Transcript Florida: A Healthy State

Florida: A Healthy State -
A 5-Year History of Disease Management in
a Florida Medicaid Population
Scott A. Wolf, D.O., MPH, FACP
Medical Director, State Initiatives
Pfizer Health Solutions Inc
November 5, 2007
©2007 Pfizer Health Solutions Inc – ALL RIGHTS RESERVED
Overview

U.S Healthcare Market Overview

Disease Management

The Florida Experience

Outcomes & Evaluation

Medicaid Reform

Q&A
NOTE: Please do not duplicate, distribute or translate this slide presentation without the prior written consent of Pfizer Health Solutions Inc.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
2
U.S. Healthcare Market

Unrelenting spending increases

Approaching $2.2 trillion, 16.5% of GDP

Spending per person expected to increase 6% through 2012
U.S. Healthcare Spend ($ Billions)
$1,608
$1,270
$1,741
$1,878
$1,359
15.9%
16.0%
2003
2004
$2,169
$2,200
16.5%
16.5%
2006
2007
$2,016
16.2%
% of GDP
15.4%
14.6%
13.8%
2000
2001
2002
2005
Source: Center for Medicare and Medicaid Services, Office of Actuary
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
3
The Business of Health Care in 2007…Chronic Health
Conditions Underlie the Bulk of Health Care Costs
1% of population
represents over
20% of spending

10% of population
represents over
64% of spending
100%
% of HC Spending



Diabetes
Heart Failure
Coronary
Artery Disease
Depression



Chronic Pain
Cancer
Asthma
and COPD
96.9%
Dementia



Falls
Obesity
Co-morbidities
80.3%
73.6%
80%
64.1%
60%
Chronic Conditions
Are Costlier to Treat
and Control
49.0%
40%
22.5%
20%
3.1%
0%
Top
1%
Top
5%
(≥$39,688) (≥$13,387)
Top
10%
Top
15%
Top
20%
Top
50%
Bottom
50%
(≥$7,509)
(≥$5,191)
(≥$3,733)
(≥$724)
(<$724)
% of Population Ranked by HC Spend
Note: Dollar amounts in parentheses are the annual expenses per person in each percentile. Population is the civilian noninstitutionalized population,
including those without any health care spending. Health care spending is total payments from all sources (including direct payments from individuals,
private insurance, Medicare, Medicaid, and miscellaneous other sources) to hospitals, physicians, other providers (including dental care), and
pharmacies; health insurance premiums are not included.
Source: Kaiser Family Foundation calculations using data from U.S. Department of Health and Human Services, Agency for Healthcare Research and
Quality, Medical Expenditure Panel Survey (MEPS), 2004.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
4
Weighing the Gravity of the System

Unrelenting Spending Increases

Spending not Securing Quality or Health
$$$$
Investment
$$$
$$
$
Healthy
“At Risk”
$$
Undiagnosed
Chronically Ill
Managed
Chronically Ill
Unmanaged
End
of Life
Continuum of Care
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
5
Responding to the Changing Landscape of
Health Care
The Evolution of Our Mission…
I. Indemnity
I. Indemnity
Process
MD Writes
Script
Patient
Receives Rx
II. Traditional Managed Care
Insurer Pays
for Rx
Process
MD Writes
Script
Patient
Receives Rx
MCO Pays
for Rx
Formulary Control
Focus
Focus
Physician
Physician
III.Consumerism
Process
MD Writes
Script
P&T Director
III. Consumerism
Informed and
Educated Consumer
Patient Receives
RX
MCO Pays
for Rx
Formulary Control
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
6
Challenges Presented by Medicaid Beneficiaries
Medicaid Beneficiaries Use Health
and Health-Related Services
Frequently and Often Intensively
Most Have Multiple Chronic Physical
and Behavioral Health Conditions Further
Complicated by Difficult Socio-economic Factors
Medicaid Beneficiaries Tend to Be Mobile,
Changing Addresses, Phone Numbers
and Health Care Providers
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
7
States Undertaking New Medicaid Cost
Containment Strategies FY 2002–2007
50 50 50
46
48
46
43
43
32
29
27
26
25
22
21
18
18
20
19
18
17
15
8
9
8
7
9
5
Controlling Drug Reducing/ Freezing
Costs
Provider Payments
Implemented 2002
Reducing/
Restricting
Eligibility
Implemented 2003
8
Implemented 2004
11
9
4
Reducing Benefits
26
13
17
14
12
10
10
10
7
3
Increasing
Copayments
Implemented 2005
Disease
Management
Implemented 2006
Long-Term Care
* Adopted for 2007
NOTE: Past survey results indicate not all adopted actions are implemented.
SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management
Associates, September and December 2003, October 2004, October 2005, October 2006.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
8
Disease Management Definition
Definition

Disease management is a system of coordinated health care interventions and
communications for populations with conditions in which patient self-care
efforts are significant
Disease Management
Components Include*
Disease Management



Supports the physician or practitioner/patient
relationship and plan of care;

Emphasizes prevention of exacerbations and
complications utilizing evidence-based
practice guidelines and patient
empowerment strategies; and

Evaluates clinical, humanistic, and economic
outcomes on an on-going basis with the goal
of improving overall health




