View
4
Download
0
Category
Preview:
Citation preview
1
Data Jam May 2017Understanding Your Population with the
Medicaid Utilization: Services and Costs Report
Scott Wetzler, PhDMontefiore Medical CenterWednesday, May 31, 2017
CMS Change Package: Primary and Secondary Drivers
Patient and Family-Centered Care Design
1.1 Patient & family engagement 1.2 Team-based relationships 1.3 Population management 1.4 Practice as a community partner1.5 Coordinated care delivery 1.6 Organized, evidence-based care1.7 Enhanced access
Continuous, Data-Driven Quality Improvement
2.1 Engaged and committed leadership 2.2 QI strategy supporting a culture of quality and safety 2.3 Transparent measurement and monitoring2.4 Optimal use of HIT
Sustainable Business Operations
3.1 Strategic use of practice revenue 3.2 Staff vitality and joy in work 3.3 Capability to analyze and document value 3.4 Efficiency of operation
President and CEO
University Behavioral Associates
Scott Wetzler, PhD
3
Data Jam Objectives
By the end of this session, participants will :
1. Understand how their utilization reports are generated
2. Know how to analyze a sample Services & Cost Report
3. Be able to evaluate reports generated from different patient populations
4. Begin to integrate report elements into their transformation plan for value based payment contracting
4
Medicaid Data Warehouse (MDW)
• New York State Department of Health stores all claims submitted to Medicaid in their Medicaid Data Warehouse (MDW)
• MMC has a Data Exchange Agreement for the Care Transitions Network to:- Access Medicaid claims of members served by Network enrollees
- Aggregate all claims for an organization’s population
- Classify claims into service categories to create reports illustrating the service utilization and cost patterns of an organization’s population
- Distribute reports to enrolled organizations to inform and support risk contracting
• Note:- Organization or provider NPI may be used to identify your population
- Due to the time lag inherent in claims data, each year of data is generated with a 3-month run-out to improve completeness and maximize comparability
- Completion factor needed to fully understand total costs
5
Report Structure
I. Population Overview• Number of members, months of service, health plan information
II. Service Categories, Subcategories, and Associated Cost Totals
III. Cost Analysis in PMPM (“per member per month”)• In organization vs. out of organization (excluding pharmacy & case management)• Medical vs. behavioral (excluding pharmacy & case management)• By aid category (HARP vs. SSI vs. TANF/SN populations)
*Each section includes a two year look-back
6
Outpatient
•Medical (PCP)
•Medical (specialty)
•Mental health
•Alcohol & opiate dependence
•Hospital-based outpatient services
Hospitalizations
•Medical
•Mental health
•Drug & alcohol
Pharmacy ER Visits
•Medical
•Behavioral health
Additional Services
•Home health
•Case management
•HCBS
•Nursing facility
•Transportation
•Test, labs, x-rays
•Durable medical equipment
•Miscellaneous
Medicaid Utilization: Services & CostCare Transitions Network
Montefiore Psychiatry Clinics: Glebe, Moses, Wakefield
Population 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14
Adult Members with Utilization1 5177 4976 4746
Member Months Total 61421 59498 56854
Dual Eligible Members with Medicare 724 711 713
HARP 2061 2039 2007
SSI 1624 1584 1557
TANF/SN 1492 1353 1182
Health Plan Population2 8/1/15 - 7/31/16
HealthFirst 1535 (29%)
Fee For Service3 1257 (24%)
Affinity 655 (12%)
Fidelis 545 (10%)
MetroPlus 393 (7%)
Other Health Plans 906 (17%)
