The%20Perspective%20of%20the%20Industry%20on%20the%20Role%20of%20Disease%20Management%20and%20Chronic%20Care%20in%20Medicare,%20Medicaid,%20and%20Health%20Reform - PowerPoint PPT Presentation

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The%20Perspective%20of%20the%20Industry%20on%20the%20Role%20of%20Disease%20Management%20and%20Chronic%20Care%20in%20Medicare,%20Medicaid,%20and%20Health%20Reform

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96% of Medicare costs from beneficiaries with multiple chronic conditions ... Cost and quality are the challenges, and chronic conditions are driving cost ... – PowerPoint PPT presentation

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Title: The%20Perspective%20of%20the%20Industry%20on%20the%20Role%20of%20Disease%20Management%20and%20Chronic%20Care%20in%20Medicare,%20Medicaid,%20and%20Health%20Reform


1
  • The Perspective of the Industry on the Role of
    Disease Management and Chronic Care in Medicare,
    Medicaid, and Health Reform

Gordon K. Norman, MD, MBA EVP, Science
Innovation, Alere Chairman, DMAA James E. Pope,
MD, FACC EVP, Chief Science Officer,
Healthways Former Director, DMAA
2
Divergent Results from MHS
  • Disease management and population health
    improvement strategies have shown positive
    results in multiple settings, including Medicare,
    Medicaid, privately insured populations
  • Many of these successful programs had different
    conditions than Medicare Health Support pilots
  • Despite some gains, interim MHS results diverge
    from pattern of results elsewhere we need deeper
    understanding of why, in order to remedy

3
How to Reconcile Leverage
  • Probe cumulative experience to identify what
    works for whom in different settings
  • Expect incremental progress, not quantum leaps
    with novel models
  • Assess cost-effectiveness to determine impact on
    value of care
  • Expand methods of inquiry, learning beyond
    traditional approaches

4
The Industry Can Help
  • Industry should do better job of extracting,
    sharing learnings
  • Explore patient-centric medical home models for
    convergence of care management and primary care
  • Offer experience and expertise to CMS, providers,
    others in hard work of perfecting population
    health improvement incrementally

5
Chronic Disease Driving Cost
Three quarters of seniors have multiple
chronic conditions . . . .
. . . . accounting for 96 of Medicare costs
Percent of U.S. population with chronic
conditionsby age group
Percent of Medicare expenses by
beneficiarychronic condition status
Source Anderson, G. Chronic Conditions Making
the case for ongoing care. Johns Hopkins
University. November 2007.
6
Compounding Effects
Ratio of Average Spending Relative to an
Individual Aged 50 64 Years
12x
The older you get the more you have The more you
have the more it costs Heterogeneous Population
9x
5x
5x
1x
Laurence Kotlikoff and Christian Hagist, Whos
Going Broke? National Bureau of Economic
Research, Working Paper No. 11833, December 2005,
p. 25 (various sub-sources by country dated
2000-2003)
7
Medicare Health Support (MHS)
  • Eight pilots, assigned specific geographies
  • Different approaches selected to maximize
    learning
  • Allowed to modify program design based on
    learning
  • Selection of sicker individuals than average FFS
    Medicare
  • HCC1 score of 1.35 or greater required for
    eligibility
  • Average HCCs for pilots ranged 2.2 2.5
  • 20-30 of pilot participants are gt300 sicker
    than average Medicare FFS beneficiary

(1) Hierarchical Condition Category
8
Population Attributes MHS vs. FFS Medicare
  • PBPM Cost per Beneficiary per Month 3.0 X
  • Hospital Admission Rate 2.5 X
  • Hospital Bed-Days 2.5 X
  • Skilled Nursing Facilities Admit Rate 1.5 X
  • Older, sicker, higher mortality
  • Seeing 7-10 physicians on average
  • Take 10-20 medications at any point in time
  • About 1 dying each month

Source Healthways MHS program experience
9
Targeting Subpopulations
  • Identification and segmentation of high risk
    populations
  • Once identified, traditional risk scores do not
    further distinguish important sub-groups
  • Development or refinement of predictive models
    identifying segments of the high-risk population

10
Outcomes - Will We Learn Everything We Want to
Know?
  • No consistent approach each a virtual case study
  • Selection of sicker individuals than average FFS
    Medicare
  • Effect of mortality and rapidly declining cohort
    size

11
Summary
  • Cost and quality are the challenges, and chronic
    conditions are driving cost
  • The Medicare population is heterogeneous and
    important subgroups need to be identified and
    managed appropriately
  • MHS has led to important advances in evolving
    care support for the high risk, high disease
    burden subpopulation
  • Partnership and collaboration with CMS is core to
    success
  • The cure will require prevention and better
    chronic condition management
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