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 (may
include communication with patient,
physician, health plan and ancillary
providers, and practice profiling)
Source: Disease Management Association of America
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
9
Disease Management Landscape
1980’s
1990’s
Boston Consulting Group
Coins the Term in 1987
2000
“The Promise of Disease
Management” – 1995
First Wave
The Pioneers
Second Wave
Pharma
Third Wave
DM Industry
Blood Glucose
Monitoring
Early HMOs
Pharm Begins to
Build Programs
Value Added
Programs
New Service
Industry
Focus:
Physician
Patient Education
Materials
Disease Tracking
Applications
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
10
Recognition of the Importance of Co-morbidities
Evolving Approaches to Implementing
Condition-oriented Cost/Quality
Management Approaches
Patient Focused
High Risk 5%

Disease Focused

90 Million
Have a
Chronic
Disease
HF
Program
Diabetes
Program
Member
s
45%
Have 2
or More
Conditions

More severe disease
Multiple conditions
Behavioral/
psychological issues
Moderate Risk 15%


Less severe
chronic disease
Poor selfmanagement skills
Low Risk 30%
CVD
Program
Asthma
Program

Uncomplicated
chronic disease
 Risk factors
Healthy


No chronic disease
No risk factors
Implications: Increasing Diversity of Implementation Approaches
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
11
Mission
Pfizer Health Solutions develops and implements innovative
care management technologies and services through
collaborations with those responsible for, or vested in, the
health outcomes of patients and communities
Building a Community Care Management Program
Impact
Patients and
Healthcare
Develop
Programs
 Identify
population
 Create
and
train network
 Intervene



 Engage
providers
and communities
 Enroll

to:
Change behaviors
Increase health literacy
Improve care coordination
Improve self-management
Measure
Outcomes
 Improved
clinical results
 Improved
health status
 Lower
health costs
 Higher
patient and
provider satisfaction
patients
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
12
Disease Management Focus and Philosophy
PatientCentered
Empowerment
Model
CommunityBased
Delivery
Physician
Alignment
Transparent,
Reportable
Outcomes










Patient education and culturally appropriate support drives
behavioral change
Improved self-care behaviors improve clinical status and
reduce utilization
This model identifies psychosocial barriers to effective self-management
Intimate community knowledge informs culturally appropriate,
effective patient interaction
Healthcare is local. Understanding the local provider
and resource landscape is integral to coordinating care
A shared commitment to evidence-based medicine supports best practices
Physician partnership provides localized support of clinical guidelines
Care managers facilitate care plan implementation
A collaborative and transparent approach to continuous quality
improvement encourages sharing of best practices
Detailed, regular reporting allows ongoing program improvement
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
13
Florida
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
14
Medicaid Crisis in the State of Florida
Annual Growth in FL Medicaid Expenditures
Chronic Disease Drives Healthcare Costs
($ Billions)
8% Annual
Growth
US Population
303MM
$13.9
US Healthcare Costs
$2.2 trillion
25%
211
13% Annual
Growth
$10.2
75%
Chronic
Disease
Sufferers
Chronic
Disease
Costs
90
Florida Suffers Disproportionately
Heart Disease Mortality Rates (per 100,000)
$2.5
309.2
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Florida
US
245.8
Source: State of Florida AHCA; CDC
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
15
January 2001 – Florida’s Challenge
Florida Medicaid Challenge: Budgetary Crisis
“At a time when Florida was looking to
be a pioneer in developing meaningful
strategies to reduce the growth in costs
and improve health care outcomes, Pfizer
offered an innovative solution… delivering
positive, measurable results well
above our original objectives.”
Responses
– Alan Levine
Former Secretary, FL Agency
for Health Care Administration
OR

Reduce reimbursement to
hospitals and physicians

Implement additional
utilization management
and prior auth processes

Demand supplemental rebates
from pharmacy manufacturers



New care management paradigm:
Pfizer Healthy State Program

Hospital-based care
management program
Health literacy program
Expanded product donation program
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
16
Public-Private Partnership
and
July 9, 2001
“health-policy experts say Pfizer and
Florida are embarking on a grand
experiment with implications well
beyond one state and company.”
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
17
FAHS – Partnership






Provider resources
Care Management
software platform
Program content
and services
Training and support
Patient education
materials
Analytics






Eligibility and enrollment
Call Center contracting
Hospital contracting
Provider
communications
Liaison to
Governor’s office
Medicaid claims
Community
Health Systems




Local clinical oversight
Delivery of Care Management Services
Ancillary professional services
Patient counseling and support
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
18
8 Priorities of Patient Centered Care
Know how and when
1
to call the doctor
Act to keep the
5 condition in
good control
Learn about the
2 condition and
set treatment goals
Make lifestyle
6 changes and
reduce risks
Take medicines
3
correctly
Build on strengths
7 and overcome
obstacles
Get recommended
4
tests and services
Follow up with
8 specialists and
appointments
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
19
Program and Impact
Behavior
Changes
Patient-Centered
Disease Management

Community involvement




10 health systems with
statewide reach
300 community events
Significant scale

Clinical
Changes
190,000+ patients eligible
More
Appropriate
Utilization
Breadth of services

