critical outcomes report analysis may 2008. agenda some logistics overview of why reports are wrong...
TRANSCRIPT
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Critical Outcomes Report Analysis
May 2008
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Agenda
• Some Logistics• Overview of why reports are wrong and
how to fix them– This will help somewhat in reading them and
in contracting for DM but critical outcomes report analysis is about learning how to read these things generally
• Sample Questions• The Test
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Logistics
• You can then either “officially” take the test or not.– There is no downside to taking it except that you can’t take it again
for 6 months
• If you don’t want to take the test, you can either “play along at home” or if there is a group which wants to work together on the questions you can do that
• Or, you can go to the ROI precon next door (about 20% overlap in my slides)
• You can’t take the test home with you. You can request the non-test portion of the slides via email to [email protected] or visit the website www.dismgmt.com and hit “contact us.”
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If you pass…
• You may apply for individual certification for $500 for two years. You get listed on the DMPC website (see next page) announced on the listserve, and may be used as a professional credential– You will also be much better at reading these
reports.
• Corporate certification is $2000
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Beginning of List on Website
Individual Corporate Affiliation (note: Boldface indicates Corporate Certification in addition to individual)
Ed Baas
HealthMedia, Inc.
Steve Bennett
HealthMedia, Inc.
David Brumley MD
Blue Cross of Massachusetts
John Charde MD
Enhanced Care Initiatives, Inc.
Brian Doran
Quantum Health Inc.
Laurie Doran
Boston Medical Center Health Plan
Thomas Hawkins
Blue Cross of Massachusetts
Sharon Hewner
Independent Health Plan
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Overview of Why Reports are wrong and how to fix them and be a
hero to your organization…
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…Rather than rely on others for your measurement
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Reasons Why Reporting is often Wrong
• Look at these “checks and balances,” and ask yourself, why aren’t you already doing this in contracts with your vendor?
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Plenty of Other Reasons too
These Reasons
Other Reasons
Slice 3
Slice 4
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Without further ado, three reasons reports are wrong: The Following don’t get done
(except by DMPC-Certified Payors)• The Dummy Year Analysis
– The exact same methodology applied to a year in which you did not have disease management
• Plausibility Testing
• Critical Outcomes Report Analysis
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Dummy Year Analysis
• Most contracts have a baseline period to which a contract period is compared (adjusted for trend)– Raise your hand if you don’t
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Dummy Year Analysis
• Most contracts have a baseline period to which a contract period is compared (adjusted for trend)– Hand-raising time
• Watch what happens when you have a baseline and then compare a contract period (adjusted for trend)– Just the analysis, no program
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In this Dummy Year Analysis example
• Assume that “trend” is already taken into account
• Focus on the baseline and contract period comparison
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Base Case: Example from AsthmaFirst asthmatic has a $1000 IP claim in 2005
2005(baseline)
2006(contract)
Asthmatic #1 1000
Asthmatic #2
Cost/asthmatic
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Example from AsthmaSecond asthmatic has an IP claim in 2006 while
first asthmatic goes on drugs (common post-event)
2005(baseline)
2006(contract)
Asthmatic #1 1000 100
Asthmatic #2 0 1000
Cost/asthmaticWhat is the
Cost/asthmaticIn the baseline?
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Cost/asthmatic in baseline?
2005(baseline)
2006(contract)
Asthmatic #1 1000 100
Asthmatic #2 0 1000
Cost/asthmatic $1000Vendors don’t count #2 in 2005 bec. he can’t be found
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Cost/asthmatic in contract period?
2005(baseline)
2006(contract)
Asthmatic #1 1000 100
Asthmatic #2 0 1000
Cost/asthmatic $1000 $550
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Base Case: How Dummy Year Analysis (DYA) fixes it
2005(baseline)
2006(contract)
Asthmatic #1 1000 100
Asthmatic #2 0 1000
Cost/asthmatic
$1000 $550
In this case, a “dummy population” falls 45% on its own without DM
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So…
• If you were to do an asthma program the vendor should not get credit for the reduction that happens anyway– But they do– How do we know that? With a plausibility test,
to be discussed later– First, some real-world Dummy Year Analyses
(DYAs)
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DYA real-world Result: Excerpt from Regence Blue Cross-DMPC study for
Health Affairs released recentlyRTM Example: Sickest 6% Patients PMPY
Identified by Predictive Model
$-
$5,000
$10,000
$15,000
$20,000
$25,000
2004 costs 2005 costs 2005 inflationexpectation
Per
Mem
ber
Per
Yea
r
regressionto mean
expected by 10% inflation
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DYA Result By Disease (using 1-year baseline and standard DMPC algorithms) –
what is the difference which is caused automatically by just trending forward?
