Soyal Momin MS, MBA September 23, 2008

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Soyal Momin MS, MBASeptember 23, 2008

Predictive Modeling 2008: The BlueCross BlueShield of

Tennessee Experience

2

Outline

• Maximizing the Value of Predictive Modeling: A Health Plan Perspective

– Care Management Challenges:

• Understand Population Care Management Needs

• Identify

• Stratify

• Triage

– Care Management Model, Implementation, Process Efficiencies

• Intervene

– Care Management Programs

• Evaluate

– Conclusions

3

Care Management Challenges: Understand Population Care Management Needs

• Cost distribution and trend over time– Quantitative assessment

• Population assessment– Qualitative assessment – clinical cost drivers based

on healthcare cost (direct cost)

• Total cost assessment – direct & indirect costs– Qualitative assessment – clinical cost drivers based

on healthcare cost and personnel cost (indirect cost)

4

Understand Population Care Management NeedsCost Distribution and Trend Over TimeCumulative Total Healthcare Cost

5

Cost Distribution and Trend Over Time Cumulative Professional and Outpatient Cost

6

Cost Distribution and Trend Over Time Cumulative Pharmacy Cost

7

Cost Distribution and Trend Over Time Cumulative Inpatient Cost

8

Understand Population Care Management Needs Population Assessment

Population Assessment is an analysis of claims and membership data to determine characteristics of a given population (Network, Region, Group) that might affect the population’s interaction with the health care system

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Propensity to Utilize Index – The average number of episodes of illness for a member month

Episode Seriousness Index – A measure of the average cost to treat the categories of illness experienced by a population

Illness Burden – A measure of the level of illness within a group determined by multiplying the propensity to utilize index by the Episode Seriousness Index

Population Assessment Major Analysis Variables

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Provider Efficiency Index – A measure of the efficiency to treat a specific episode of illness determined by dividing the cost to treat the specific episode by the average cost for the category of illness

PMPM Cost Index – An index that measures the PMPM submitted costs for a population determined by multiplying the Illness Burden by the Provider Efficiency Index

Population Assessment Major Analysis Variables, Continued

11

Population Assessment Population Profile

0

0.5

1

1.5

2

2.5

Propensity to Utilize Episode SeriousnessIndex

Provider Efficiency PMPM Cost Index

Population A Population B

12

00.020.040.060.08

0.10.120.140.16

Infectio

us Dise

ases

Endocri

nology

Hemato

logy

Psych

iatry

Chemica

l Dep

enden

cy

Neuro

logy

Ophthalmolo

gy

Cardiology

Otolar

yngo

logy

Pulmonolo

gy

Gastro

enter

ology

Hepato

logy

Nephro

logy

Urology

Obstetri

cs

Gynec

ology

Dermato

logy

Ortho &

Rhe

um

Neonato

logy

Major Practice Category

Illne

ss In

dex

Population A Population B

Population Assessment Illness Burden by Major Practice Category

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00.5

11.5

22.5

33.5

44.5

Major Practice Category

Prov

ider

Effi

cien

cy In

dex

Population A Population B

Population Assessment Provider Efficiency by Major Practice Category

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00.05

0.10.15

0.20.25

0.30.35

Infectio

us Dise

ases

Endocri

nology

Hemato

logy

Psych

iatry

Chemica

l Dep

enden

cy

Neuro

logy

Ophthalmolo

gy

Cardiology

Otolar

yngo

logy

Pulmonolo

gy

Gastro

enter

ology

Hepato

logy

Nephro

logy

Urology

Obstetri

cs

Gynec

ology

Dermato

logy

Ortho & R

heum

Neonato

logy

Major Practice Category

Cos

t Ind

ex

Population A Population B

Population Assessment PMPM Cost Index by Major Practice Category

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Direct costs are dollars paid out for medical treatment Indirect costs are labor resources lost due to illness

Direct CostsDirect Costs = Inpatient + Professional/Outpatient + Pharmacy

Indirect CostsIndirect Costs = Sick Leave + Presenteeism + Family & Medical Leave + Short Term Disability + Long Term Disability

+ Turnover + Worker’s Compensation

Understand Population Care Management Needs Total Cost Assessment

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Total Healthcare Cost = $23,237,422Total Healthcare Cost = $23,237,422$5,631 per FTE$5,631 per FTE

