The 2004 Healthcare Conference

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The 2004 Healthcare Conference

• 25-27 April 2004, Scarman House, University of
  Warwick
• David Mirkin Joanne Alder

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DISEASE MANAGEMENT

• What is a DM program?
• Why do we need DM?
• Clinical Measures of Success
• Actuarial Issues in Measurement
• Does a DM program save money?

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DMAA Definition of DM

• 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
• supports the physician or practitioner/patient
  relationship and plan of care
• emphasizes prevention of exacerbations and
  complications utilizing evidence-based practice
  guide lines and patient empowerment strategies
• evaluates clinical, humanistic and economic
  outcomes on an ongoing basis with the goal of
  improving overall health.

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DMAA Definition of DM

• Disease Management Components include
• 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)

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Critical to DM Success

• Best Practice Making sure physicians know and
  use the latest treatment approaches. (evidence
  based best practice guidelines)
• Compliance Teaching patients about the disease
  and how to self-manage
• Utilization Monitoring care for appropriateness.
• Outcomes Data analysis and feedback to providers
  and patients

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Types of DM Programs

• Silo or Disease Specific Programs
• Diabetes
• CHF
• Coronary Artery Disease
• Asthma
• COPD
• Integrated DM Programs (Patients with 2 or more
  chronic diseases)

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DM Goals

• Short Term Goals and Interventions
• Identify and enroll patients with the disease.
• Assess patients risk level and assign to risk
  category.
• Improve treatment regimens.
• Reduce related hospitalizations, emergency room
  visits and ancillary services.
• Increase required outpatient screening visits and
  tests.
• Monitor pertinent clinical data.
• Improve therapy adherence.
• Increase patient satisfaction

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DM Goals

• Outcomes Long Term Goals and Measurements of
  Effect
• Improve/maintain optimal health.
• Evidence of therapy adherence.
• Improved clinical status as measured by disease
  specific clinical indicators.
• Reduced utilization of hospitalization, emergency
  room.
• Reduced specific disease related complications.
• Patient satisfaction.
• Physician compliance.

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Why Disease Management?

• A Common Lay Question Perception
• Why do we need disease management programs? I
  thought that we paid doctors to manage the
  patients. Why do we need to pay extra money to do
  what the doctors are being paid to do

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Why Disease Management?

• Outcomes which are possible (evidence based
  literature supports) are not being achieved for
  the population at risk
• Clinical
• Functional
• Financial

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The Bottom Line
Premium
KFF/HRET, 9/2003
Workers Earnings
General Inflation
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Population Outcome Failure

• Evidence based best practice not applied
• Large Variances in practices nationwide
• Poor patient compliance
• Lack of knowledge of disease
• Not empowered
• Lack of self management
• Fragmentation of Care
• Lack and Fragmentation of Resources
• Lack of system integration

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From Silos To Quality Care
Payers
Providers
Consumers/ Patients
Healthcare System DM Integration
Hospitals
Employers
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Do You Need To Have Programs For All Diseases?

• The 80-20 rule still holds
• 80 of the health care costs tend to come from
  20 of the patients, therefore thats where the
  attention should focus.

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Chronic Disease United States 2000

• US Population Year 2000 276 million
• 151 million (55) are well or have acute
  illnesses
• 125 million (45) have chronic conditions
• 125 Million With Chronic Illness
• 70 million (56) have 1 chronic Condition
• 55 million (44) have 2 or more chronic
  conditions

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Future Cost of Chronic Disease

• By 2030, 148 million Americans will have a
  chronic disease and their health bill will reach
  798 Billion.

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DM Program Outcomes Metrics

• Clinical/Functional ROI
• Decreased Morbidity
• Decreased Mortality
• Improved Quality of Life
• Financial ROI
• Cost Minimization
• Cost Benefit
• Cost Effectiveness

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CLINICAL OUTCOME METRICS FOR DIABETES
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CLINICAL OUTCOME METRICS FOR DIABETES
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Diabetes Disease Management Outcomes

• DCCT/NIH Trials
• Retinopathy ? 35 - 74
• Severe non-proliferative retinopathy and laser
  therapy ? 45
• 1st appearance any retinopathy ? 27
• Development Microalbuminuria ? 35
• Development Neuropathy ? 60

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Congestive Heart Failure Outcomes

• University of Pennsylvania Health Systems-
  Hospitalization rates dropped dramatically from
  532/1,000 patients to 19/1,000 patients.

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Ischemic Heart Disease Outcomes - Statin
Treatment Reduces CHD Events and Deaths
Milliman Actuarial Models, Framingham Risk
Scoring, NHANES III, ATP III
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Actuarial Issues in the Financial Measurement of
Disease Management Programs

• Return on Investment
• Regression to the Mean
• Statistical Credibility
• Trend Estimation
• Operational Other Issues

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Measurement of Total Program Savings

• Method One Comparison of pre-enrollment medical
  expenses (baseline year) to post enrollment
  expenses (intervention year).
• Method Two Comparison of medical expenses for a
  control group to an intervention group for like
  period.
• Method Three Comparison of requested services to
  approved services or other detailed comparisons

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Actuarial Considerations in the Measurement of
Total Program Savings

• Regression to the Mean
• Statistical Credibility
• Others
• 1. Depends on method used
• 2. Population management issues
• 3. Operational issues

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Other Considerations for Measurement of Program
Savings

• Method One Pre-enrollment expenses to post
  enrollment expense comparison
• 1. Utilisation and cost trend estimation
• 2. IBNR and claims runoff issues
• Method Two Control group versus intervention
  group expense comparison
• 1. Age/sex 4. Underwriting
• 2. Benefit design 5. Others
• 3. Industry

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Modified Exponential Modeling for AMI Admissions
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Modified Exponential Modeling for Bypass Surgery
(CABG)
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Table 3Comparison of One Year, Three Year, and
Modeled Ultimate Rates of Utilization
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Why Should We Talk About Statistical
Credibility?

• Disease populations are often small percentages
  of the total population
• Disease population is high cost, high variance
• Often savings calculations are based on only a
  portion of the health care dollar for the
  diseased members
• Savings guarantees and ROI target calculations
  need to reflect program impact rather than
  statistical fluctuation
• An ignorance of credibility can lead to faulty or
  misleading conclusions

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Typical Disease Prevalence Rates for a US
Commercial Population (Employer Insured Active
Employees)

• Diabetes 3.8 - 8.1
• Asthma 1.6 - 5.1
• CAD 1.9 - 2.6
• CHF 0.3 - 1.1
• COPD 0.3 - 1.2
• Source Disease Management News, September 25,
  2002

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Typical PMPM Claim Costs Ranges by Disease
Category for a Commercial Population (US )

• Diabetes 400 - 800
• Asthma 150 - 500
• CAD 400 - 1,300
• CHF 1,500 - 2,100
• COPD 500 - 1,400
• Source Disease Management News, September 25,
  2002

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The Choice