0
20
40
60
80
100
120
asthma CAD diabetes CHF
Old baseline indexedto 100
Taking out regressionto the mean with DYA
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DYA Result in Wellness
0
10
20
30
40
50
60
First Measure SecondMeasure
High-RiskLow-Risk
Source: Ariel Linden – citationOn request
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There was no program in this case – just two samplings and the average stayed the same
0
10
20
30
40
50
60
First Measure SecondMeasure
High-RiskLow-Risk
Source: Ariel Linden – citation on request
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Other evidence for Dummy Year Analysis (DYA)
• CMS studies – very carefully designed -- get results opposite those done without DYAs, and consistent with those done with DYAs
• Most Vendors oppose DYAs (and they aren’t in the DMAA guidelines)
• ROIs without DYA adjustment flunk plausibility testing…
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Reason #2
• The Dummy Year Analysis
• …Plausibility Testing
• Critical Outcomes Report Analysis
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What is a plausibility test?
• You do it all the time…outside DM• An easy way to directionally check results• Measure total event rates for diseases being
managed, like you’d measure a birth rate. Couldn’t be easier– Ask me for the specific directions. They’re free from
DMPC (and now DMAA). See next page
• Example from previous asthma hypothetical
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Event rates tracked by disease: the Plausibility Indicators
Disease Program Category ICD9s (all .xx unless otherwise indicated)
Asthma 493.xx (including 493.2x[1])
Chronic Obstructive Pulmonary Disease 491.1, 491.2, 491.8, 491.9,. 492, 494, 496, 506.4
Coronary Artery Disease (and related heart-health issues)
410, 411, 413, 414
Diabetes 250
Heart Failure 428, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 425.0, 425.4
[1] 493.2x is asthma with COPD. It could fit under either category but for simplicity we are keeping it with asthma
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Cost/asthmatic in contract period?
2005(baseline)
2006(contract)
Asthmatic #1 1000 100
Asthmatic #2 0 1000
Cost/asthmatic $1000 $550
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Asthma events in the payor as a whole
2005(baseline)
2006(contract)
Asthmatic #1 1000 100
Asthmatic #2 0 1000
Inpatient events/year
1 1
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Plausible?
• How can you reduce asthma costs 45% without reducing planwide asthma event rate?
• Answer: You can’t. Not plausible
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Several Examples of Plausibility Analysis
• Pacificare
• Some which didn’t turn out so well
• Plausibility-testing generally and benchmarks
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PacifiCare HF Results
Enterprise Commercial Shared Risk CHF
0.00
0.20
0.40
0.60
0.80
I-2 I-1 I I+1 I+2
Intervention Time Period
IP C
ost
Equi
vale
nt
-20%
-10%
0%
10%
20%
30%
Perc
ent
Chan
ge
IP Cost Equivalent Year over Year % change
Enterprise Secure Horizons Shared Risk CHF
15.0016.0017.0018.0019.0020.0021.00
I-2 I-1 I I+1 I+2
Intervention Time PeriodIP
Cos
t Eq
uiva
lent
-30%
-20%
-10%
0%
10%
Perc
ent
Chan
ge
IP Cost Equivalent Year over Year % change
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Several Examples of Plausibility Analysis
• Pacificare
• Some which didn’t turn out so well
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Example of just looking at Diagnosed people: Vendor Claims for Asthma Cost/patient Reductions
-25%
-20%
-15%
-10%
-5%
0%
1st year 2nd year
ER ER
IP
IP
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What we did to plausibility-test…
• We looked at the actual codes across the plan
• This includes everyone
• Two years of codes pre-program to establish trend
• Then two program years
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Baseline trend for asthma ER and IP Utilization 493.xx ER visits and IP stays/1000 planwide
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
1999(baseline)
2000(baseline)
ER ER
IP IP
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Expectation is something like…493.xx ER visits and IP stays/1000 planwide
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
1999(baseline)
2000(baseline)
2001 (study)2002 (study)
ER ER ER ER
IP IP IP IP
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Plausibility indicator Actual: Validation for Asthma savings from same plan
including ALL CLAIMS for asthma, not just claims from people already known about493.xx ER visits and IP stays/1000 planwide
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
1999(baseline)
2000(baseline)
2001 (study)2002 (study)
ER ER ER ER
IP IP IP IP
How could the vendor’s methodology have been so far off?
