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Steven K. Schelhammer Founder and President. Managing Costly Chronic Conditions. Through Integrated Disease Management. Managing Costly Chronic Conditions Agenda. Costly chronic conditions Specialized disease management Predictive modeling Integrated care Care coordination Interventions

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Steven k schelhammer founder and president

Steven K. Schelhammer

Founder and President

Managing Costly Chronic Conditions

Through Integrated Disease Management

Managing costly chronic conditions agenda
Managing Costly Chronic ConditionsAgenda

  • Costly chronic conditions

  • Specialized disease management

    • Predictive modeling

    • Integrated care

    • Care coordination

    • Interventions

  • Results

Specialty drug costs per patient per year
SpecialtyDrugCostsPer Patient Per Year

Costly Chronic Conditions

Examples of Their Direct Impact on Spend

Multiple Sclerosis


Rheumatoid Arthritis

$15,000 +

Hepatitis C





Gaucher Disease


Pulmonary Hypertension

$30,000 -100,000


$200,000 +



Growth Hormone Deficiency


Costly chronic conditions are complex unique and progressive
Costly Chronic ConditionsAre 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

Costly chronic conditions significant total cost trend for conditions
Costly Chronic ConditionsSignificant Total Cost Trend For Conditions

Medical cost increases for unmanaged chronic diseases average 15.6 percent, surpassing the rate of inflation






Avg. PMPM Chronic Diseases






CMS- Reported Inflation








Source: Accordant Health Services, Inc.

Specialized dm solution
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

Specialized dm predictive modeling leads a targeted approach
Specialized DM: Predictive ModelingLeads 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 high-cost patients

  • For co-hort of Accordant diseases, the diagnosis IS the prediction of high-cost patients

Specialized dm predictive modeling population management
Specialized DM: Predictive Modeling Population Management

70% of today’s high-cost patients were not high-cost 2 years ago

Note: Population migration analysis, AHS vs. MCO. Figure shows percent of population at or above the “top” cost threshold.

Unmanaged 95 of patients exceed the 90 th cost percentile
Unmanaged: 95% of Patients Exceed the 90th Cost Percentile

Specialized DM: Predictive Modeling A 24-month Cost Threshold

  • For Accordant diseases, diagnosis is the best predictor of future near-term costs

  • Patients exceed 90th cost percentile

    • 8 months, on average

    • Based on 24-month continuous enrollment

Source: AHS-MCO-011113

Specialized dm integrated care
Specialized DM: Integrated Care

  • Address entire condition and its typical course with population-based approach to:

    • Minimize the magnitude of acute events and high cost cases

    • Reduce the frequency of predictable events and high-cost cases

Population DM opportunity







Every patient with

the condition is eligible

Opportunity for Specialty Pharmacy Integration Benefits Information flow from typical Specialty Rx vendors

Accordant Health Services DM Coordination














Nonexistent or One-Way Information Flow

Solid Bidirectional Information Flow

As-Needed Information Flow

  • Incompatible Systems

  • Mis-Aligned Incentives

  • Operational Priorities

  • Competitive Concerns

Accordant dm with advancepcs specialty rx better communication and service
Accordant DM with AdvancePCS Specialty RXBetter Communication and Service

DM Coordination














Solid Bi-directional Information Flow

Solid Bidirectional Information Flow

As-Needed Information Flow

  • Compatible Systems

  • Aligned Incentives

  • Consistent Operational Priorities

  • No Competitive Concerns

Specialized dm integrated care with specialty pharmacy
Specialized DM: Integrated Carewith 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

Specialized dm care coordination
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

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

Specialized DM: Care CoordinationwithPhysicians

Specialized dm interventions research development
Specialized DM: InterventionsResearch & 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

Specialized dm interventions preventing complications
Specialized DM: InterventionsPreventing 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

Specialized dm interventions promoting patient self management
Specialized DM: InterventionsPromotingPatient 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

Specialized dm interventions data analysis
Specialized DM: InterventionsData 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

Specialized dm intervention example promoting better self management skills for ms
Specialized DM: Intervention ExamplePromoting 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

Specialized dm intervention example falls with fractures are common for ra patients
Specialized DM: Intervention ExampleFalls 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

Specialized dm intervention example overutilization among hemophilia patients
Specialized DM: Intervention ExampleOverutilization 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

Specialized dm intervention promoting drug safety
Specialized DM: InterventionPromoting 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

Results value ensuring that myasthenia gravis patients carry a list of contraindicated drugs

Percent Carrying AHS Medication List


Source: Assessment Data through 6/30/2002 (95% CI Shown)





















Length of Time in Program (LOTIP) by Qtr

Results: ValueEnsuring That Myasthenia Gravis Patients Carry a List of Contraindicated Drugs

Results value comparing pre and post cost trends pmpm
Results: ValueComparing Pre and Post Cost Trends PMPM


Based on a specific client experience. Claims incurred through May 31 2002

Preprogram PMPM cost

Post program PMPM cost

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

Results value comparing preprogram hospital admit costs
Results: ValueComparing Preprogram Hospital Admit Costs


Based on a specific client experience. Claims incurred through May 31 2002

LOTIP: Length Of Time In Program

Preprogram hospital admits / 100

Post program cost / 100

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