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Soyal Momin MS, MBA December 14 th , 2007

Maximizing the Value of Predictive Modeling: The BlueCross BlueShield of Tennessee Experience. Soyal Momin MS, MBA December 14 th , 2007. Outline. Understanding Population Needs Historical View: Care Management at BCBST Concept: Next Generation Care Management (NGCM)

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Soyal Momin MS, MBA December 14 th , 2007

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  1. Maximizing the Value of Predictive Modeling: The BlueCross BlueShield of Tennessee Experience Soyal Momin MS, MBA December 14th, 2007

  2. Outline • Understanding Population Needs • Historical View: Care Management at BCBST • Concept: Next Generation Care Management (NGCM) • Implementation of NGCM • Improving the • Process Efficiency • Information Shared with CM • Using Predictive Modeling to Evaluate Care Mgmt. ROI • Conclusions

  3. Utilization distribution • Total healthcare cost and its components • Population assessment • Total cost assessment – direct & indirect costs Understanding Population Needs

  4. Cumulative Total Healthcare Cost

  5. Cumulative Professional and Outpatient Cost

  6. Cumulative Pharmacy Cost

  7. Cumulative Inpatient Cost

  8. Population Assessment Population Assessment is an analysis of claims and membership data to determine characteristics of a given population (Network, Region, Group) that might affect the population’s interaction with the health care system

  9. Major Analysis Variables Propensity to Utilize Index – The average number of episodes of illness for a member month Episode Seriousness Index – A measure of the average cost to treat the categories of illness experienced by a population Illness Burden – A measure of the level of illness within a group determined by multiplying the propensity to utilize index by the Episode Seriousness Index

  10. Major Analysis Variables, Continued Provider Efficiency Index – A measure of the efficiency to treat a specific episode of illness determined by dividing the cost to treat the specific episode by the average cost for the category of illness PMPM Cost Index – An index that measures the PMPM submitted costs for a population determined by multiplying the Illness Burden by the Provider Efficiency Index

  11. Population Profile

  12. Illness Burden by Major Practice Category

  13. Provider Efficiency by Major Practice Category

  14. PMPM Cost Index by Major Practice Category

  15. Total Cost Assessment • Direct costs are dollars paid out for medical treatment • Indirect costs are labor resources lost due to illness Direct Costs= Inpatient + Professional/Outpatient + Pharmacy Indirect Costs= Sick Leave + Presenteeism + Family & Medical Leave + Short Term Disability + Long Term Disability + Turnover + Worker’s Compensation

  16. Total Cost Assessment: Company XYZ Total Healthcare Cost = $23,237,422 Total Healthcare Cost = $23,237,422 Total Healthcare Cost = $23,237,422 Total Healthcare Cost = $23,237,422 $5,631 per FTE $5,631 per FTE $5,631 per FTE $5,631 per FTE Direct $ = Direct $ = Indirect $ = Indirect $ = $13,761,278 $13,761,278 $9,476,144 $9,476,144 $3,334 / FTE $3,334 / FTE $2,296 / FTE $2,296 / FTE 59.2% 59.2% 40.8% 40.8% Inpatient Inpatient Pharmacy Pharmacy Presenteeism Presenteeism STD STD Turnover Turnover Professional/ Professional/ Work Work $376 $376 $804 $804 $318 $318 $220 $220 $74 $74 Outpatient Outpatient Comp Comp 6.7% 6.7% 14.3% 14.3% 5.7% 5.7% 3.9% 3.9% Sick Leave Sick Leave 1.3% 1.3% $2,154 $2,154 $82 $82 FMLA FMLA LTD LTD $1,322 $1,322 38.3% 38.3% 1.5% 1.5% $274 $274 $4 $4 23.5% 23.5% 4.9% 4.9% 0.1% 0.1%

  17. Top 20 Cost Drivers

  18. History • Identifying Members for Case Management • Referrals from • Internal Sources • External Sources • An internally developed ICD9 Trigger list • The ICD9 Trigger list included Asthma, Diabetes, High Risk OB, AIDs, Cancer, CHF, COPD etc • Case managers workload • 103/CM/Month • PM implementation validation revealed missed opportunities for case management

  19. Next Generation Care Management:Triage Guidelines

  20. Lifestyle/Health Counseling for Healthy and Worried Well • Information on disease/condition • Web resources • Pamphlets • Telephonic health library • Encouragement to take more active role/accountability

  21. Care Coordinationfor Chronically Ill • Telephonic coordination with members and their providers • Ensures appropriate treatments and pharmaceuticals • Five different programs included in this model

  22. Care Coordination Programs • Pharmacy Care Management • Emergency Room (ER) Visits Mgmt. • Transition of Care • Condition Specific Care Coordination • Disease Management