Direct $ = $13,761,278$3,334 / FTE

59.2%

Indirect $ = $9,476,144

$2,296 / FTE40.8%

Inpatient

$376

6.7%

Professional/Outpatient

$2,154

38.3%

Pharmacy

$804

14.3% Sick Leave

$1,322

23.5%

Presenteeism

$318

5.7%

FMLA

$274

4.9%

STD

$220

3.9%

LTD

$4

0.1%

Turnover

$74

1.3%

Work Comp

$82

1.5%

Total Healthcare Cost = $23,237,422Total Healthcare Cost = $23,237,422$5,631 per FTE$5,631 per FTE

Direct $ = $13,761,278$3,334 / FTE

59.2%

Indirect $ = $9,476,144

$2,296 / FTE40.8%

Inpatient

$376

6.7%

Professional/Outpatient

$2,154

38.3%

Pharmacy

$804

14.3% Sick Leave

$1,322

23.5%

Presenteeism

$318

5.7%

FMLA

$274

4.9%

STD

$220

3.9%

LTD

$4

0.1%

Turnover

$74

1.3%

Work Comp

$82

1.5%

Total Cost AssessmentAccount Group XYZ

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$0

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

$1,400,000

$1,600,000

$1,800,000

$2,000,000

JOIN

T DEGEN/IN

FLAM

BENIGN NEOPLASM

GASTRO INFEC/IN

FLAM

HYPERTENSION

DEPRES & ANXIETY D

IS

ORTHO DERANGE/TRAUMA

PREG & DELIVERY W

/ C-S

EC

MALIGNANT N

EOPLASM

DIABETES

RHINITIS/SINUSITIS

PREG & DELIV N

O C-S

EC

ASTHMA

CORONARY DISEASE

OTHER CARDIAC D

IS

COND ASSOC M

ENST/INFERT

GALL BLADDER DISEASE

VISUAL DISTURBANCES

HYPERLIPIDEMIA

HEREDITARY/CONGEN D

IS

MINOR O

RTHO DIS

Direct Costs Indirect Costs

Total Cost AssessmentTop 20 Cost Drivers

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• Identifying Members for Care Management – Referrals from

• Internal Sources• External Sources• An internally developed ICD9 Trigger list

– The ICD9 Trigger list included Asthma, Diabetes, High Risk OB, AIDs, Cancer, CHF, COPD etc

– High cost member report

• Case managers workload• 103/CM/Month

• High predicted cost member report

• Stratification index report

Care Management Challenges: Identify & Stratify Members for Care Management

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Commercial LOB 2005

Allowed >= $50K GROUP A

N = 9,017 (100%)

PMPM: $9,025PMPY: $108,305

Average MM: 10.98

IP PFO Rx $4,379 $4,211 $441 $52,543 $50,534 $5,289

Experience in 2006

Allowed >= $50K GROUP B

N = 1,968 (22%)

PMPM: $10,706PMPY: $128,469

Average MM: 11.12

IP PFO Rx $3,107 $6,686 $913 $37,280 $80,232 $10,957

?N = 7,049 (78%)

Eligible Members With < $50KGROUP C

N =5,180 (57%)

PMPM: $1,414PMPY: $16,966

Average MM: 10.44

MembersNot

EligibleN = 1,723 (19%)

Eligible MembersW/O Claims$N = 146 (2%)

N = 2,011,903

PMPY: $2,979

Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report (Y1Y2)

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Commercial LOB 2006

Allowed >= $50K GROUP A

N = 10,194 (100%)

PMPM: $8,772PMPY: $105,258

Average MM: 11.09

IP PFO Rx $4,110 $4,196 $467 $49,316 $50,358 $5,608

Experience in 2005

Allowed >= $50K GROUP B

N = 1,969 (19%)

PMPM: $10,155PMPY: $121,857

Average MM: 11.60

IP PFO Rx $3,285 $6,082 $761 $39,426 $72,990 $9,131

?N = 8,225 (81%)

Eligible Members With < $50KGROUP C

N =6,651 (65%)

PMPM: $1,095PMPY: $13,134

Average MM: 11.14

MembersNot

EligibleN = 1,166 (11%)

Eligible MembersW/O Claims$N = 408 (5%)

N = 2,091,256

PMPY: $2,995

Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report (Y2Y1)

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Year 2004

Commercial LOB 2004N = 1,837,214PMPY: $2,836

Allowed >= $50K N = 7,404 (100%)

PMPM: $8,910PMPY: $ 106,921

Average MM: 10.94

Year 2005

Allowed >= $50KN = 1,635 (22%)

