Transcript Document

Presentation to the
Vermont Commission on
Health Care Reform
Kenneth E. Thorpe, Ph.D.
Robert W. Woodruff Professor and Chair
Department of Health Policy and Management
Rollins School of Public Health
Emory University
[email protected]
December 2005
Agenda
1. Challenges facing a “fast-track”
implementation of the state’s chronic
care initiative
2. How do other states / state Medicaid
programs design disease
management programs?
3. Lessons and implications for the
Commission discussion
December 2005
Chronic Care Blueprint
1.
2.
3.
4.
5.
6.
Population identification processes
Evidence-based practice guidelines
Collaborative practice models to include physician
and support-service providers
Patient self-management education (may include
primary prevention, behavior modification
programs, and compliance/surveillance)
Process and outcomes measurement, evaluation
and management
Routine reporting / feedback loop
December 2005
Key Challenges Facing the
Rapid Implementation of the
Chronic Care Blueprint
1.
2.
3.
4.
5.
Time remaining to complete the patient registry –
key infrastructure to identify chronically ill patients
Integrating providers and patients into the model –
“buy-in”
Changing provider payments – payment reforms
needed
Finalizing measurable set of standard clinical
performance measures, outcomes measures,
patient satisfaction measures
Role of OVHA / State employees: Build vs.
contract with external vendor (latter much faster)
December 2005
Challenges Facing the
Chronic Care Blueprint
1.
Identification of patients eligible for disease
management service (i.e. know who your
patients are!)
•
•
Need Patient registry to identify all eligible members
and stratify for risk/level of intervention. Also allows for
comprehensive tool for managing clinical needs
Cannot move ahead without automated registry, or
external vendor identifying potential candidates
Challenges: Requires data from several providers, labs,
pharmacy clearinghouses, hospitals, physician
practices, health plans.
–
–
Full completion could be two years away
Key first step is the accelerate the completion of the registry
December 2005
Challenges
2. Finalize clinical protocols that will be
adopted across all patients.
• Successful program will need
•
Outcome, utilization, and process
measurements
December 2005
3. Process and Outcomes
Measures (still under construction)
• Member and Provider Satisfaction Surveys
• Health status outcome - examples
– Improved overall health status of members at
least 10%
– Decrease in hospital admissions at least 10%
– Decrease in total inpatient days at least 10%
– Decrease in Emergency Department visits by at
least 10%
– Increased education (knowledge) of providers and
members by 10%
December 2005
Illustrative Clinical Outcome Metrics for
Diabetes – Variables to be Measured
Percent of members with diabetes who completed one foot examination, palpation of pulses
and visual examination in the measurement year
Percent of diabetes members with microalbuminuria or clinical albuminuria (per ADA
Guidelines) taking ACE inhibitors or ARB
Percent of diabetes members with an A1C level <7.0% in the past year (ADA Guideline)
Percent of diabetes members with LDL level <100mg/DL within the past two measurement
years (use last measure to report) (ATP III Guideline)
Percent of diabetes members with BP <130/80. (Use last measure to report) (ADA
Guideline)
Percent of members with diabetes who had one dilated retinal exam in the measurement
year.
Percent of members with diabetes who had at least two A1C test in the measurement year.
Percent of members with diabetes who had one microablumin screening test in the
measurement year or receiving treatment for existing nephropathy
December 2005
Illustrative Clinical Outcome Metrics for
Diabetes – Variables to be Measured
Percent of members with diabetes who completed one fasting lipid panel test in the
measurement year
Percent of members with diabetes >30 years of age taking an aspirin each day
Percent of diabetes members who reported smoking at the beginning of the
measurement period who at the time of measurement had quit smoking
Percent of all diabetes members who receive flu vaccination within the last 12
months
Percent of all diabetes members who have ever received a pneumococcal vaccine
Percent of all diabetes members who had a depression screening in accordance
with United States Prevention Services Task Force (USPSTF)
December 2005
4. Create Comprehensive
Care Plans that Include:
• Management of disease states and co-morbid
conditions
• Severity of care
• Improvement of risk factors related to disease (i.e.
obesity)
• Management of appropriate usage of all medications
• Preventative care and wellness promotion
• Evaluation of home environment for levels of
common environmental triggers
December 2005
4. Create Comprehensive
Care Plans that Include: (continued)
• Action plans for diseases that are required per
clinical guidelines (i.e. asthma)
• Prevention of acute episodes including
hospitalizations and emergency-room visits
• Member self-management strategies
• Communication feedback among all providers
• Member and provider adherence to clinical
guidelines
• Member’s compliance with care plan
• Are compliant and cooperative with the
recommended care plan
December 2005
5. Payment Reform
•
•
•
Plans paid a PMPM amount for managing health care
of enrollees
Cannot fully develop all aspects of chronic care model
absent changes in how providers are paid.
Not currently planned
6. Physician Buy-in
•
Must seamlessly integrate all parts of the CCI
7. Role of OVHA / State Employees in the
CCI
•
•
Could include OVHA and the state employees through
an RFP process with an external vendor
Not currently anticipated
December 2005
How Do Other States Provide
Disease Management for
Medicaid / State Employees?
