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The SCAN FoundationDefining the Business Case
for Targeted Care Coordination

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January 22, 2015

• Defining the Business Case for Targeted Care
  Coordination
• Featuring
• Gretchen Alkema, Ph.D.
• VP Policy Communications, The SCAN Foundation
• Dianne Munevar
• Director of Data Analytics, Avalere Health
• Sally Rodriguez
• Director of Business Intelligence for Healthcare
  Providers, Avalere Health

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Agenda

• Introduction
• Effective Management of High-Risk Medicare
  Populations
• QA

4
Effective Management of High-Risk Medicare
Populations
January 2015 avalere.com
5
Avalere Team Presenting Today
6
Overview

• The goals of the collaborative work between the
  scan foundation and avalere were to

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Webinar Agenda

• The Opportunity to Take a More Proactive Stance
  on Managing Risk
• Identifying High-Risk Beneficiaries
• The Opportunity to Enhance the Use of Patient
  Care Surveys
• Estimating the ROI from Effective Care Transition
  and Coordination Interventions
• Key Takeaways
• Discussion

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The Opportunity to Take a More Proactive Stance
on Managing Risk
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The Health Care Delivery System Is Evolving to
Reward Value Over Volume

• FEE-FOR-SERVICE (FFS) - THE TRADITIONAL APPROACH
  TO PAYMENT - VIEWED AS INSUFFICIENT AT CONTAINING
  COSTS

PAST Rewards Volume FUTURE Rewards Quality and Efficiency
Siloed FFS Volume-based rewards Limited coordination or shared risk Value-based purchasing Public reporting Bundled payments Direct link between payment and outcomes Greater focus on care coordination and prevention
FFS Fee-for-service
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To Succeed In the Evolving Environment, Providers
and Health Plans Need Strategies To Mitigate Risk
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However, Most MA Plans and Providers Rely Only On
Administrative Claims Data To Identify High-Risk
Members
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Non-Medical Characteristics Are Critical to Care
Coordination and Can Increase Utilization and
Spending
13
Identifying High-Risk Beneficiaries
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Medical Characteristics Associated with Being At
Risk For High Healthcare Utilization and Spending

• MEDICAL ISSUES RELATED TO HIGH-RISK BENEFICIARIES
  ARE EXPECTED

Patient-Level Characteristic Increase in Probability1
High Medicare spending in the prior year (PMPM)2 11.3 8.8
Diabetes with complications 8.8
Neurological or psychological conditions, respectively 8.8 6.4
AMI or vascular conditions without complications, respectively 8.6 7.5
Kidney disease 6.8

1. Average percentage point increase for patients
having the factor based on a logistic regression
model using the validation sample (2009 and 2010
data) and are rounded to the nearest tenth
decimal 2. Defined as being in the top 10 or 20
percent of Medicare spending, respectively, based
on a Per Member Per Month estimate
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Looking Beyond Medical Information

• HOWEVER, AND POTENTIALLY MORE IMPORTANTLY, SOME
  NON-MEDICAL CHARACTERISTICS INCREASE THE
  PROBABILITY OF BEING HIGH-RISK THAT CANNOT BE
  DEFINITIVELY IDENTIFIED USING ADMINISTRATIVE
  CLAIMS

Patient-Level Characteristic Increase in Probability1
High home health (41 or more visits)3 16.2
Self-reported fair or poor health status 8.1
High hospital outpatient (34 or more visits) utilization in the prior year3 7.8
Functional impairment (between 2 and 5 ADLs and/or IADLs) 6.9
Age 85 and older 6.6

1. Average percentage point increase for patients
   having the factor based on a logistic regression
   model using the validation sample (2009 and 2010
   data) and are rounded to the nearest tenth
   decimal
2. High utilization is defined as being in the top
   75th percentile of the number of stays
   (inpatient services) or visits (ambulatory care)
   in the prior year
3. Estimates are consistent from one year to another
   but there is relatively low precision of
   predictive power

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The Opportunity to Enhance the Use of Patient
Care Surveys
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Patient Care Surveys Can Strengthen Risk
Stratification and Care Management Activities

• Avalere conducted a literature review and
  interviewed industry experts to evaluate the
  state of patient care surveys used by payers

• AWV Annual wellness visit CMS Centers for
  Medicare Medicaid Services

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Plans Should Leverage Other Available Data
Sources to Create a Comprehensive Patient Profile
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HRAs Can Help MA Plans Identify LTSS Needs