PMPM: $10,251PMPY: $ 123,006

Average MM: 11.47

Year 2006

Allowed >= $50KGROUP D N = 650 (9%)

PMPM: $9,493PMPY: $ 113,915

Average MM: 11.24

Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report (Y1Y2Y3)

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ETGCode ETG Description Allw

%TotalAllw

ETGCode ETG Description Allowed

% TotalAllw

553 Chronic Renal Failure, w ith ESRD $47,923,994 5.4 553 Chronic Renal Failure, w ith ESRD $38,761,827 16.1

721 Joint Degeneration, Local, w / Surgery $35,771,711 4.0 656 Malignant Neoplasm of Breast w /o Surgery $10,600,438 4.4

786 Other major Neonatal d/o perinatal origin $30,891,125 3.5 75 Non-Neoplastic Blood Disease, Major $9,977,285 4.1

73 Neoplastics Disorder Blood & Ly mph, Ex Leuk $30,658,775 3.4 73 Neoplastic Disorder Blood & Ly mph, Ex Leuk $9,880,412 4.1

260 Coronary Disease w /o AMI w / CABG $27,081,959 3.0 72 Leukemia w /o Splenectomy $7,787,074 3.2

655 Malignant Neoplasm Breast, w / Surgery not BMT$21,565,875 2.4 76 Non-Neoplastic Blood Disease, Minor $7,526,867 3.1

251 Coronary Disease w / AMI w /CABG $21,287,899 2.4 991 Orphan Drug Record $5,929,881 2.5

401 Malignant Pulmonary Neoplasm, w /o Surgery $20,113,568 2.2 401 Malignant Pulmonary Neoplasm, w /o Surgery $5,921,153 2.5

72 Leukemia w /o Splenectomy $19,282,495 2.2 478 Malignant Neoplasm Rectum/Anus, w /o Surgery$4,566,464 1.9

75 Non-Neoplastic Blood Disease, Major $17,920,993 2.0 721 Joint Degeneration, Local, w / Surgery $3,616,225 1.5

253 Coronary Disease w /o AMI w / Angioplasty $16,713,020 1.9 373 Bacterial Lung Infection w ith Comorbidity $3,494,225 1.4

477 Malignant Neoplasm Rectum/Anus w /Surgery $16,288,401 1.8 51 Other Metabolic Disorder $3,339,403 1.4

656 Malignant Neoplasm of Breast w /o Surgery $16,052,116 1.8 655 Malignant Neoplasm Breast, w / Surgery not BMT$3,310,015 1.4

262 Coronary Disease w /o AMI w /Angioplasty $15,814,419 1.8 810 Late Effects and Late Complications $3,206,696 1.3

373 Bacterial Lung Infection w ith Comorbidity $11,639,075 1.3 454 Malignant Neoplasm Intest/Abdom w /o Surgery$3,178,822 1.3

264 Coronary Disease w /o AMI w /Cardiac Cath $10,862,902 1.2 477 Malignant Neoplasm Rectum/Anus w /Surgery $2,985,750 1.2

153 Malignant Neoplasm of CNS w /Surgery $10,366,887 1.2 262 Coronary Disease w /o AMI w /Angioplasty $2,352,321 1.0

282 Cardiac Congenital Disorder w /Surgery $10,178,199 1.1 452 Inflam of Intestines/Abdomen w /o Surgery $2,293,327 1.0

76 Non-Neoplastic Blood Disease, Minor $9,999,538 1.1 282 Cardiac Congenital Disorder w /Surgery $2,103,403 0.9

162 Major Brain Trauma w /o Surgery $9,938,655 1.1 153 Malignant Neoplasm of CNS w /Surgery $2,011,666 0.8

Total For Top 20 ETGs $400,351,606 45.0 Total For Top 20 ETGs $132,843,254 55.0

Grand Total = $893,294,617 Grand Total = $241,542,404

GROUP B: >=$50K in 2005 and 2006 GROUP A: >=$50K in 2005

Commercial LOB: TOP 20 ETGs

Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report: Cost Drivers

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ETGCode ETG Description Allowed

%TotalAllw

ETGCode ETG Description Allowed

%TotalAllw

722 Joint Degeneration, Local, w /o Surgery $2,592,627 3.3 553 Chronic Renal Failure, w ith ESRD $20,649,142 23.2

73 Neoplastic Disorder Blood & Ly mph, Ex Leuk $2,297,356 2.9 75 Non-Neoplastic Blood Disease, Major $5,249,796 5.9

656 Malignant Neoplasm of Breast w /o Surgery $1,887,226 2.4 76 Non-Neoplastic Blood Disease, Minor $4,212,880 4.7

721 Joint Degeneration, Local, w / Surgery $1,873,126 2.4 656 Malignant Neoplasm of Breast w /o Surgery $4,192,427 4.7

401 Malignant Pulmonary Neoplasm, w /o Surgery $1,736,043 2.2 73 Neoplastic Disorder Blood & Ly mph, Ex Leuk $3,544,421 4.0

