#esoutcomes19 1...pmpm savings opportunity summary: overall northeast mid-atlantic southwest member...

2© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19 2

MEASURE, MANAGE, MITIGATEHow Smarter Assessment Can Transform Risk into OpportunityLynne Nowak M.D. Vice President/General Manager, Clinical, Data & Provider Solutions

Chris Lehmuth Senior Director, Enterprise Data Science

3© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19

Data Governance, Architecture & Analytics

Clinical Quality, Performance &

Outcomes

Revenue & Expenses

Your challenges…


Director of Care & CaseManagement

Chief Information

Officer

ChiefFinancialOfficer

Our cast…

Chief Medical Officer &PharmacyDirector

BusinessDevelopment

Manager


HEALTHCARE DATA IS MESSY AND DISORGANIZED


CLEANSING, ENRICHING AND ORGANIZING DATA is essential to accurate and meaningful analytics


WE DELIVER ACTIONABLE INSIGHTS THAT SUPPORT YOUR GOALS


Demographics

Pharmacy claims

Med claims

Mobile

CM/DM

Lab results

Data Transformation

Data Logistics & Management (DL&M)

Data Enrichment

Advanced Insights

Machine Learning


HOW CAN I PLAN FOR WHAT’S AROUND THE CORNER?


329 HR 15 MIN

14 HR 1 MIN

2 HR 15 MIN

ST. LOUIS

•Relevant•Diverse•Reproducible

•Clean-up•Summary stats•Partition

•Response/Target•Bins/Logits•Non-linearity

•Stat Method•Training

•Assess on Held-out Data

•Choose threshold

•Production Code•Monitoring

Algorithm Development

PREDICT. VALIDATE. REFINE.

Obtain data

Analyze and organize

data

Identity and convert features

Chosen configuration

Test performance

Implement scores


Exposing Clinical and Financial Opportunities

$922K Expected annual savings from addressing ER overutilization

56.6% Non-compliance with LDL-C testing for patients with heart disease

49.8% Higher PMPM savings opportunity in Mid-Atlanticcompared to Northeast

TOP AREAS OF OPPORTUNITY

5. High Risk Pregnancy4. Diabetes Diagnosis1. Hip, Knee, Low back surgery 2. Primary Admissions 3. ER Overutilization

EXPECTED SAVINGS OPPORTUNITIES BY CATEGORY:

PMPM$8.62 MEMBER

REDIRECTION

PMPM$4.60 IMPACTABLE

GAPS IN CARE

PMPM$2.53 EMERGING

DISEASE ONSET

2,136 Commercial members w/high risk of developing diabetes

31.3% Non-adherence with statin use in patients with diabetes

INSIGHTS AND OPPORTUNITIES FOR FOCUS


Population level opportunity analysis by disease stateSTRATIFY BY CONDITION

RESPIRATORY

CARDIOVASCULAR

DIABETES

$$$

$1.50 $1.52

HbA1c TestingCompletion Rate

Appropriate TreatmentHypertension

Completion Rate

Total opportunity: $3.02 PMPM


Population level risk analysis by geography

$538 $507 $572

$642 $544

$512 $579 $523

$-

$100

$200

$300

$400

$500

$600

$700

-

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

PMPM

Sav

ings

Opp

ortu

nity

Risk

Sco

re


OVERALL NORTHEAST MID-ATLANTIC SOUTHWEST

EMERGING DISEASE ONSET $2.53 $1.89 $2.84 $2.38

IMPACTABLE GAPS IN CARE $4.07 $3.76 $5.77 $3.33

MEMBERREDIRECTION $8.62 $6.36 $9.39 $8.00

PMPM savings opportunity by geography:

Total PMPM Savings Opportunity

$15.22

MID-ATLANTIC

$2.84

$5.77

$9.39


EMERGING DISEASE ONSET

PMPM savings opportunity summary: OVERALL NORTHEAST MID-ATLANTIC SOUTHWEST

EMERGING DISEASE ONSET $2.53 $1.89 -25.3% $2.84 12.3% $2.38 -5.9%

CAD AND CHF $0.38 $0.28 -26.3% $0.41 7.0% $0.25 -34.2%

DIABETES $1.59 $1.04 -34.6% $1.89 18.9% $1.69 6.3%

OPIOID ABUSE $0.55 $0.56 1.8% $0.53 -3.6% $0.43 -21.8%

Diabetes prevention/onset delay ($1.59 PMPM) emerged as an area of substantial opportunity, representing 63% of the Emerging Disease Onset cohort.