• Interviewees noted that hras can assess LTSS
  needs by evaluating the following domains

• ADLs and/or IADLs
• Behavioral/mental health
• Cognitive function
• Family and caregiver support
• Frailty and fall risk
• Functional status
• Living situation
• Having a regular primary care physician
• Nutrition and/or access to proper meals
• Skin issues
• Home safety
• Transportation

• LTSS Long-term supports and services ADL
  Activities of daily living IADL Instrumental
  activities of daily living

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Medical History Alone Cannot Explain High-Cost
Utilization
Likelihood of Being Top 20 High-Cost
High-Cost Utilization
Total Payment
Patient Profile

• Forgetful
• No family in the area
• Smoker (1 pack/ day)
• Widowed/ lives alone
• No exercise
• High blood pressure
• High glucose levels
• High sodium levels
• Bone loss
• Diabetes
• Age 91
• High Medicare spending prior year

?
128k
35
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Using Comprehensive Patient Data Helps Prevent
High-Cost Surprises
Patient Profile
Likelihood of Being Top 20 High-Cost
High-Cost Utilization
Total Payment

• Case Management Input
• Forgetful, sometimes agitated
• No family in the area
• Bored during the day
• HRA
• Smoker (1 pack/ day)
• Widowed/ lives alone
• No exercise
• Improper nutrition
• Medical Record
• High blood pressure
• High glucose levels
• Bone loss
• History of falls
• Claims Data
• Diabetes

80
75
128k
45
35
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Plans Should Use Targeted Questions in Patient
Care Surveys to Support and Inform Care
Coordination Efforts

• Although Enhanced patient care surveys may
  require more financial investment, the ability to
  meaningfully assess risk can allow plans to

Improve patient satisfaction scores
Better coordinate the care of their members
Help keep members in the community
Increase member retention rates
Support patient education and engagement efforts
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Estimating the ROI from Effective Care Transition
and Coordination Interventions
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Plans Should Support Risk Identification Efforts
with Care Management Programs To Reduce High-cost
Utilization
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Effective Care Transition and Coordination Models
Can Reduce Healthcare Utilization
Care Model Description Target Location
Focused on hospital to home Emphasizes patient engagement and discharge education for high-risk patients immediately after discharge Hospital Home
Focused on hospital to home and SNF to home Empowers patients to manage their care through the use of a transitions coach Can include a Group Visit SNF Home
Focused on hospital to home Enhances care coordination through the use of an APRN for up to three months post-discharge Hospital Home
Focused on coordinating information sharing during transitions of care (e.g., on hospital to home and SNF to home) to prevent avoidable hospitalizations Enhances communication between key care team staff (e.g., APRNs, social workers, PCPs, and geriatric teams) Hospital SNF Home
Focused on hospital to home Outlines ways to identify high-risk patients and gives providers an 11-step discharge checklist Hospital SNF Home
SNF Skilled nursing facility NH Nursing home
NP Nurse Practitioner APRN Advanced practice
registered nurse PCP Primary care physician
Project BOOST was reviewed as part of the ROI
analysis, but the result is not included in the
next slide because of the limitations of the
evidence.
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Employing Care Transition and Coordination Models
Can Lead to Positive ROI for Health Plans
Program Model Annual Cost Per Enrollee Annual Savings Per Enrollee ROI Per Year PMPM Savings
Care Transition Intervention (Group Visit) 678 4,795 607.02 343.06
Transitional Care Model 1,492 5,334 257.48 320.14
Care Transition Intervention 999 2,311 131.3 109.34
GRACE 2,201 4,291 94.96 174.17
Project RED 373 493 32.37 10.05
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MA Plans and Providers Can Strengthen Their
Programming to Realize an ROI
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Matching Appropriate Services to the Patient Has
Potential to Reduce High-Cost Utilization
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Putting It All Together
Costs
Benefits
32,000
8,000
300
30
Key Takeaways
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Key Takeaways

• To effectively manage high-risk populations,
  plans and providers must

32
The SCAN FoundationDefining the Business Case
for Targeted Care Coordination

• Q A

33
The SCAN FoundationDefining the Business Case
for Targeted Care Coordination

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Our mission is to advance a coordinated and
easily navigated system of high-quality services
for older adults that preserve dignity and
independence. Our vision is a society where
older adults can access health and supportive
services of their choosing to meet their needs.

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