4 chronic diseases
–


Hypertension, Asthma,
Diabetes, Heart Failure
24/7 triage and advice
Multidisciplinary care team
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
Reduced
Cost
20
Individual Patient Impact
“I was adding sugar to
everything, even to my milk.
Before Florida: A Healthy State,
I didn’t know I had diabetes.”
“If it weren’t for Nancy and
Florida: A Healthy State, I
wouldn’t be here.”
Jose G. – Heart Failure,
Hypertension and Diabetes
Jesus H. –
Hypertension and Diabetes
 Reduced
hospital/
ER utilization from
6 visits/year to none
 Reduced
blood pressure
from 130/70 to 112/60
 Lost
 Improved
asthma severity
score from 4 to 1
nearly 40 pounds
 Reduced
hospital/ER utilization
from 5 visits/year to 1
 Reduced
hospital/
ER utilization from
2 visits/year to none
 Improved
BP from 143/80 to
134/78
“I didn’t know how bad I
was until I saw how life could be
again.”
“Before Florida: A Healthy
State, nobody ever told me how
to fix my diet.”
Pierre J. . – Asthma,
Hypertension and Diabetes
Bobbie A. – Asthma,
Hypertension and Diabetes
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
21
The Florida Journey
Jul 2001–Jun 2003
Jul 2003–Sep 2005
Oct 2005–Dec 2006
Jan 2007–Dec 2008
1st Public-Private
Partnership for
Medicaid DM
Extension Agreement
for Disease
Management
Fee for Service
Agreement
PHS Wins Competitive
Award for Statewide
Disease Management
Three Components:

22% decrease in
inpatient admissions

9% decrease in
ER visits
1. Disease management

4 chronic conditions

122K patients
eligible

16K high and
moderate risk
patients under
care management
State of FL pays PHS for:
1. Project management

4% increase in
outpatient visits
2. InformaCare software

Training

Upgrades

Maintenance

3 chronic conditions
added

Sickle Cell

COPD

ESRD/CKD
3. Overall quality
assurance
2. Health literacy

New materials
developed

Culturally and
literacy adjusted
3. Product donation

Guarantee of $33MM

Savings and
investment of
$58.5MM
DATA ON FILE with PHS INC
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
22
The Next Generation
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
23
Community-Based Care Team Initiative

7 DISEASE STATES

Including a Unique Component
for Mental Health Care

Asthma
Diabetes
Heart Failure




Hypertension
COPD
ESRD
Sickle Cell Disease
Medical Director (1)

Serve as the local program champion and liaise to PHS Medical Director
Hospital- and Community-Based
Nurse Care Managers (49)

Care Management happens from within the community
Complex Care Managers (6)

Manage beneficiaries with Sickle Cell and End Stage Renal Disease

Provide referral and linkage to community support
and crisis intervention
Behavioral Health Specialists (4)

Complete in-depth Mental Health Screenings and coordinate
mental health care services
Community Health Workers (10)

Culturally concordant, community-based health workers performing
patient education and data collection
Registered Pharmacists (2)

Conduct in-depth medication review
Dietician (1)

Supports custom dietary plans and provides dietary counseling
Social Workers (4)
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
24
Care Management Intervention
8 Priorities of Care
Know How and When to Call
1 the Doctor
2 Learn About the Condition and
Set Goals
Care managers act as
coaches to provide Patients
with the knowledge and skills
for better self-management

Information

Motivation

Support

Tools

Planning skills
3 Take Medicines Correctly
4
Get Recommended Tests
and Services
5 Act to Keep the Condition in
Good Control
6 Make Lifestyle Changes and
Reduce Risks
7 Build on Strengths and
Overcome Obstacles
8 Follow Up with Specialists and
Appointments
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
25
Credibility with Advocacy Groups
and Community Resources
Advocacy Groups
Community Resources
Acknowledged
Support
Established
Relationships
Expanded Patient
Resources
Documented
Endorsements
“In short, Florida Healthy State is an innovative and beneficial
program that Floridians with chronic conditions have come to rely on
in order to continue to have access to needed support, medications,
and reliable information that improves their quality of life.”
– Cheryl Small, Executive Director,
Asthma & Allergy Foundation, Fl Chapter
“Congratulations! This is the greatest
Disease Management Program
of our time.”
– Tad P. Fisher, Executive Director,
Florida Academy of Family Physicians
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
26
Provider Outreach: A Team Approach

Medical Oversight Team: Oversight and approval of clinical policies, quality
assurance, and best practice adoption

Local Medical Director: Program champion, physician liaison, peer-to-peer
meetings on outliers, evidence-based guidelines and PDL adherence

Physician Advisory Board: Direction, review and support guidelines
Leverage Existing Partners
for Advisory Board Development
Medical
Oversight
Team
Physician
Advisory
Board
Care
Team
Local Medical
Director
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
27
Success Factors
Success Factor 1


Create a long-term, adaptable approach
Successful programs need to accommodate the changing healthcare
environment. State Medicaid agencies, beneficiaries, and practicing
physicians require programs that evolve with policy, coverage,
reimbursement and clinical guideline changes
Success Factor 2

Build a community-based care network
Success Factor 3

Empower people to improve their own health
Coac
hing
and
Educ
ation
Beha
vior
Chan
ges
Clini
cal
Chan
ges
More
Appropriate
Utilization
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
Redu
ced
Cost
28
“Sick” Care Delivery Model
Tx

