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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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Maximizing the Value of Predictive Modeling: The BlueCross BlueShield of Tennessee Experience Soyal Momin MS, MBA December 14th, 2007
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
Utilization distribution • Total healthcare cost and its components • Population assessment • Total cost assessment – direct & indirect costs Understanding Population Needs
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
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
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
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
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%
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
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
Care Coordinationfor Chronically Ill • Telephonic coordination with members and their providers • Ensures appropriate treatments and pharmaceuticals • Five different programs included in this model
Care Coordination Programs • Pharmacy Care Management • Emergency Room (ER) Visits Mgmt. • Transition of Care • Condition Specific Care Coordination • Disease Management
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
Next Generation Care Management:Implementation • Predictive Modeling Using • DCG • ETG • Rolling 12 Months DCG Explanation Prospective Model • ETG Cost to Supplement DCG Prediction
Next Generation Care Management:ProcessEnhancements • Developed SQL database containing DCG and ETG information • Improved processes/workflow • Easy and continuous access • Better documentation
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
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
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
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
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?
Distribution of Index Scores Commercial LOB 10/2005 High Scores: >=11 (10.2%) Moderate Scores: 6-10 (18.4%) Low Scores: <=5 (71.4%)
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
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
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
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
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