention
$0
$1,000
$2,000
$3,000
$4,000
$5,000
Pai
d P
MP
M
Enrolled Not Enrolled
Baseline Intervention
-29% -1% -17% 0%
Frail Member Care – PCC
0
5000
10000
15000
20000
25000
30000
Day
s P
TM
PY
Enrolled Not Enrolled
Baseline Intervention
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
Pai
d P
MP
M
Enrolled Not Enrolled
Baseline Intervention
-10% -8% -16% 4%
Baseline Period: 11/99 - 10/00 Intervention Period: 11/00 - 11/01
SHNet Savings $4.8M
CO Net Savings $0.4M
Mem Mos5,121 13,654
1,072 2,228 Mem Mos
5,121 13,654
1,072 2,228
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End of Life Care – PCC
0%
5%
10%
15%
20%
25%
30%
% In
-pt.
Dea
thss
Enrolled Not Enrolled
Baseline Intervention
$0
$5,000
$10,000
$15,000
$20,000
Pai
d p
er D
eath
Enrolled Not Enrolled
Baseline Intervention
-24% 12% -6% 1%
Baseline Period: 1/00 - 12/00 Intervention Period: 1/01 - 11/01
SH
Mem Mos579 8,241 579 8,241
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• 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
.…a health and consumer services company making people’s lives better
Disease Management Portfolio – 2002
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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
.…a health and consumer services company making people’s lives better
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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
.…a health and consumer services company making people’s lives better
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CAD Programs
Population-based Case-based
Taking Charge of Your Heart HealthSM
Evidence-based management of CAD
DM vendor
Includes all members with CAD
Member and Provider Interventions
Member Testing, Provider Intervention
Lower Risk Higher Risk
.…a health and consumer services company making people’s lives better
Double-Barreled Approach – CAD
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Diabetes Programs
Population-based Case-based
Taking Charge of DiabetesSM
Coronary artery diseaseCongestive heart failureEnd-stage renal disease
Manage diabetes-related end-organ conditions
4 DM vendors
Includes all members with diabetes
Member and Provider Interventions
Case-based*
Intensive MemberCase Management
Diabetics with worst control, highest risk, readiness to change
1 DM vendor
Low Risk Moderate Risk High Risk
*pilot program in negotiation.…a health and consumer services company making people’s lives better
Triple-Barreled Approach – Diabetes
24 .…a health and consumer services company making people’s lives better
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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Fatigue Management
Anticancer Treatment
Palliative Care
Diagnosis Primary Treatment
End-of-Life
Psychosocial Counseling
Nutrition Services
Pain Management
Cancer Rehabilitation
Advanced Care
Planning
Hospice Referral
Ongoing Symptom
Management
Cancer DM
Approach
Cancer DM
Approach
Curative Anticancer TreatmentCurative Anticancer Treatment
Palliative CarePalliative Care
Traditional Practice
Traditional Practice Palliative CarePalliative Care
-End-of-Life
< 1 Month
Curative Anticancer TreatmentCurative Anticancer Treatment
Pain
Management HospiceReferral
Diagnosis Primary Treatment
(Futile Treatment)
(Unwanted Treatment)
What’s Different about Cancer DM?
.…a health and consumer services company making people’s lives better
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DISEASE MANAGEMENTHEALTH IMPROVEMENT
HEALTH MANAGEMENT
Population-based Case-based
Today – Full Service Health Management
.…a health and consumer services company making people’s lives better
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Disease Management – “Baked Into” Our...
• Brand Promise
• Quality Initiatives
• HEDIS Performance
• NCQA Accreditation
• Medical Management
• Member, Provider Satisfaction
• Competence/Achievement Culture
• Financial Performance & Membership Growth
CatastrophicCatastrophic
Special Special PopulationsPopulations
Chronically Ill Chronically Ill
Acutely IllAcutely Ill
WellWell
Me
mb
er
Co
nti
nu
um
.…a health and consumer services company making people’s lives better