Acute illness focused

Reactive

Locus of control is with
the practitioner
"My doctors told me this
morning my blood pressure
is down so low that I can
start reading the
newspapers."
Ancillary
Providers
Primary Lab
– Ronald Reagan
40th U.S. President
Passive Patient
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
29
Patient-Centered Care Model
“Each patient carries
his own doctor inside
him. We are at our best
when we give the
doctor who resides
within each patient the
chance to go to work.”
Health Information
References
Chat Rooms
Support Groups
Physician
Empowered
Patient
– Albert Schweitzer
Consumer
Organizations
Alternative
Practitioners
Tx
Treatment
Plan
Source: Von Korff M et al. Collaborative management of chronic illness – essential elements. Annals Int Med. 1997; 127:1-97-102.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
30
Managing Individuals
Physician and Patient
Defined Populations
Health Care Team
and Population
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
31
Waiting for the Big One
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
32
Shifting the Gravity of the System
$$$$
Investment
$$$
$$
Healthy
“At Risk”
Undiagnosed
Chronically Ill
Managed
Chronically Ill
Unmanaged
End
of Life
Continuum of Care
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
33
The Catch
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
34
Total Health Management (THM) Framework

Prevention/Wellness

Size of Impacted Population

Goal:
Keep
People
Healthy
Longer
Healthy/
“Worried Well”

Goal:
Manage
or Mitigate
Risk
“At Risk”
Early identification and prevention
Access to new forms of care delivery to improve
patient knowledge, self help and health
Connection to benefit design to increase coverage
for those services which prevent disease and
improve health over long term
Reducing administrative and clinical waste
Disease/Care
Management
Goal:
Diagnose
and
Reduce
Treatment
Delay
Undiagnosed
Goal:
Move to
SelfManaged
Chronically Ill
Managed
Goal:
Manage
Chronically Ill
Unmanaged
Goal:
Informed
Decisions
End
of Life
Continuum of Care
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
35
Conclusions/
Principles
Community
Based
Patient
Centered
Coordinated
Across
Providers
Driven by the
Long Term

Healthcare should be local, building upon
organizations that patients know and trust

Interventions need to be tailored to individual
patients’ needs, taking into account literacy level,
cultural background, and lifestyle

Physician buy-in and coordination of care is critical
to patient health and quality of care improvement,
as well as total cost reduction

Access to care and an investment in patient health
drives long-term results and improvements in the
healthcare system
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
36
Measure of Success
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
37
Disease Management
Evaluation and Outcomes:
The Case of Florida: A Healthy State
David Jones
Pfizer Health Solutions Inc
November 5, 2007
©2007 Pfizer Health Solutions Inc – ALL RIGHTS RESERVED
Overview

Analytical Challenges in Medicaid DM

Measures of Success

The Florida Program

Summary of Program Results

Lessons Learned
NOTE: Please do not duplicate, distribute or translate this slide presentation without the prior written consent of Pfizer Health Solutions Inc.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
39
Analytical Challenges in Medicaid DM

Lack of standards

Disparate data sources

Lab data

Current inpatient data

Self-reported

Claims

Overburdened providers

Lack of real-time data flows

High churn rate of eligible population

Imperfect contact information
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
40
InformaCare Data Import
File Imports
Medicaid
Claims,
Eligibility
Stratification
Claims Data,
Risk Score
Lab/DME
Lab Kit
Results
Pharmacy
Pharmacy
Claims
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
Pre-Auth
Utilization
Review Data
41
Methodology: Pre/Post
Pre
X
Post
X
-1
1
Care Management
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
42
Methodology: Performance vs. Projection
Expected Utilization
Utilization
Actual Utilization
97
98
99
00
Available Historic
Data Used
for Projection
01
Inception
02
03
04
Program
Period
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
43
Methodology: Control Group
Intervention Group
Control Group
vs.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
44
Methodology: Propensity Scores
Care
Managed
Patient
Propensity
Score
Non-Care
Managed
Patient
Propensity
Score
Patient A
1.0
Patient A
1.0
Patient B
1.0
Patient B
0.9
Patient C
1.0
Patient C
0.9
Patient D
0.9
Patient D
0.8
Patient E
0.9
Patient E
0.8
Patient F
0.8
Patient F
0.7
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
Care Managed
Patients
Benchmarked
Against Similar
Patients
45
Success Measurements
Patient
Educatio
n

Nurse contacts

Other care
team member
contacts

Mailings

Survey
completion
Behavior
Changes

Blood glucose
self-monitoring

Foot exam

Monitoring

Weight and
blood pressure
monitoring



Smoking
cessation
Medication
adherence
Asthma selfmanagement
More
Appropr
iate
Utilizati
on
Clinical
Changes

Hemoglobin A1c

Eye exams

Lipid profile


Blood pressure
Micro albumin
testing

Asthma
symptoms

ACE/ARB and
beta blocker use

Antibiotic
prophylaxis

Flu shots

Fewer inpatient
visits

More medical and
outpatient visits

Fewer ED visits

Fewer hospital
readmissions
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
Reduced
Cost

