Download Accordant Medical Management

Steven K. Schelhammer
Founder and President
Managing
Costly
Chronic
Conditions
Through Integrated
Disease Management
©2003 Accordant
Managing Costly Chronic Conditions
Agenda
 Costly chronic conditions
 Specialized disease management
 Predictive modeling
 Integrated care
 Care coordination
 Interventions
 Results
©2003 Accordant
Costly Chronic Conditions
Examples of Their Direct Impact on Spend
Rheumatoid Arthritis
$15,000 +
Gaucher Disease
$250,000
Multiple Sclerosis
$15,000
Hepatitis C
$24,000
Specialty
Drug
Costs
Oncology,
BMT HIV/AIDS
$5,000-10,000
Pulmonary Hypertension
$30,000 -100,000
Growth Hormone Deficiency
$18,000
Per Patient
Per Year
Hemophilia
$200,000 +
Infertility
$18,000-20,000
©2003 Accordant
Costly Chronic Conditions
Are Complex, Unique and Progressive
 Require:
 Specialized expertise
 Patient self-management
 Dynamic interventions to meet varying complications
 Support to prevent crises
 Result in:
 High costs for inpatient hospitalization
 Expensive specialty drugs utilization
 Patient identification difficulty, due to many false positives
 Progression of expense over time
©2003 Accordant
Costly Chronic Conditions
Significant Total Cost Trend For Conditions
15%
Medical cost increases for unmanaged
chronic diseases average 15.6 percent,
surpassing the rate of inflation
9.6%
10%
6.9%
5.7%
$1,200
$900
$600
CMSReported
Inflation
5%
$1,500
$300
Avg. PMPM Chronic Diseases
20%
$0
0%
1999
Source: Accordant Health Services, Inc.
2000
2001
©2003 Accordant
Specialized DM:
Solution
 Improves health and lower costs, through:
 Predictive modeling
– Supports patient identification
 Case management
– Nurses provide patient education and compliance
monitoring
 Disease management expertise
– Serving patients with chronic, complex, progressive
diseases
 Specialty pharmacy services
– Integrated workflow, reporting and intervention
©2003 Accordant
Specialized DM: Predictive Modeling
Leads a Targeted Approach
 Why predictive modeling?
 Use when the correlation between near-term costs and
disease diagnosis is weak, like COPD, diabetes or asthma
But, predictive modeling is not enough …
 Standard predictive models can’t identify complex,
chronic patients
 For example, one client’s former predictive modeling
vendor was only able to identify 161 of over 1,900 highcost patients
 For co-hort of Accordant diseases, the diagnosis
IS the prediction of high-cost patients
©2003 Accordant
Specialized DM: Predictive Modeling
Population Management
100%
70% of
today’s
high-cost
patients
were not
high-cost
2 years
ago
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Cost Status 2 Years Prior
Cost Status 6 Months Prior
Highest Cost
Middle Cost
Highest Cost Status
Lowest Cost
Note: Population migration analysis, AHS vs. MCO. Figure shows percent of population at or above
the “top” cost threshold.
©2003 Accordant
Specialized DM: Predictive Modeling
A 24-month Cost Threshold
100
Unmanaged:
95% of Patients
Exceed the 90th
Cost Percentile
90
80
70
60
50
 For Accordant
diseases, diagnosis is
the best predictor of
future near-term costs
 Patients exceed 90th
cost percentile
40
30
20
 8 months, on average
10
0
Patients
Exceeding
Threshold
Source: AHS-MCO-011113
Patients Not
Exceeding
Threshold
 Based on 24-month
continuous enrollment
©2003 Accordant
Specialized DM: Integrated Care
 Address entire
condition and its
typical course with
population-based
approach to:
Population DM opportunity
PMPM
Least
Costly
Most
Costly
 Minimize the magnitude
of acute events and
high cost cases
 Reduce the frequency
of predictable events
and high-cost cases
Every patient with
the condition is eligible
©2003 Accordant
Opportunity for Specialty Pharmacy
Integration Benefits
Information flow from typical Specialty Rx vendors
Accordant Health Services DM Coordination
MCO
Info
Patient
Info
Physician
Info
Solid Bidirectional
Information Flow
 Incompatible Systems
 Mis-Aligned Incentives
Homecare
Info
As-Needed
Information Flow
Provider
Info
Specialty
Pharmacy
Info
Nonexistent
or One-Way
Information Flow
 Operational Priorities
 Competitive Concerns
©2003 Accordant
Accordant DM with AdvancePCS
Specialty RX
Better Communication and Service
DM Coordination
MCO
Info
Patient
Info
Physician
Info
Solid Bidirectional
Information Flow
 Compatible Systems
 Aligned Incentives
Homecare
Info
As-Needed
Information Flow
Provider
Info
Specialty
Pharmacy
Info
Solid
Bi-directional
Information Flow
 Consistent Operational Priorities
 No Competitive Concerns
©2003 Accordant
Specialized DM: Integrated Care
with Specialty Pharmacy
 Increases program savings by an additional 20%
and ROI by 40%
 Greater control over specialty drug spend with patient
steerage and standard therapy guidelines
 Enhanced patient services with single point of contact
 More effective real-time interventions
 Example