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We then went back and looked…
• …at which claims the vendor included in the analysis…
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We were shocked, shocked to learn that the uncounted claims on previously undiagnosed people accounted for virtually all the “savings”
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
1999(baseline)
2000(baseline)
2001 (study)2002 (study)
ER ER ER ER
IP IP IP IP
PreviouslyUndiagnosedAre aboveThe lines
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Is it fair…
• To count the people the vendor didn’t know about?
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You should be able to reduce visits in the known group by enough so that adding back the new group yields the reduction you claimed –
otherwise you didn’t do anything
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
1999(baseline)
2000(baseline)
2001 (study)2002 (study)
ER ER ER ER
IP IP IP IP
PreviouslyUndiagnosedAre aboveThe lines
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Applying Plausibility to Mercer presentation which found a “range” of possible savings in
Respiratory DM• Mercer’s view:
“Varying the methodology has a significant impact on the results” Results “somewhere in that range”
• Our View: There is only one right answer and a Plausibility test will point to it
$0
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
$7,000,000
LowEnd
HighEnd
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How Mercer could do a plausibility test on asthma
• Take two-three years of claims history in all primary-coded 493.xx claims for ER and IP
• Add together and divide by # of covered lives to get a rate
• Then Ask: What happens in the program year?
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Possible trend prior to program
0
0.5
1
1.5
2
2.5
3
3.5
2001 2002 2003 2004 2005 2006
Total # asthma ER/IPclaims/1000
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For the program to have saved $6-million, this indicator would have to plunge
(it didn’t)
0
0.5
1
1.5
2
2.5
3
3.5
2001 2002 2003 2004 2005 2006
Total # asthma ER/IPclaims/1000
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Let’s Macro-Plausibility-Test Wellness
• The Dummy Year Analysis
• Plausibility Testing– For Wellness
• Critical Outcomes Report Analysis
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Macro Plausibility for WellnessHere’s how you know wellness reports are inflated or
impossible
• Compare all these reported dramatic results in smoking cessation and weight loss to CDC statistics for the US as a whole– Even as most large (and many smaller)
companies are “producing” these results, obesity continues to climb and the drop in adult smoking rates has stalled
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October 26, 2006
Drop in Adult Smoking Rate StallsTHURSDAY, Oct. 26 (HealthDay News) -- The number of adult smokers in the United States did not change from 2004 to 2005, suggesting that the decline in smoking over the past seven years has stalled, a new federal report found.In 2005, 45.1 million adults, or 20.9 percent, were cigarette smokers – 23.9 percent of men and 18.1 percent of women. In addition, 2.2 percent of U.S. adults were cigar smokers and 2.3 percent used smokeless tobacco, according the report."After years of progress, what we are seeing is no change in adult prevalence of smoking between 2004 and 2005," said report author Terry Pechacek, the associate director for science at the U.S. Centers for Disease Control and Prevention's Office on Smoking and Health.