DIABETES $1.59 $1.04 -34.6% $1.89 18.9% $1.69 6.3%


IMPACTABLE GAPS IN CARE

PMPM savings opportunity summary:OVERALL NORTHEAST MID-ATLANTIC SOUTHWEST

IMPACTABLE GIC TOTAL $4.07 $3.76 -17.4% $5.77 31.9% $3.33 -29.5%

CARDIOVASCULAR $1.42 $1.05 -26.1% $2.29 61.3% $0.98 -31.0%

DIABETES $0.99 $0.84 -15.2% $0.89 -10.1% $1.01 2.0%

RESPIRATORY $0.13 $0.08 -38.5% $0.13 0.0% $0.01 -92.3%

MUSCULOSKELETAL $0.50 $0.29 -42.0% $0.34 -32.0% $0.12 -76.0%

MENTAL HEALTH $0.35 $0.62 77.1% $0.17 -51.4% $0.11 -68.6%

OTHER/NON CHRONIC $0.74 $0.48 -35.1% $1.55 109.5% $0.64 -13.5

Care dedicated to members with cardiovascular disease ($1.42 PMPM) emerged as a substantial opportunity to address impactable gaps 32% of the total available opportunity).

CARDIOVASCULAR $1.42 $1.05 -26.1% $2.29 61.3% $0.98 -31.0%


MEMBER REDIRECT ION

PMPM savings opportunity summary: OVERALL NORTHEAST MID-ATLANTIC SOUTHWEST

MEMBER REDIRECTION TOTAL $8.62 $6.36 -26.2% $9.39 8.9% $8.00 -7.2%

ER OVERUTILIZATION $1.68 $1.29 -23.2% $1.69 0.6% $1.45 -13.7%

FALL RISK $0.01 $0.01 0.0% $0.01 0.0% $0.01 0.0%

HIGH RISK PREGNANCY $1.57 $1.43 -8.9% $1.78 13.4% $2.23 42.0%

HIP, KNEE, LOW BACK SURGERY $2.55 $1.68 -34.1% $2.68 5.1% $1.77 -30.6%

PRIMARY ADMISSIONS $1.96 $1.15 -41.3% $2.37 20.9% $1.75 -10.7%

READMISSIONS $0.85 $0.80 -5.9% $0.86 1.2% $0.79 -7.1

Hip, knee, and low back surgery emerged as the largest expected single savings opportunity, representing $2.55 PMPM (over 29% of the available expected savings opportunities for member redirection)

HIP, KNEE, LOW BACK SURGERY $2.55 $1.68 -34.1% $2.68 5.1% $1.77 -30.6%


MAKE EVERY intervention count.


MOST LIKELY TO ENGAGE

HIGHEST RISK

GREATEST MODIFIABLE GAPS

Maximize every healthcare dollar

Where to find your greatest opportunities


Sally G. Fred S. Jane D.FINANCIAL RISK $72,440 $209,519 $10,396

CHRONIC CONDITIONSHTN, DM,

Asthma/COPD, Chronic Pain

COPD, CAD, HTN, CHF Asthma, Psoriasis

OPEN GAPS IN CARE 6 11 2

CLINICAL ONSET RISK Opioid Dependence

REDIRECTION RISK Back Surgery Hospitalization ER Utilization

ENGAGEABILITY High Medium Low

SAVINGS OPPORTUNITY $16,052 $8,799 $1,064

Patient level opportunity assessments


Intervene sooner using predictive risk scores

POTENTIAL RISK SCORE:

8.90

ENGAGEABILIT Y SCORE:

MODIFIABLE RISK DRIVERS:

86%

$16,052POTENTIALANNUAL SAVINGS:

Pharmacy opportunities• Adherence to hypertension (RAS) therapy (open gap)• Statin omission in patients with diabetes (open gap)• Use of high risk medications in elderly

Medical opportunities• A1C testing in patients with diabetes (open gap)• High risk of low back surgery in next 12 months• High risk of opioid dependency in next 12 months

Name: Sally G.Age: 66

RISK SCORE:

14.48


OPPORTUNITY SUMMARY


SEAMLESS INTEGRATION INTO YOUR OWN SYSTEMS AND WORKFLOW


SUPPORT FOR YOUR CLIENT GROWTH & RETENTION


CONFIDENCE FOR RISK-BASED ARRANGEMENTS


ALIGNMENT FOR YOUR ORGANIZATION

#esoutcomes19 1...pmpm savings opportunity summary: overall northeast mid-atlantic southwest member...

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