Member Outpatient Behavioral Health Visit Count 8/1/15 - 7/31/16
1-2 Visits 517 (12%)
3-5 Visits 899 (20%)
6-10 Visits 1357 (30%)
11 or More Visits 1679 (38%)
Section (I) Population Overview
7
Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14
OUTPATIENT SERVICES
Medical - PCP4 Visits Per 1000 Members 11472 9148 11185
Total Cost5 $5,833,388 (7%) $4,514,226 (6%) $5,594,729 (7%)
Medical - SpecialtyVisits Per 1000 Members 4255 4960 4562
Total Cost5 $3,508,147 (4%) $3,571,521 (5%) $2,759,128 (4%)
Mental HealthVisits Per 1000 Members 4547 7112 5558
Total Cost5 $3,243,109 (4%) $4,886,265 (6%) $3,823,376 (5%)
Alcohol & Opiates Dependence TreatmentVisits Per 1000 Members 7068 11337 10551
Total Cost5 $1,935,252 (2%) $2,985,966 (4%) $2,318,054 (3%)
Hospital based Outpatient Services Total Cost(Injection Therapy, Diagnostics, Other Imaging)
$1,024,062 (1%) $698,521 (1%) $593,904 (1%)
PMPM6 (%) $253 (20%) $280 (22%) $265 (23%)
OUTPATIENT TOTAL $15,543,958 $16,656,499 $15,089,189
OUTPATIENT
Section (II) Service Categories
8
11%
Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14
HOSPITALIZATION
Medical
Average LOS 5 5 5
Days Per 1000 Members 958 945 903
Discharge Per 1000 Members 190 172 172
Total Cost5 $7,465,477 $6,826,430 $5,973,079
Mental Health
Average LOS 15 15 17
Days Per 1000 Members 1216 1193 1298
Discharge Per 1000 Members 81 81 77
Total Cost5 $4,261,143 $4,508,504 $4,727,604
Drug and Alcohol (D&A)
Average LOS 7 6 7
Days Per 1000 Members 178 260 304
Discharge Per 1000 Members 27 42 43
Total Cost5 $464,457 $562,160 $641,010
PMPM6 (%) $198 (16%) $200 (16%) $199 (17%)
HOSPITALIZATION TOTAL $12,191,077 $11,897,094 $11,341,693
Section (II) Service Categories
9
HOSPITALIZATIONS
Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14
ER VISITS
ER Visits
ER Visits Per 1000 Members 779 409 495
Medical Percentage7 85% 80% 82%
Behavioral Health Percentage 15% 20% 18%
PMPM6 (%) $16 (1%) $7 (1%) $8 (1%)
ER TOTAL $998,062 $400,544 $438,143
Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14
PHARMACY
Pharmacy Prescriptions Per 1000 Members 50739 49710 48773
PMPM6 (%) $325 (25%) $349 (28%) $303 (26%)
PHARMACY TOTAL $19,949,566 $20,784,747 $17,227,201
Section (II) Service Categories
10
PHARMACY
ER VISITS
Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14
ADDITIONAL SERVICES
Home Health8 PMPM (%) $224 (18%) $188 (15%) $143 (12%)
Total Cost5 $13,746,368 $11,162,455 $8,130,854
Case Management (Health Home) PMPM (%) $69 (5%) $61 (5%) $47 (4%)
Total Cost5 $4,224,770 $3,641,158 $2,696,710
Mental Health Rehabilitation Services - HCBS PMPM (%) $26 (2%) $24 (2%) $24 (2%)
Total Cost5 $1,624,038 $1,416,672 $1,381,895
Nursing Facility (SNF) PMPM (%) $9 (1%) $5 (0%) $6 (1%)
Total Cost5 $533,660 $267,749 $340,931
Transportation PMPM (%) $36 (3%) $29 (2%) $24 (2%)
Total Cost5 $2,218,361 $1,753,998 $1,389,435
Test, Labs, X-Rays PMPM (%) $30 (2%) $20 (2%) $20 (2%)
Total Cost5 $1,815,669 $1,166,719 $1,134,368
Durable Medical Equipment (DME) PMPM (%) $10 (1%) $9 (1%) $10 (1%)
Total Cost5 $625,437 $563,505 $592,209
Miscellaneous PMPM (%) $82 (6%) $87 (7%) $97 (8%)
Total Cost5 $5,010,179 $5,202,975 $5,489,414
ADDITIONAL SERVICES TOTAL $29,798,482 $25,175,230 $21,155,818
ADDITIONAL SERVICES
Section (II) Service Categories
11
Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14
TOTAL PMPM6 (%)
Total PMPM $1,278 $1,259 $1,148
NON PHARMACY PMPM6 (%)
Montefiore PMPM $300 (34%) $254 (30%) $210 (26%)
Outside of Montefiore PMPM $584 (66%) $595 (70%) $587 (74%)
PMPM Total $884 $849 $797
Medical PMPM Total $611 (69%) $544 (64%) $492 (62%)