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Obesity Trends* Among U.S. AdultsBRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
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Obesity Trends* Among U.S. AdultsBRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
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Obesity Trends* Among U.S. AdultsBRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
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Obesity Trends* Among U.S. AdultsBRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
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Obesity Trends* Among U.S. AdultsBRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
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Obesity Trends* Among U.S. AdultsBRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
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Obesity Trends* Among U.S. AdultsBRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
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Obesity Trends* Among U.S. AdultsBRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
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Agenda
• Some Logistics• Overview of why reports are wrong and
how to fix them– This will help somewhat in reading them and
in contracting for DM but critical outcomes report analysis is about learning how to read these things generally
• Sample Questions• The Test
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Sample Question #1
• Look at each of these slides and both together to find major reporting concerns if any
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Table 1: Inpatient Impact of Program (Year One)
Disease Baseline IP days/1000
Program IP days/1000
Change
Asthma 996 747 -25%
CAD 1897 1391 -27%
CHF 9722 8581 -29%
COPD 2512 2151 -14%
Diabetes 1534 1522 -1%
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Table 2: Impact on Physician Visits
Disease Baseline MD visits/1000
Program MD Visits/1000
Change
Asthma 6990 5907 -15%
CAD 8829 8580 -3%
CHF 7876 7506 -5%
COPD 8481 8090 -4%
Diabetes 7927 7737 -2%
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What you might have noticed – first slide
• No plausibility test for very high utilization reduction
• Asthmatics don’t have 996 days per 1000– Not clear whether they are referring to days
per 1000 disease members or days per 1000 overall (either way, it’s wrong)
• Nor does CHF have so many days per 1000
• CHF days did not decline 29%
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Second slide, and both combined
• Ridiculously high number of doctor visits
• Doctor visits should be going up or staying the same, not going down– This suggests strongly that a DYA is needed
because they seem to have selected a high-using sample as a baseline
• No correlation between MD-intensity and IP-intensity of diseases
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Sample #2: Comment on these CHF measures
0%10%20%30%40%50%60%70%80%90%
2x/year MD visit
ACE Scripts
BUN Test
Creatinine test
Potassium Test
200320042005
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Sample #3: Improvement in Plan A of HEDIS Scores: Why is/isn’t
this a valid improvement?HEDIS EFFECTIVENESS OF CARE MEASURES
Commercial 2003 2004 2005
Controlling High Blood Pressure 62.2 66.8 68.8
Beta blocker after AMI 69.8 72.5 77.7
Diabetes: HbA1c Testing 84.6 86.5 87.5
Diabetes: Lipid Control (<100 mg/dL) 34.7 40.2 43.8
Medical Assistance with Smoking Cessation 68.6 69.6 71.2
Medicare 2003 2004 2005
Controlling High Blood Pressure 61.4 64.6 66.4
Beta blocker after AMI 92.9 94 93.8
Diabetes: HbA1c Testing 87.9 89.1 88.9
Diabetes: Lipid Control (<100 mg/dL) 41.9 47.5 50
Medical Assistance with Smoking Cessation 63.3 64.7 75.5
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Asthma Plausibility Test
Baseline vs PY01
Program Year
Baseline PY01 Variance
Net Paid $6,671,855 $9,656,959 44.7%
Events 3,416 4,346 27.2%
Days 3,875 5,183 33.8%
Risk MM's 874,878 1,245,783 42.4%
PMPM $7.63 $7.75 1.6%
Events / 1000 46.85 41.86 -10.7%
Days / 1000 53.15 49.93 -6.1%
Cost / Day $1,722 $1,863 8.2%
Sample #4: Does this one pass the Sniff test?
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Sample #5: Does this pass the sniff test for diabetes?
Disease Management Conditions
0.6%0.9%
1.5% 1.4%
Percent of TotalBenefits Paid
Percent of TotalEpisodes
Actual
Expected
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Sample #6 small group bid
• Comment on this bid for a group of 80,000 people
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Cost/case assumptions as follows: prevaenceasthma 2,500$ 3.0%cad 7,000$ 1.0%chf 22,000$ 0.2%copd 14,000$ 0.3%diabetes 8,000$ 2.2%
6.7%Total DM vendor DM FeesYear 1 $4,959,800 multiplied by 80000 people
equals: total spending by disease OPT-OUTGross $ savings PER MONTH
asthma 6,000,000$ Year 1 $12,513,308 cad 5,600,000$
chf 3,520,000$ copd 3,360,000$ diabetes 14,080,000$
Net $ savings 32,560,000$ total chronic spend
Year 1 $7,553,508
ROI 2.5 x