• Generally through an RFP process
• RFP requires vendor to describe (examples)
– Approach for identifying eligible members
– Approach for conducting baseline assessments of
health risk, and non-adherence risk.
– Identify educational / wellness / clinical
management protocols by risk state (i.e. mild
asthmatics v. severe asthmatics)
– Approach for enrolling patients opt-in / opt-out
December 2005
How Do Other States Provide
Disease Management for
Medicaid / State Employees?
• Identify how vendor would integrate
with:
– Medicaid provider community
– FQHCs
– Rural and public health clinics
• Process for coordinating interventions
and care
• Measure /evaluate outcomes
December 2005
RFPs Require
•
•
•
•
•
•
•
•
Evidence based guidelines
Case managers (face to face, telephone)
Care Plans that include:
Management of disease states and co-morbid
conditions
Severity level of care
Improvement of risk factors related to disease
Management of appropriate usage of all medications
Preventative care and wellness promotion
December 2005
RFPs Require
(continued)
• Evaluation of home environment for levels of
common environmental triggers
• Action plans for diseases that are required per
clinical guidelines (i.e. asthma)
• Prevention of acute episodes including
hospitalizations and emergency-room visits
• Member self-management strategies
• Communication feedback among all providers
• Member and provider adherence to clinical
guidelines
• Member’s compliance with care plan
• Are compliant and cooperative with the
recommended care plan
December 2005
Key Part Many RFPs:
• Guaranteed Net Savings
– Expect generally 4% savings for
aged/blind/disabled populations
– Higher savings (10%) for other populations
– Pay a PMPM fee to vendor that is at risk
(see example)
December 2005
SAMPLE CALCULATION OF SAVINGS FOR “BEND THE TREND”
PROGRAM (Georgia Medicaid RFP)
.
All numbers provided are for demonstration purposes only
Base year
First Contract
Year
Comments
Financial Baseline
and Contracted
Fees and
Guarantee
Claims cost/eligible
patient/month for
that year.
$1000
Total claims cost/total member-months (based
on fiscal year 2004 claims experience)
Vendor Guarantee,
gross/net
10% gross/5%
net
Negotiated 5% savings AFTER fees. 10%
gross is needed to reach 5% net because
the fee itself equates to 5% of claims cost
Vendor fees
$50 PMPM
Negotiated fee (equals 5% of claims)
Vendor NET
guarantee
$50 PMPM
5% of financial baseline
Vendor targets,
before financial
baseline
adjustments
$900 gross,
$950 net
10% and 5% reduction off the $1000,
respectively
Vendor ROI
guarantee
2:1
$100 in claims savings/$50 in fees.
December 2005
SAMPLE CALCULATION OF SAVINGS FOR “BEND THE TREND”
PROGRAM (Georgia Medicaid RFP)
.
All numbers provided are for demonstration purposes only
Baseline
Adjustment
Base year
First Contract
Year
Comments
PMPM spending
increase trend in
absence of DM
10%
This is a contractually agreed upon number
Financial baseline
adjusted for trend
BEFORE net
savings guarantee
$1100
Previously calculated financial baseline,
adjusted for the 10% inflation means that
the target goes up by 10%
Target (A)—AFTER
5% net savings
guarantee
$1050
With 10% inflation factored in, this is the
target that the vendor much reach after
fees to save a net of 5%
Target (B) –gross
claims cost target
needed to hit 5%
net target
$1000
If fees are $50, a net total cost of $1050
requires reducing gross claims to $1000
December 2005
Did the Vendor hit the
Target? Example of
missing
Actual PMPM claims cost
for period
$1025
Calculated during reconciliation
Actual savings
$75
Claims saved from $1100 projection
Savings needed to “make
their numbers”
$100
The target of $1000 was $100 less than the projected
number in absence of DM
% of number hit
75%
$75/$100
Vendor claims
performance vs.
GROSS claims
target
$1025 vs. $1000
target
Gross claims reduction was 75% of reduction needed to
hit the NET target number even though…
Amount of miss in claims
target
$25 (25%)
They needed to save $100 in gross claims. They saved
$75, so they missed by $25
% of fees which must be
returned
25%
This ALWAYS EQUALS the % of the miss, in order to
maintain the guaranteed ROI
Payout by Vendor for
missing target,
proportionate
guarantee
$12.50 (25% of $50)
Vendor achieved 75 % of the reduction in claims needed
to hit the net savings number and missed by 25%.
The vendor must return 25% of the fee to the state in
order to meet its contractual obligation to keep the
state whole and maintain the ROI of 2:1
Remaining gross
savings/gross fees
$75/$37.50 = 2:1
ROI
ROI is maintained due to fee giveback
December 2005
Key Issue: Role of OVHA in
Chronic Care Blueprint
• Build vs. RFP (lease) Issue
• Could develop RFP contract with
external vendor and jump start the
process
• Could require performance guarantees
on savings
December 2005