Behavioral Health PMPM Total $273 (31%) $304 (36%) $306 (38%)
HARP PMPM9 $1,568 $1,625 $1,506
SSI PMPM9 $1,220 $1,189 $1,038
TANF/SN PMPM9
$929 $783 $679
Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14
UTILIZATION TOTAL COST
UTILIZATION TOTAL $78,481,144 $74,914,114 $65,252,044
PMPM TOTAL6 $1,278 $1,259 $1,148
TOTAL COST
Section (II) Service Categories
12
Section (III) Cost Analysis
Cost Trends using Look-Back Periods
13
$265 $280 $253
$199 $200 $198
$303 $349 $325
$8 $7
$16
$372 $423 $485
$1148 $1259 $1278
$-
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
2 Year Look-back 1 Year Look-back Target Year
Column1
Additional Services
ER Visits
Pharmacy
Hospitalization
Outpatient
* Increasing costs may due to population selection (we selected people in care during target year, and they may not have been in treatment in prior years)
Health Care Cost Comparisons
14
Medical Services
24%
Mental & Behavioral
Health Services
13%Pharmacy25%
Additional Services
38%
OMH ClinicsTotal PMPM
$1278
Conclusions from Sample Report
• Majority of costs are medical and pharmacy, even though these patients were identified through attendance at a mental health clinic
• Costs are stable over time
• A high proportion of spending is pharmacy
• Overall expenditures relative to rates (HARP, SSI, etc.)
Elaborations on the MDW report:
• Calculate completion factors for category and total costs (in progress)
• Identify high and frequent users
• Post hoc analyses of population by diagnosis
• Considerations for value contracting (*medical services)
15
16
Comparing Reports Between PopulationsMental Health Clinics Substance Abuse Clinics
Clinic Comparisons
17
Article 31: Department of Psychiatry
• Three mental health clinics licensed by OMH
• Focus on treatment and recovery of persons with a mental illness
• Services include:• outpatient psychiatric evaluation and
treatment
• medical care *primary care offered at one location
Article 32: Division of Substance Abuse
• Three substance abuse clinics licensed by OASAS
• Focus on treatment and recovery of persons with a substance use disorder
• Services include:- substance abuse treatment- medication-assisted opioid treatment- medical care *primary care on-site
o Hep C & HIV prevalence
*Value labels removed for values <$70 PMPM
$151
$122
$152
$152
$611 $1,022
$325
$258
$485
OASAS
OMH
18
Health Care Cost Comparisons (PMPM)
Total PMPM$1278
Total PMPM$2285
Health Care Cost Comparisons
19
Medical Services
14%
Mental & Behavioral
Health Services
30%
Pharmacy45%
Additional Services
11%
OASAS ClinicsTotal PMPM
$2285
Medical Services
24%
Mental & Behavioral
Health Services
13%Pharmacy25%
Additional Services
38%
OMH ClinicsTotal PMPM
$1278
Conclusions from Report Comparisons
• Total dollars spent PMPM
• Relative areas of higher spending- Pharmacy
- Outpatient services for Drug & Alcohol
• Different populations have different patterns of utilization and different total costs
- Substance use patients have much more total cost
- Increased cost is not driven solely by substance abuse treatment costs
20
Key Considerations for Contracting
• High cost areas for greatest impact- Improving loyalty for medical care as well as behavioral care
- Intervening around medical care as well as behavioral care (Hep C)
- High cost areas differ by population
• Reducing hospitalizations by increasing outpatient engagement
21
Questions?
22
23
Thank you!www.CareTransitionsNetwork.org
CareTransitions@TheNationalCouncil.org
The project described was supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. Disclaimer: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
Recommended