Leadership Preparation for

Designing the Business Case

Dale Jarvis, CPADale Jarvis and Associates

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If you take away only one thing…• There is enormous pressure on everyone working in

health and behavioral healthcare in California. • If you want to get anyone’s attention…

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What does this have to do with Care Coordination?

• 5% of the population use 50% of the health care resources (the 5/50 population).

• 1% use 20%.• Half of both groups have a

behavioral health disorder.• We cannot achieve the triple

aim (especially the cost saving part)…

• Without successfully addressing the needs of those with a serious mental illness and comorbid medical conditions!

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Consider the Following Care Coordination Target Populations…

• Clients with the most serious mental illness and substance use disorders. (Fresno)

• The people we are targeting have complex co-occurring conditions and required coordinated services. (Inyo)

• Existing and potential mutual clients of partner agencies that are high acuity in any of the three domains: mental health, physical health, and substance abuse. (Lake)

• High risk adult patients at the medical center who have behavioral health and substance issues, as well chronic medical conditions, particularly those who come through the emergency department. (LA)

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Can you identify which column the projects are targeting?

Medi-Cal FFS No SMI

Medi-Cal FFS SMI

Medi-Cal FFS Enrollees 1,413,654 166,786 11% SMI % of TotalMedi-Cal FFS Costs $3,790,393,322 $2,395,938,298 39% SMI % of TotalMedi-Cal FFS Cost/Enrollee $2,681 $14,365 5.4 SMI/Non-Ratio

Diabetes 3.2% 11.0% 3.5 SMI/Total-RatioIschemic Heart Disease 1.5% 6.0% 3.9Cerebrovascular Disease 0.8% 3.0% 3.9Chronic Respiratory Disease 4.1% 13.0% 3.2Arthritis 1.4% 7.0% 5.0Health Failure 0.8% 3.0% 3.9

Inpatient Episodes/1,000 77 293 3.8 SMI/Total-RatioER Visits/1,000 239 1,167 4.9Inpatient Acute Days/1,000 434 2,094 4.8Primary CareVisits/1,000 85 492 5.8Specialist Visits/1,000 639 6,058 9.5

California Fee for Service Medi-Cal Analysis - 2007

Metric

Data from JEN Associates, Cambridge, MA

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These are the some of MOST expensive folks in the U.S. Healthcare System

JEN Associates - Cambridge, MA

Medi-Cal Only

Population Type

CY 2006 FFS Beneficiaries with

12 Months Eligibility

Medi-Cal Payments in Prediction Year

Per Person Annual Payments

All SMI 249,254 $2,758,001,218 $11,065 Total Risk 28,080 $976,381,877 $34,771

Highest Risk 9,569 $484,485,372 $50,631

Using flags for diagnoses, patterns of drug use and selected procedure codes a risk population was identified from a base period. The model identified 2.3% of the population as highest risk

JEN Associates

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These are the some of MOST expensive folks in the U.S. Healthcare System

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And many care coordination efforts being put in place for this population may not work…

• Missouri Study: Face to face care management of those with a serious mental illness: 17% savings;

• Compared with telephonic care management of those with a serious mental illness : 0% savings.

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Closer to Home…• Sonoma County’s

Intensive Case Management Program

Tides Intensive Case Management analysis: Oct 2012-Mar 2013

Site

Adjusted Savings (6 month)

Health Center Cost (6 month)

Estimated PHC Cost

Net Savings (6 month) ROI

Vista $567,598 $86,000 $2,500 $479,098 5.4West county $330,590 $78,000 $2,500 $250,090 3.1

Combined $898,188 $164,000 $5,000 $729,188 4.3

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Motivational Interviewing

Barrier reduction

Care Coordination

Mental Health

Support

Trust Building

Addiction Management

Self-Management

Coaching

Rethinking access

Frequent Touches

Accomplished through High Touch Care Management and Lots of Nudging

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But unlike the Sonoma folks, most care coordination projects take this approach

Hurray, we got a grant to start an integrated pilot!

But the grant lasts for only 2 years and we don’t think we can generate billings to cover the cost…

That’s okay. Let’s get the program started and we’ll figure it out. We have 2 years.

Time passes….

2 years are up, and nothing has been done to build the business case to sustain the program.

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1) Organize for Sustainability

2) Serve High Cost Individuals

3)Track and Analyze Health

Cost & Utilization

4) Build the Business

Case

To fix this we want to help the teams develop Sustainability Plans

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I’ve been working with communities to build their business cases

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Bending the Cost Curve • 94 References to

Recent Studies

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The process is straightforward• Organize For Sustainability

– Engage the Executive Teams in the concept of building the Business Case for Sustainability.

– Identify the Point Person in each project who will lead this part of the effort and organize these folks into a separate Workgroup.

– Train up on the Business Case Methodology.– Customize the Methodology for each Project,

recruiting the partners to support the data collection process.

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Key Ingredient – Utilization/Cost Data

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Key Ingredient – Utilization/Cost Data

• For the clients/patients in the care coordination program…

• Ideally:– Pre-Intervention: 1-2 years– Quarterly during the intervention

• To determine whether your efforts are following Missouri and Sonoma’s success;

• Or require course correction.

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Key Partners – Health Plans and Hospitals

• Who are the holders of utilization and cost data.• If they are already at the table, begin to work with

them to identify how to compile the key data.• If they don’t yet recognize that they should be

your best friends, it’s your job to pitch the business case in order to bring them in under the tent:– “We can help you deal with your most complex

patients/enrollees, helping manage your risk and save you money”

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Remember…

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Questions for the Group• Where to you fit on the continuum:

(we haven’t thought about this >>>> it’s a top priority)

• Do you have the right people at the table?• Do your health plans understand the importance of the

people being served in the care coordination projects?• Can you identify a point person at one of the collaborative

organizations to be in charge of building the business case?• Is it possible to find someone at the health plan(s) who can

pull the claims data for the target population so you can track progress?

• Can we help with: Sharing data requests? Providing tracking report templates? Providing technical assistance? What else?

• What might your next steps be for building your business case? 20

Attachment 1: Building the Business Case Change Package

1. Create a Business Case Workgroup that consists of executive leadership and financial officers from the agencies participating on the care coordination team along with Health Plans, the Mental Health Plan, and other funders of care

2. Review care coordination return on investment research and identify relevant data that can be used to set targets for reductions in utilization and cost

3. Develop a care coordination revenue and expense budget (similar to creating a grant proposal) to identify the costs of the program

4. Work with health plans and mental health plans to identify data sets that can be accessed to collect historical utilization and cost data for clients served in the care coordination project; design spreadsheet and/or database repositories for compiling this information

5. Begin collecting historical and current data about target populationa. Care coordination program actual revenue and expense data b. Historical health plan and mental health plan utilization and cost datac. Current health plan and mental health plan utilization and cost data

6. Develop reports that summarize the historical and current data in an easy to understand format7. Business Case Work Group meets on a periodic basis to review the reports and assess how well the care

coordination project is bending the cost curve8. Business Case Work Group shares their ROI findings with the clinical team, identifying areas where things

seem to be working (and not)9. Assuming that not all data will be readily available in the early stages of the project, work with health plans

and mental health plans to expand access to data10. Based on the business case results and projections, convene meetings with Executive Leadership of Health

Plans. Review and discuss with Health Plan short and long term support for care coordination21