PMPM changes
46
Behavior
Changes
More
Appropria
te
Utilization
Clinical
Changes
Snapshot of Success: CHF
Improved Self-Care Abilities
% Patients Rarely/Never Having Trouble Following a Care Plan
85.5%
73.7%
68.0%
Impact on Utilization
57.3%
48.3%
38.8%
27.4%
40.9%
32.9%
92.3%
N=729
11%
Weighing
Selves
Daily
Checking
BP
Regularly
Following
Diet
Baseline
Exercising Medication
Compliance
Follow-up
Reduction in Acute Symptoms
35.8%
Shortness of Breath
Chest Pain/Discomfort
Dizziness, Lightheadedness,
or Systolic BP<90
Weight Gain or Increase
in Leg Swelling
Palpitations
Baseline
22.9%
15.3%
10.6%
14.5%
9.3%
11.6%
5.7%
13.0%
5.8%
-20%
N=757
-29%
ER
Visits
Inpatient
Days
Outpatient
Visits
Most Recent Follow-up
Note: Analyses show results through 12/04 (left) and through 9/05 (right) – Data on file with PHS Inc.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
47
Behavioral Changes
Asthma: Improved Symptom Monitoring*
CHF: Better Weight Monitoring*
Patients Using a Peak Flow Meter at Home
Patients Weighing Themselves Daily
46%
68%
64%
Most Recent
Follow-up
Peak flow meter user
Non-user
Diabetes: Improved Self-Monitoring**
Patients Not Checking Their Feet
5.0%
% of Patients
13%
Baseline
(n=718)
1.3%
Most Recent
Follow-up
Most Recent
Follow-up
Hypertension: Special Diet Adherence**, 1
% Increase in Patients
Following a Special Diet
Baseline
(n=1,218)
Baseline
(n=2,830)
% of Patients
36%
32%
Baseline
25%
28%
18%
6-Month
Follow-up
(n=655)
12-Month
Follow-up
(n=627)
18-Month
Follow-up
(n=367)
* Data collected between 11/2001 – 9/2005. Data on file with PHS Inc.
** Data did not migrate from CMS to InformaCare in 6/2004, and therefore was collected between 11/2001 – 5/2004.
1 Populations differ across periods but have significant common membership; baseline scores for each population are similar, allowing comparison across periods.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
48
Clinical Indicators
Asthma: Improvement in Symptoms*
Congestive Heart Failure: Drop in Severity*
NHLBI Classification
Change in NYHA Class
(Baseline to Most Recent Follow-up)
21%
11%
21%
45
%
36%
25%
19%
Baseline (n=3,995)
Most Recent Follow-up
Mild Intermittent
Moderate Persistent
77.1%
% of Patients
(n=718)
21%
Mild Persistent
Severe Persistent
Diabetes: Lower HbA1c Values*
45.5%
22.9%
31.6%
Improved (lower) or
Maintained (upper)
Regressed
Hypertension: Sustained, Improved BP*1
50.0%
43.9%
(n=1,194)
Baseline
Most Recent
Follow-up
% Increase in Patients
with BP<140/90
Percentage with Mean HbA1c Value  7.0
Baseline
35%
20%
6-Month
Follow-up
(n=1,278)
24%
12-Month
Follow-up
(n=905)
28%
18-Month
Follow-up
(n=598)
24-Month+
Follow-up
(n=669)
* Data collected between 11/2001 – 9/2005. Data on file with PHS Inc.
1 Populations differ across periods but have significant common membership; baseline scores for each population are similar, allowing comparison across periods.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
49
FAHS Quality Outcomes
Lab Data Collection*
Enhanced Clinical Outcomes from Better Data Collection
Patients with One Or More Lab Values
Patients with Two or More Lab Values
60%
90%
82%
81%
80%
50%
48%
79%
71%
70%
52%
40%
66%
38%
32%
44%
31%
60%
50%
54%
62%
30%
24%
25%
47%
20%
18%
40%
41%
30%
Dec-04
10%
Dec-05
0%
Dec-04
Dec-06
HDL & LDL
HbA1c
Dec-05
Dec-06
Total Cholesterol
Source: InformaCare. Data on file with PHS Inc.
Note: Sample includes only patients who have been care managed for more than six months.
N (12/2004) = 4,086; N (12/2005) = 4,210; N(12/2006) = 3,277.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
50
Buy-In from Physicians
Key Physician Satisfaction Indicators
Percentage of Physicians Very or Somewhat Likely to Recommend Program to…
80.8%
Other Physicians
88.4%
Chronically Ill Patients
Positive Program Impact on Patients
High Overall Program Satisfaction
Percentage of Physicians Agreeing or Disagreeing
Percentage of Physicians Expressing Satisfaction
Improved Health
Status
Improves
Understanding
of Disease
Improves Self
Management
70.7%
5.1%
79.0%
8.0%
73.3%
5.8%
Strongly Disagree/Disagree
Strongly Agree/Agree
73.2%
Overall
Satisfaction with
FAHS
8.2%
76.3%
Quality of
Information in
Patient Report1
Clinical
Knowledge of
Care Managers
3.1%
73.3%
1.1%
Dissatisfied/Very Dissatisfied
Very Satisfied/Satisfied
Source: 2005 Provider Satisfaction Survey. N = 181 responding physician who had heard of FAHS. Data on file with PHS Inc.
1 Patient reports are provided to physicians and reflect either acute care issues or periodic follow-up.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
51
Impact on Utilization*
Percentage Change in Utilization
11
2
0
0
1
2
3
-2
-3
-7
-11
-12
CHF
Diabetes
Hypertension
Asthma
-13
-20
-29
ER Visits
-29
Hospitalizations
Outpatient Visits
Rx Use
Methods: Direct-adjustment, high-risk care managed vs. high-risk non-care managed. Shows all utilization, both disease-related and
non-disease-related. Shows impact after 12 months of care management.
* Data collected 11/2001 – 9/2005. Data on file with PHS Inc.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
52
External Validation – Impact on Utilization
“[O]ur findings support the conclusion that meaningful reductions in inpatient
days and ER visits can be achieved on a large-scale among Medicaid recipients
in geographically diverse regions within a large state.”
– Afifi, et al., Preventive Medicine, 2007
Utilization Change Among Care Managed Participants
Per-participant Annual Decline in Units of Utilization in Care-Managed Patients vs. Non-Care-Managed
0.2
-0.5
-0.4
-0.4
-0.2
-0.5
-0.6
0.2
-0.1
-0.4
CHF
-1.0
Diabetes
Hypertension
Asthma
-2.5
ER Visits
Inpatient Days
Outpatient Visits
Notes: N=3,902. Analysis includes only SSI patients in the post-care-management period.
Based on data collected 11/2001 – 11/2004. Data on file with PHS Inc.
Source: Afifi, A. A., Morisky, D.E., Kominski, G.F., Kotlerman, J.B. Impact of disease management on health care utilization: Evidence
from the “Florida: A Healthy State (FAHS)” Medicaid Program. Preventive Medicine (2007), doi:10.1016/j.ypmed.2007.02.002.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
53
Lessons Learned

