Transcript State of South Carolina Employee Health Plan Initiatives to Promote

State of South Carolina Employee
Health Plan Initiatives to
Promote Quality of Care
Academy Health
SCI National Meeting
Minneapolis, MN
August 5, 2010
Rob Tester
Former director (1992-2010), SC State
Health Plan
[email protected]
State Employee Insurance in South Carolina
 PPO model self-insured health plan available to state employees, school
employees and local government employees; membership including
active employees, retirees, and dependents currently numbers around
395,000
 Three claims payers: BCBS of SC (medical); Medco (pharmacy); APS
Healthcare (behavioral)
 Disease management program within medical plan
 Direct contracting with hospitals and physicians; network administration
through BCBS of SC
2
Evidence-Based Medicine Program
 SC adds evidence-based claims monitoring program

Care gaps continue to occur despite existing programs

Quality of care improvement initiative

Savings associated with improvement in guideline adherence

Equal programming for both active and retired employees
– Including Medicare primary and non-Medicare primary

Provider-focused program
 RFP issued to administer the program and awarded to ActiveHealth
Management. The State of South Carolina program began in
February 2006

ActiveHealth Management provides treatment recommendations according to best practice
guidelines

ActiveHealth program also in South Carolina through BCBS and covers over 200,000 member lives

Mission is to prevent adverse clinical events by leveraging evidence-based clinical information,
innovative technology and targeted communications
The State of South Carolina Program
 Aggregate claims data and patient-centric records
 Analyze patient records through a clinical rules engine with
thousands of clinical algorithms
 The clinical rules engine is called CareEngine® System and it
identifies gaps between treatment and evidence-based
recommendations
 Recommendations identified by CareEngine are then sent out
to physicians
The State of South Carolina Program
• CareEngine was developed by physicians for physicians
• CareEngine is maintained by a staff of 21 full-time
clinicians
• Recommendations identified by CareEngine are called
Care Considerations
• Care Considerations help physicians to:
–
–
–
–
See aggregated patient history
Understand treatment delivered by other physicians
Benefit from updated studies published in medical journals
Prevent clinical adverse events
Program Implementation
 Review of Care Consideration library
 Over 800 messages activated
 Establish data feeds
 Four ongoing data feeds
 Five years of historical data
 Schedule of implementation meetings
 Weekly meetings
 Provider Awareness Campaign
 Partner with medical plan to meet with high volume providers
 Meeting with the Hospital Association and Medical Leadership
Council
 Development of provider-directed informative documents
delivered via mail and on request
Program Results
Example of a Care Consideration/Case Study
– 58 year old female with a history of diabetes and hyperlipidemia
– CareEngine received claims indicating diagnosis of both conditions
– CareEngine received claims for the prescription medications Zocor, Avandia, and
Metformin
– ActiveHealth Care Consideration #79 fired
• “Absence of an ACE inhibitor in patients with a history of diabetes and hyperlipidemia”
– The following was communicated to the doctor on 2/8/2006:
• Your patient is 55 years of age or older, has claims evidence for diabetes, an additional coronary
artery disease (CAD) risk factor (e.g., history of CAD, dyslipidemia, microalbuminuria) and has
no claims evidence for an ACE inhibitor. The American Diabetes Association recommends an
ACE inhibitor in these patients, with or without hypertension, to reduce the risk of
cardiovascular events. If your patient fits this clinical profile, and if not already done or
contraindicated, consider starting an ACE inhibitor and titrating the dosage as tolerated.
– CareEngine received claims indicating that Enalapril 5mg. (ACE inhibitor) was added to
the patient’s drug regimen on 3/3/2006
Health Economic Model: Stroke
*Costs of treatment in the model are for illustration.
CONFIDENTIAL- May not be copied, reprinted or redistributed without prior written approval.