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Agenda
• Some Logistics• Overview of why reports are wrong and how to
fix them– This will help somewhat in reading them and in
contracting for DM but critical outcomes report analysis is about learning how to read these things generally
• Sample Questions• Break • The Test
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Test Overview
Answer each question by number by saying what’s wrong or indicating that it can be concluded, based on the data provided, that nothing major is obviously wrong. Keep it concise. Don’t just automatically say no DYA or plausibility test
Scoring:3 points for each item found which DMPC missed2 points for each major item found1 point for each minor item and watch-out found0 points for each item where there was none -1 point for each item found which were really OK enough
to be plausible but which were identified
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Answer Sheet (if you are taking the test and want to be scored)
• Name_____________
• Organization_____________
• Email________________
• Phone_______________
Make sure to number each question and put the sheets in order on top of this oneAnd just in case they get separated put your NAME or identifier on each page. Then clip them together at the end using the handy clip provided
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Question 1 – comment on this website
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Question #2
• In the following example, utilization figures were multiplied by the (assume to be correct) cost figures to get a savings– Note that the savings is the difference
between the two bars
• Assume (correctly) no other changes were talking place
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Savings by Category of Utilization per 1000 members per month (2004 vs. 2003)
(note: The difference between the bars is the savings)
$0
$500
$1,000
$1,500
$2,000
$2,500
IPAdmits
ERVisits
OPFacility
MDVisits
Drug Other
2003
2004
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Question 3
• Assume on the next slide that the admission reductions are calculated validly and are the result of the program
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Question #3: Comment on the plausibility of this Cigna report (assume a reasonable valid methodology was used
to calculate admission reduction)
Disease Category
All-cause Admission Reduction per disease member
All-cause Claims Cost Reduction per disease member
Asthma 2% 12%
cardiology 5% 15%
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Question 4
• Comment on the Indiana Medicaid results
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Indiana MedicaidCHF Study Group vs. Usual Care
$0
$500
$1,000
$1,500
$2,000
$2,500
Overall High Risk Low Risk
Per
CH
F P
erso
n p
er m
on
th
Total N = 186
Issue-Spotter #4: What is wrong with this slide
Overall savings of $758 PMPM
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Question #5
• Comment on these results reported to a major employer (assume here as in all cases that low-risk and high-risk sum to the total managed population AND that these are asthma-specific changes)
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AsthmaHospital Days and Admissions
0
100
200
300
400
500
600
700
per 1
000
mem
bers
Baseline 223 656 186
Reporting 114 197 107
HMO total High Risk Low Risk
-48%
-70%
-43%0
20
40
60
80
100
120
140
per 1
000 m
embe
rsBaseline 77 131 72
Reporting 33 115 26
HMO total High Risk Low Risk
DAYSADMISSIONS
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Question #6
• The next two slides with all-in admissions and ER visits are from the same payor, same study – Find a major issue(s) which invalidates the
result or indicate that the result is probably reasonably valid
• “R#1” and “R#2” refer to reporting periods of one year each
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CHF Group #1Emergency Room Visits/Year
0
1,000
2,000
3,000
4,000
5,000
6,000
per
1000 m
em
bers
Baseline 3,081 4,940 2,526
R#1 2,739 4,366 2,254
R#2 2,801 4,918 2,169
HMO total High Risk Low Risk
Total N = 1166 High Risk N = 268 Low Risk N = 898
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CHF Group #1Inpatient Admissions/Year
0
100
200
300
400
500
600
per
1000 m
em
bers
Baseline 350 494 252
R#1 273 478 195
R#2 280 491 216
HMO total High Risk Low Risk
Total N = 1166 High Risk N = 268 Low Risk N = 898
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CHF Group #1Inpatient Admissions/Year
0
100
200
300
400
500
600
per 1
000 m
embe
rsBaseline 350 494 252
R#1 273 478 195
R#2 280 491 216
HMO total High Risk Low Risk
Total N = 1166 High Risk N = 268 Low Risk N = 898
0
1,000
2,000
3,000
4,000
5,000
6,000
per 1
000
mem
bers
Baseline 3,081 4,940 2,526
R#1 2,739 4,366 2,254
R#2 2,801 4,918 2,169
HMO total High Risk Low Risk
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Question #7
• Find the mistake(s) if any (assume inflation adjustment is done correctly)
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Pre-post comparison: Asthma Medicaid Disabled Population