Aggregate data as much as possible –
no pain, no gain

Focus and simplify

Reports

Findings

Internal and external communications

Resulting quality initiatives

Strive for transparency

Analyze across the value chain
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
54
Reform Focus:
Improving Quality and Efficiency in the
Healthcare System
Mary Kay Owens, RPh., CPh.
President,
Southeastern Consultants, Inc.
November 5, 2007
©2007 Pfizer Health Solutions Inc – ALL RIGHTS RESERVED
Discussion Topics



Overview of Reform Efforts

State Strategies

Basic Principles
Improving Quality and Efficiency in the Healthcare System

SEC Analyses: Cost of Uncoordinated Care

Strategies to Improve Care Coordination and Quality

New Approaches for “True Reform”
Florida Reform Plan

Florida Reform Plan Expansion Status
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
56
Overview of Reform Efforts
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
57
State Medicaid Strategies to
Expand and Reform Health Programs

Offer multiple benefit packages based on needed
service levels

Public/private partnerships — private plans to
administer benefits

Increased and/or sliding scale cost sharing based on
income and benefit packages

Incentives for promoting health behaviors

Subsidize employer coverage for low-income families

Expanding Medicaid and SCHIP programs

Coverage for uninsured
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
58
Basic Principles of Reform

Focus on more efficient models in coordination of care and
delivery of services

Improve the quality of care while reducing
unnecessary costs

Utilize technology to improve coordination and delivery

Engage and reward providers and patients as active
responsible participants

Seek to improve efficiency and quality without reducing
access to needed services

Do not use cost reduction as the single measure of success

Expansion of MCO enrollment alone is not necessarily
going to achieve the reform goals
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
59
Overview and Findings of SEC
Multi-State Medicaid Claims Analysis
Identifying and Quantifying the Costs of
Uncoordinated Care
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
60
Goal of Analysis: Identify Uncoordinated Care
SEC Has Determined that the Vast Majority of Utilization
Outliers Are Directly Correlated with:

Excessive and/or inefficient utilization patterns such as
duplicative and excessive drugs and medical services

Uncoordinated access behaviors, which contribute to
much higher than expected costs, compared to similar
non-outliers with same demographic, disease, and
severity profiles

Behaviors may include using many different prescribers and
pharmacies, accessing the ER for primary care, excessive
narcotic use, and others
SEC independent claims data analysis completed 2005-07.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
61
Key Findings
Utilization Outliers with Uncoordinated Care:

Represent a small subset of patients (<10%)

Account for over 30% of total spending

Represented in:

All disease, co-morbidity, and severity of illness groups

Cost groups (very low to very high)