Initial Program Results
Program inception through Q’3 2007
– Care Considerations generated: 167,317
• Severity 1 and 2* – 162,057
– Medicare
» 17% of total population
» 49% of all Care Considerations
– The State Program began with five years of historical medical and Rx claims. As a result,
CareEngine was able to identify 30,415 potential gaps in care during the first month of
production.
– Health Economic Model savings 2007 (the projected dollars saved as a result of
providers implementing Care Considerations)
• $16.45 Per Member Per Month (systemwide savings: Medicare, Plan, patient liability)
• Approximate actual Plan savings during this period = $7.86 PEPM (1.75% of claims expense)
* Severity 1: Clinically urgent, Severity 2: Clinically important
Subsequent Program Results:
2008, 2009
•
Care Considerations delivered thru Q3 2008 totaled 71,228
– 67,021 were Severity Level 1 and 2 Care Considerations
– HEM savings for this period $8.07 PMPM
•
Care Considerations delivered thru Q3 2009 totaled 85,720
– 73,004 were Severity Level 1 and 2 Care Considerations
– HEM Savings for this period $7.52 PMPM
•
Overall Care Consideration compliance has increased through 2008; declined
somewhat in 2009 with release of additional Severity 3 Care Considerations
–
–
–
–
•
2006: 21%
2007: 28%
2008: 40%
2009: 32%
Highest Care Consideration compliance categories:
–
–
–
–
Condition screening: 33%
Stop/modify a drug: 55.8%
Condition/drug monitoring: 33%
Drug-drug interaction: 69.8%
Top Ten Most Effective Care
Considerations
(with at least 10 issued for a rolling 12 month period)
Severity
Short Description
Number
Issued
Effectiveness
Rate
1
Avoid Antipsychotics in the elderly with Dementia
563
100.00%
1
Estrogen Containing Preparations - Contraindicated in
Venous Thromboembolic
87
100.00%
2
Avoid Ketorolac in the Elderly
30
100.00%
1
Promethazine (Phenergan) - Avoid in Pediatric
Patients Younger Than 2 Years
30
100.00%
2
Renal Insufficiency – Caused or Exacerbated by
Drugs
27
100.00%
1
Phosphodiesterase Inhibitor - Contraindicated with
Concomitant Nitroglycerine
139
96.4%
2
Terbinafine - Consider LFT Monitoring
24
94%
1
Itraconazole - Contraindicated Drugs
33
94%
1
Ketorolac - Contraindicated Conditions
111
94%
2
Depression - Caused or Exacerbated by Certain
Drugs
12
92%
Actual Plan Savings Based on
Health Economic Model: 2009
Members
Employees/
Retirees
Q3 2009
PMPM
HEM
Savings
Plan
Payment
Factor
Medicare
Supplement
46,775
34,902
$24.65
Medicare
Carve-Out
16,240
12,110
Savings Plan
9,412
Standard
NonMedicare
295,309
Network
Pricing
Adj.
Adj.
PMPM
Converted
to PEPM
0.0776
$1.91
$2.55
$24.94
0.0587
$1.46
$1.89
5,839
$0.64
0.468
0.730435
$0.22
$0.36
155,584
$3.15
0.8077
0.730435
$1.86
$3.52
Weighted
PEPM
Savings
$3.24
Total PEPM
Est. Claims
Payout - 2009
$519.21
Savings as a
% of Total
PEPM
0.62%
Estimated $
Savings-2009
$8.159 M.
Reward-Based Hospital Reimbursement
• The Plan direct contracts with all general hospitals in South
Carolina.
• Beginning in 2006, the Plan provided an add-on to the general
inpatient reimbursement schedule for hospitals that achieved
90th percentile status on a number of National Quality Forumendorsed measures
• In the initial year, hospitals that achieved 90th percentile on
two of the 10 measures for which at least one year of data
was available received an additional 0.25% on their inpatient
rates, and an additional 0.25% for each achieved measure
over two
Reward-Based Hospital Reimbursement
Threshold for receiving reward-based reimbursement has
increased as data for more measures has become available;
number of hospitals achieving reward status has increased as
well; in addition, the reward was increased in 2009 from
0.25% to 0.5% :
Reward $/
Threshold
Reward
Qualifiers
Inpatient $
2006 2 of 10
0.25%
6
.07%
2007 4 of 20
0.25%
4
.04%
2008 4 of 20
0.25%
12
.28%
2009 4 of 21
0.5%
20
.74%
2010 5 of 23
0.5%
18
na
Reward-Based Hospital Reimbursement
• Hospitals have reacted positively toward reward-based
reimbursement
• Through reward-based program, hospitals have been able to
increase base reimbursement by as much as 4%
• A new reward-based measure relating to re-admission rates
was introduced for 2010; however, no hospitals qualified to
receive additional reimbursement based on the re-admission
measure for this year