Baseline Period 1/03-12/03 paid through 6/30/04
Study Period 1/04-12/04, paid through 2/28/05
Member-months
15047 31884
PDMPM $432 $391
Gross savings & ROI
$2,400,125
2.72 – to -1
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Question #8
• Comment on multiple issues on the following two slides representing the same study. Notes:– “Core Conditions” are the sum of the conditions above
the line– “Extended Conditions” are managed conditions other
than the Core Conditions– “Care Support” is disease managed group– Under each of the 3 categories, the two columns are
comparisons between the baseline and reporting periods for the study and concurrent control groups
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Cohort Study Results (all claims, all members)
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ROI and PMPM reductions at 6 Months
• Reporting Period – July - December 2002
• Base Period – July - December 2001
• Total ROI 2.48 : 1– Extended Conditions
4.23 : 1– Core Conditions
1.86 : 1
• “Our Auditors validated a $42 PMPM reduction due to this program”
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Combined
• Reporting Period – July - December 2002
• Base Period – July - December 2001
• Total ROI 2.48 : 1– Extended Conditions 4.23
: 1– Core Conditions 1.86 : 1
• Auditors validated a $42 PMPM savings
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Sidebar Note
• Even though the previous slides were published I am not using the name because it wouldn’t be fair to the health plan which has subsequently dramatically improved its methodology(ies)– So if you recognize it don’t hold it against
them. They would win a “most improved measurement” award
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Question 9
• Comment on the likely validity of the following slide
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Program Year One – Clinical IndicatorsProgram Year One – Clinical Indicators
Clinical Outcomes:
Base Post Year 1 Improvement
% of CHD Members with an LDL screen 75.0% 77.0% 2.0%
% of CHD Members with at least one claim for a Statin 69.0% 70.5% 1.5%
% of CHD Members receiving an ACE inhibitor or alternative 43.5% 44.7% 1.2%
% of CHD Members post-MI with at least one claim for a beta-blocker
0.89 0.89 0.0%
Hospitalizations/1,000 CHD Members for a primary diagnosis of Myocardial Infarction*
47.60 24.38 -48.8%
*measure based on total membership, not just "continuously enrolled" membership
Percentage of Continuously Enrolled Members
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Question #10
• Comment on the following slide – CAD disease management program
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Top Ten 2003 Diagnoses—admissions per 100 Cardio Disease Management Members
(pre- and post-DM – savings is difference)“Symptoms” really is a nICD9 code
0
50
100
150
200
250
300
350
Angina
Sympto
ms
CAD
Dorsopat
hies
Hyperte
nsion
Arthro
pathie
s
persons
without r
eporte
d Dx
Oth
er m
etab
olic
rheu
amtis
m, e
xcl.
back
2003--pre
2004--post
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Question 11—Comment on CT Medicaid Current RFP
• May be a little hard to read
• I will display on Word
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APPENDIX XII – Disease Management Data
Cardiovascular disease (cardiology, vascular diseases, vascular surgery, and Cardiopulmonary) 346
Below data is for State Fiscal Year 2005-2006
The below information for recipients with the diagnosis specified. One recipient may have more than one diagnosis and so would be represented in more that one cell below.
Congestive Heart Failure ICD-9 428
Under 21 yrs of Age
Recipients Units of Service Amount Paid
Fee-for-Service 5 52 $709 HUSKY A 41 385 $13,630
21 yrs. or older Recipients Units of Service Amount Paid
Fee-for-Service 1,314 67,929 $793,970 HUSKY A 121 903 $33,608
Other Heart Disease Diagnosis (21 yrs or older) Fee-for-Service Recipients Units of Service Amount Paid Dysrhythmias 4,160 234,723 $3,077,251 current heart attack
904 194,390 $2,221,051
Hypertension 18,350 796,318 $10,233,495 Ischemic 6,863 425,910 $5,731,919 MCO Dysrhythmias 640 8,201 $418,374 current heart attack
73 12,487 $174,012
Hypertension 5,945 30,717 $845,856 Ischemic 851 18,320 $845,800
Services covered include many types of care from a hospital day to a fifteen-minute home health service. Excludes: Nursing Home Services and services to clients in Nursing Facilites the whole year.
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Question 12: Comment on this release
• IRVING, Texas--(BUSINESS WIRE)--Nov. 18 --A pediatric asthma disease management program offered by AdvancePCS saved the State of North Carolina nearly one-third of the amount the government health plan expected to spend on children diagnosed with the disease
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Question 13: Comment on validity of this statement by a major
commercial health plan• “Over a 10-year period, we have reduced
the rate of heart attacks by 5 per 100 people”