All eligibility groups (TANF and ABD)
SEC independent claims data analysis completed 2005-07.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
62
State Example: Number of Co-Morbid Conditions
for Selected Major Diseases
Medicaid-Only (Excludes Duals and LTC groups)
16%
18%
29%
6%
39%
9%
33%
6%
9%
41%
10%
11%
13%
10%
16%
24%
20%
13%
12%
14%
14%
20%
15%
12%
13%
21%
12%
8%
7%
Asthma/
COPD
Depression
13%
12%
8%
2%
Cardiac
3
2
12%
1
13%
15%
17%
12%
8%
5%
Diabetes
12%
5%
6%
10%
Inflamm.
Cond.
Seizure
Psychosis
4
12%
17%
26%
15%
10%
6+
5
0
SEC independent claims data analysis completed 2005-07.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
63
State Example: Utilization Outliers
Utilization and Cost Percentages Medicaid-Only
(Excludes Duals and LTC Groups)
46%
45%
32%
36%
Percent
Medical
Costs
Percent All Costs
(Drug + Medical)
$1.8 B
10%
Percent
Patients
Percent
Percent
Prescription Prescriptions
Costs
SEC independent claims data analysis completed 2005-07.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
64
State Example: Outliers
Per Patient Utilization and Cost Comparison
Medicaid-Only (Excluding Duals and LTC Groups)
$3,477
Average Annual Medical
(non-Rx) Cost Per Patient
Average Annual Number
of Prescriptions Per Patient
Average Annual
Prescription Cost
Per Patient
$13,487
12
87
$766
$5,389
Outliers
Non-Outliers
SEC independent claims data analysis completed 2005-07.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
65
State Example:
Average Contribution of Cost Components
Outliers vs. Non-Outliers*
Medicaid-Only (Excludes Duals and LTC groups)
Lab
Out Pt/Hm Hlth
ER
Pharmacy
Practioner
Hospital
$189
$1,039
$1,669
$4,907
$5,295
$46
$714
$1,340
$506
$2,001
Outlier $15,100
$222
$287
Non-Outlier $3,116
* This includes patients that received at least one prescription.
Note: Less than 3% of patients in either group used personal care services, and these cost are excluded.
SEC independent claims data analysis completed 2005-07.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
66
State Example:
Avoidable Medicaid ER Visits and Cost
ER Cost
ER Visits
9,869
$9.8 M
55,917
30,501
69,971
56%
$59.9 M
$25.1 M
30%
$10.3 M
29,601
Total ER Visits = 125,888
Not Preventable and Other
Preventable/Avoidable
$5 M
Total ER Cost = $85 Million
Emergent/Primary Care Treatable
Non-emergent
Source: The classification system is from Billings, J., et al. Emergency Department Use: The New York Story. The Commonwealth
Fund Issue Brief, November 2000.
SEC independent claims data analysis completed 2005-07.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
67
State Example: Outliers
Medical and Drug Cost Data Comparison by Number of Prescribers
Medicaid-Only (Excludes Duals and LTC groups)
$8,562
Average Annual
Drug Cost
$5,226
$3,635
$2,131
$724
$18,433
$13,714
Average Annual
Medical (non-Rx) Cost
$8,953
$5,646
$2,274
$0
$5,000
1-3
$10,000
4-5
6-8
$15,000
9-11
$20,000
12-35
SEC independent claims data analysis completed 2005-07.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
68
State Example: Percent Recipients by Cost Groups
Comparison of Utilization Outliers vs. Non-Outliers by Total Cost Groups
(Percentage and Number of Recipients)
Outliers
Non-Outliers
Total Recipients
51,386
26,777
91%
12,658
2,509
97%
6,925
57%
43%
70%
3%
$500-$999
9%
30%
57%
43%
$1,000$4,999
$5,000$9,999
$10,000$19,999
1,942
$20,000$29,999
$30,000$49,999
1,805
59%
41%
$50,000$99,999
560
59%
41%
49%
51%
≥$100,000
Total Cost Groups (Medical and Drug Costs)
SEC independent claims data analysis completed 2005-07.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
69
State Example:
Percent Total Dollars by Cost Groups
Comparison of Utilization Outliers vs. Non-Outliers by Cost Groups
(Percentage and Amount of Total Cost)
$130 M
Total Dollar Amounts
$123 M
Outliers
Non-Outliers
$97 M
$87 M
58%
$82 M
$74 M
90%
58%
$61 M
47%
69%
59%
57%
$19 M
42%
42%
97%
3%
$500-$999
10%
$1,000$4,999
31%
$5,000$9,999
43%
$10,000$19,999
$20,000$29,999
53%
41%
$30,000$49,999
$50,000$99,999
≥$100,000
Total Cost Groups (Medical and Drug Costs)
SEC independent claims data analysis completed 2005-07.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
70
Recommended Strategies to Improve
Coordination and Quality of Care in
“True” Reform Efforts
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
71
States Undertaking New Medicaid Cost
Containment Strategies FY 2002–2007
50 50 50
46
48
46
43
43
32
29
27
26
25
22
21
18
18
20
19
18
17
15
8
9
8
7
9
5
Controlling Drug Reducing/ Freezing
Costs
Provider Payments
Implemented 2002
Reducing/
Restricting
Eligibility
Implemented 2003
8
Implemented 2004
11
9
4
Reducing Benefits
26
13
17
14
12
10
10
10
7
3
Increasing
Copayments
Implemented 2005
Disease
Management
Implemented 2006
Long-Term Care
* Adopted for 2007
NOTE: Past survey results indicate not all adopted actions are implemented.
SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management
Associates, September and December 2003, October 2004, October 2005, October 2006.
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
72
New Approaches:
Improve Coordination and Quality

Coordination of Care Via DM/CM Programs – Address multiple
conditions due to the high co morbidity profile of the Medicaid
population DM/CM programs have evolved from a single disease
focus to a comprehensive health focus addressing multiple
diseases

Targeted Intervention Approach – Due to the identified
patterns among a small subset of patients who exhibit
uncoordinated care (multiple providers and duplicative services)
yet consume over 30% of total dollars