A large health plan client
Implemented integrated specialty pharmacy service
Realized $600K in savings to date
On track for an additional 20% savings
©2003 Accordant
Specialized DM: Care Coordination
 Benefits review
 Facilitation between patient, physician, health plan
and vendors
 Coordination includes home infusion and
therapies, DME, PT, OT
 Same benefits review, coordination, facilitation
with comorbid conditions, as with the DM program
they are enrolled in
©2003 Accordant
Specialized DM: Care Coordination
with Physicians
 Offers physician support in caring
for patients
 Highly trained and experienced
patient support partner
 Helps promote treatment compliance
 Coordinates an array of complex
care and services that ordinarily
bewilder patients
 Improves health outcomes by
providing additional service and
support to the physician
©2003 Accordant
Specialized DM: Interventions
Research & Development
 Research natural history of the disease and
develop construct
 Identify and rank significant complications and
their associated costs
 Baseline cost analysis
 Assess significant risks and match proven
strategies to prevent problems and complications
Medical guideline: Strategy-intervention grid
©2003 Accordant
Specialized DM: Interventions
Preventing Complications
 Risk stratification, each with their own interventions
 Multiple sclerosis:
– Exacerbations
– UTI
– Falls with fractures
– Skin breakdown
 Rheumatoid arthritis:
– Flares
– Infections
– Falls with fractures
– GI bleeding
 Assess and monitor closely
©2003 Accordant
Specialized DM: Interventions
Promoting Patient Self-Management
 Access to general information and assessments
 Education about disease, medications and
therapies
 Better communication with the health care team
 Compliance with the treatment plan
 Skills development assistance including coping,
lifestyle and service coordination
©2003 Accordant
Specialized DM: Interventions
Data Analysis
 Analysis of integrated claims and patient-reported
data on MS flares
 Findings:
– Antidepressant users were 3 times more likely to have
a flare
– Patients with a concurrent infection are 1.5 times more
likely to have a flare
– Incidence and frequency of flares are related to
disease progression
 Results:
– Investigating the link between these associations and
flares
©2003 Accordant
Specialized DM: Intervention Example
Promoting Better Self-Management Skills for MS
Goal: Decrease admissions to hospital for urinary tract infection
and Pyelonephritis -- Ranked # 2 for hospital admissions
 Assess patient’s knowledge of:
 UTI and its major symptoms
 Symptoms of spastic “neurogenic” bladder
 What to do if they develop acute Sx’s
 Intervene with:
 Education
 Assessment of clinical status
 Facilitate appointments with physician,
 Alert the physician of acute symptoms and untreated spastic neurogenic
bladder
Guidelines: American Academy of Neurology and NMSS
©2003 Accordant
Specialized DM: Intervention Example
Falls with Fractures are Common for RA Patients
Goal: Decrease falls and fractures that lead to hospitalization
 Assess:

Risk of falls with mobility scales such as HAQ for rheumatology
conditions.
 Individual risks (lives alone, frequent trips to bathroom, etc)
 Risk of osteoporosis (steroids, cytotoxic drugs)

Intervene with:





Education to prevent falls
Arrange home safety evaluation
Education about use of Calcium and Vitamin D
Alert physician for preventive medications for osteoporosis
Monitor for compliance with medications
Guidelines: American Academy of Rheumatology, Osteoporosis Foundation
©2003 Accordant
Specialized DM: Intervention Example
Overutilization Among Hemophilia Patients
Goal: Reduction of product overutilization
 Manage by:
 Preventing bleeding episodes
 Minimizing the number of treatments needed to stop a bleed
 Monitoring inventory/deliveries compared to prescription
 Providing competitively priced products with aligned incentives
 Intervene with:
 Patient education
 Behavior modification
 Competitively-priced fulfillment of factor concentrates
Guidelines: Hemophilia Treatment Center/National Hemophilia Foundation
©2003 Accordant
Specialized DM: Intervention
Promoting Drug Safety
 Proactive interventions (education)
 Patient pharmacy communications
 Safe medicine practice at home
 Safe medicine practice at hospital
 Reactive intervention (monitoring)
 Drug interactions
 Contraindicated drugs
 Medication duplications
©2003 Accordant
Results: Value
Ensuring That Myasthenia Gravis Patients
Carry a List of Contraindicated Drugs
MG-3
Percent Carrying AHS Medication List
Source: Assessment Data through 6/30/2002 (95% CI Shown)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1
2
3
4
5
6
7
8
Length of Time in Program (LOTIP) by Qtr
©2003 Accordant
Results: Value
PMPM
Comparing Pre and Post Cost Trends PMPM
Preprogram PMPM cost
Post program PMPM cost
Based on a specific
client experience.
Claims incurred
through May 31 2002
Length of Time in Program (LOTIP) Monthly
Eligible members - Excluding members that have died, members for whom coverage is secondary, and members covered
by another disease management organization. All Diseases
©2003 Accordant
Results: Value
Utilization
Comparing Preprogram Hospital Admit Costs
Based on a specific
client experience.
Claims incurred
through May 31 2002
Preprogram hospital admits / 100
Post program cost / 100
LOTIP: Length Of
Time In Program
Length of Time in Program (LOTIP) monthly
Eligible members - Excluding members that have died, members for whom coverage is secondary, and
members covered by another disease management organization. All Diseases
©2003 Accordant