  23. Catastrophic Case Management • Directed to members with • Terminal illness • Major trauma • Cognitive/physical disability • High-risk condition • Complicated care needs • Systematic process of assessing, planning, coordinating, implementing, and evaluation of care

  24. Next Generation Care Management:Implementation • Predictive Modeling Using • DCG • ETG • Rolling 12 Months DCG Explanation Prospective Model • ETG Cost to Supplement DCG Prediction

  25. Next Generation Care Management:ProcessEnhancements • Developed SQL database containing DCG and ETG information • Improved processes/workflow • Easy and continuous access • Better documentation

  26. Next Generation Care Management:ProcessEnhancements

  27. Next Generation Care Management:ProcessEnhancements

  28. Care Management Staff Feedback • Under prediction at all risk levels • Use pharmacy data for prediction • NDCs • Prediction of utilization • Provide information to help prioritize members for interventions • Evidence-based guideline gaps

  29. Use pharmacy data for prediction Prediction of utilization • Mover identification • Impact index • Acute • Chronic Provide information to help prioritize members for interventions • Risk drivers Evidence-based guideline gaps MEDai RNC • Forecasted cost • Overall • Pharmacy • ER and IP LOS prediction • Gaps in care

  30. Improving the Information Shared with Care Management Staff • Enhancing SQL database with RNC information ETG Low/Med/High Amount • MEDai forecasted costs (total and Rx) • ER and IP LOS prediction • Impact index • Care management history • Active PCP - Risk drivers - Latest Rx data - Gaps in Care - Risk History

  31. Developing a Stratification Index (SI) • Why? • 1) To reliably identify higher cost, highly impactable members • 2) To enhance prioritization of members for nurse-intervention management • How? • Use predictive output from MEDai • Select key MEDai measures to construct a composite score • Use the composite score as an index to stratify members • Focus on members with the highest index scores

  32. Chronic Impact: Break Down by SI Score

  33. Acute Impact: Break Down by SI Score

  34. Chronic Gaps: Break Down by SI Score

  35. Preventative Gaps: Break Down by SI Score

  36. NGCM Risk Levels: Break Down by SI Score

  37. Mover Identification • Movers are members who are likely to make the transition from low or moderate to high risk • Movers can be identified by comparing current vs. forecasted NGCM risk level • if a member’s current cost is less than $1,000 (Risk Level I) and is predicted to cost more than $25,000 (Risk Level V) • Do movers have higher index scores?

  38. Index Scores for Movers

  39. Distribution of Index Scores Commercial LOB 10/2005 High Scores: >=11 (10.2%) Moderate Scores: 6-10 (18.4%) Low Scores: <=5 (71.4%)

  40. How Do We Measure Care Management (CM) Impact? • Basic research problem: measuring what would have happened vs. what actually happened • Methodologies: • Randomized Control Group • Population-Based Pre-Post Methodology • Predictive Modeling • Control Group Matching • Combination

  41. Group's Inflation Factor 5% 7% CM Mbrs Actual PMPM $ 574 $ 542 CM Mbrs Predictive Modeling PMPM $ 629 $ 638 Inflated CM Mbrs Predictive Modeling PMPM $ 659 $ 682 CM Savings PMPM $ 85 $ 140 Total CM Savings $ 42,005 $ 99,560 Admin Cost $ 29,399 $ 26,749 Predictive Modeling

  42. Non CM Mbrs Actual PMPM $ 225 $ 217 Non CM Mbrs PMPM Predictive Modeling $ 205 $ 232 Inflation Adjusted Non CM Mbrs PMPM Predictive Modeling $ 214 $ 248 Adjustment for Actual to Predictive Modeling 5% -13% CM Mbrs Actual PMPM $ 574 $ 542 CM Mbrs Predictive Modeling PMPM $ 629 $ 638 Inflated CM Mbrs Predictive Modeling PMPM $ 659 $ 682 Adjusted Predictive Model $ 692 $ 597 Adjusted CM Savings PMPM $ 117 $ 55 Adjusted CM Savings $ 57,819 $ 39,113 Admin Cost $ 29,399 $ 26,749 Adjusted Net Savings $ 28,296 $ 12,364 Adjusted ROI 1.96 1.46 Predictive Modeling w/Adjustments

  43. Conclusions of DM Evaluations • A statistically valid predictive model should be incorporated in lieu of randomized control group • Adjustments (inflation factors, inaccuracy of predictive models, etc.) should be made to the model information

  44. Conclusions • More scientific/standardized approach • Able to touch more lives efficiently • Well accepted by our case managers • NGCM has helped • Streamline our processes • Better manage case managers case load • Provide “Peace of Mind” to our members and clients

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