New Provider Reimbursement Models – Recognized need to
engage providers in a more active coordination of care role with
appropriate financial incentives (i.e., FL Asthmatic ER
Diversion Program)
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
73
New Approaches:
Improve Coordination and Quality

Patient Incentive Programs


Health Information Technology Systems and Tools


Offer rewards for healthy behaviors, compliance, and active
participation in treatment
Adopt and integrate health information technology and
systems to promote care/disease management, utilization
management, and compliance
Restructure/Coordinate Utilization Review/Audit Programs

Drug Use Review (DUR) programs, surveillance and
utilization review (SURS), and audit and investigative services
need to be coordinated with each other in terms of common
exception criteria applied, procedures for referrals and followup, and clear goals for success
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
74
“True” Reform: Implications of Coordinating Care

Drive changes in service delivery and payment
mechanisms

Dramatically reduce unnecessary health care expenditures
while maintaining existing services and access

Ease the cost of care burden in the future

Greatly enhance patient outcomes

Preserve existing scope of services

Expand access to care (i.e., to uninsured)
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
75
What Do We Need To Do?

Encourage states and private plans to identify, quantify, and
target uncoordinated care with direct provider incentive
strategies and enhanced tools

Focus their efforts on utilization reduction, intervention and
monitoring for the outliers (5–10%), rather than apply access
barriers to everyone in population

Carefully monitor cost sharing and access policies to encourage
appropriate utilization without denying needed care

Support state and federal efforts that increase access and
enhance continuity of care

Consistent messaging among insurers/plans, legislative/ policy
makers, providers, and patient advocates
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
76
Florida Medicaid
Reform Plan
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
77
Key Elements of Florida Medicaid Reform

Outreach Efforts with Choice Counseling

Use Existing Delivery Systems



New Options / Choice




Coordinated Systems of Care
HMOs and Provider Service Networks (PSNs)
Customized plans based on needs
Enhanced benefits for good patient behaviors
Opt-Out of Medicaid for employer coverage
Financing


Premium based
Risk-Adjusted premiums
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
78
Florida Reform Timeline
May
2005

Reform authorized by Florida Legislature in SB838
December
2005

Waiver approved by Florida Legislature in HB3-B
September
2006

Enrollment began for Duval and Broward counties

Enrollment began for Baker, Clay, and
Nassau counties
September
2007
Current Total Enrollment
as of Sept 2007 is 179,903
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
79
Eligibility

Auto assignment if plan not selected within 30 days

Lock-in for 12 months; can change first 90 days

Mandatory minimum benefits for children and pregnant
women, for others must be actuarially equivalent to current
mandated benefits
Eligibility Groups
Mandatory:
TANF, aged and disabled adults/children
(SSI) groups
Voluntary:
Dual eligibles, developmentally disabled,
foster children, and SOBRA groups
Excluded:
Hospice, LTC, medically needy, and
breast/cervical cancer groups
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
80
Customized Plans

Customized Benefit Packages

Reform health plans create benefits to meet beneficiaries’
needs so they can choose package

Benefit packages include all federally required benefits

Benefit packages must have the same actuarial value as the
current Medicaid benefit package
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
81
Enhanced Benefits

Promotes self involvement in one’s health care needs

Rewards for participation in healthy behaviors with positive
outcomes and improving health status

Rewards are in form of credit dollars ($125/yr) to be used to
purchase health-related products and supplies

Over 111,000 beneficiaries have received credits for health
behaviors, totaling $5,997,201 in credit dollars

As of August 9,000 unique beneficiaries have used
$260,691 in credits

4,475 recipients have earned the annual cap of $125
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
82
Opt-Out Program

Employed Medicaid beneficiaries offered choice to opt-out
of Medicaid and direct their Medicaid paid premium to an
employer-sponsored plan

If beneficiary chooses to opt-out, state pays up to the
amount it would have paid a Medicaid plan toward the
employee’s share of premium

Families can combine premiums to purchase family
coverage through their employer
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
83
Risk-Adjusted Premiums


Risk-Adjusted Rates

Process to predict health care expenses based on chronic
diagnoses identified by drug claims data

Distributes capitation payments across health plans based
on aggregate health risk of members enrolled in each
health plan
Risk-Adjusted Process

Matches payment to risk

Pay for risk associated with each plan’s enrolled population
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
84
Evaluation of FL Pilot and Status of Expansion

Medicaid Inspector General released program review report Sept 2007
Findings

Problems with access to needed medications and lack of information
regarding HMO formulary covered drugs
 Provider networks insufficient in access to specialists and did not
provide accurate data on participating PCPs during choice counseling
and plan selection process
 No available encounter data from plans to evaluate performance and
access to services or cost effectiveness
 No consolidated complaint system in place
Conclusion

Reform expansion should not proceed until all issues are
addressed
©2007 Pfizer Health Solutions Inc. All Rights Reserved.
85
Mary Kay Owens, R.Ph., C.Ph.
President and Principal Consultant
Southeastern Consultants, Inc.
3019 N. Shannon Lakes Dr., Suite 202
Tallahassee, Florida 32309
(850) 668-8524 | [email protected]
www.sec-rx.com
©2007 Pfizer Health Solutions Inc – ALL RIGHTS RESERVED