265 Ischemic Heart Disese, Ex , CHF w /o AMI $1,718,398 2.2 991 Orphan Drug Record $3,063,321 3.4

553 Chronic Renal Failure, w ith ESRD $1,589,758 2.0 72 Leukemia w /o splenectomy $2,571,613 2.9

655 Malignant Neoplasm Breast, w / Surgery not BMT$1,465,064 1.9 51 Other Metabolic Disorder $1,810,990 2.0

262 Coronary Disease w /o AMI w / Angioplasty $1,409,685 1.8 478 Malignant Neoplasm Rectum/Anus w /o Surgery$1,748,250 1.9

29 Non-Insulin Dependent Diabetes w / Comorbidity $1,352,197 1.7 454 Malignant Neoplasm Intest/Abdom w /o Surgery$1,380,751 1.5

786 Other Major Neonatal D/O Perinatal Origin $1,194,070 1.5 373 Bacterial Lung Infection w ith Comorbidity $1,350,668 1.5

999 Orphan Record $1,145,019 1.5 401 Malignant Pulmonary Neoplasm $1,174,693 1.3

991 Orphan Drug Record $1,090,253 1.4 394 Emphy sema w ith Chronic Bronchitis $1,053,345 1.2

433 Inflammation of Esophagus w /o Surgery $1,018,298 1.3 262 Coronary Disease w /o AMI w /Angioplasty $985,902 1.1

160 Cereb Vasc Accident w /o Surgery $981,220 1.3 810 Late Effects and Late Complications $861,726 1.0

51 Other Metabolic Disorder $908,220 1.2 27 Insulin Dependent Diabetes w /Comorbidity $846,994 1.0

75 Non-Neoplastic Blood Disease Major $888,965 1.1 452 Inflam of Intestines/Abdomen w /o Surgery $754,833 0.9

47 Hy perlipidemia $887,798 1.1 280 Benign Hy pertension w /Comorbidity $723,403 0.8

72 Leukemia w /o Splenectomy $856,636 1.1 167 Hered/Degen Dis CNS w /o Surgery $708,984 0.8

253 Coronary Disease w /o AMI w / Angioplasty $792,093 1.0 266 Pulmonary Hear Disease w /o AMI $698,100 0.7

Total For Top 20 ETGs $27,684,052 35.0 Total For Top 20 ETGs $57,582,239 71.0

GROUP C: >=$50K in 2005 and <$50K in 2006 GROUP D: >=$50K in 2004, 2005 and 2006

Grand Total = $78,098,373 Grand Total = $81,451,176

Commercial LOB: TOP 20 ETGs

Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report: Cost Drivers

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• Why?

• 1) To reliably identify higher cost, highly impactable members

• 2) To enhance prioritization of members for nurse-intervention management

• How?• Use predictive output from MEDai

• Select key MEDai measures to construct a composite score

• Use the composite score as an index to stratify members

Focus on members with the highest index scoresFocus on members with the highest index scores

Identify & Stratify Members for Care ManagementDeveloping a Stratification Index (SI)

25

0%

20%

40%

60%

80%

100%

0 10 80-85 86-90 91-95 96-100

Chronic Impact Level

Perc

ent o

f Mem

bers

High Index ScoresModerate Index ScoresLow Index Scores

Validating SI ScoreChronic & Acute Impact: Break Down by SI Score

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-50 51-70 71-85 86-95 96-100

Acute Index Level

Perc

ent o

f Mem

bers

High Index ScoresModerate Index ScoresLow Index Scores

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 1 - 2 3 - 4 > = 5

Number of Chronic Gaps

Perc

ent o

f Mem

bers High Index Scores

Moderate Index ScoresLow Index Scores

Validating SI Score Chronic & Preventative Gaps: Break Down by SI Score

0%10%20%30%40%50%60%70%80%90%

100%

0 1 - 2 > = 3

Number of Preventative Gaps

Perc

ent o

f Mem

bers High Index Scores

Moderate Index ScoresLow Index Scores

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0%

20%

40%

60%

80%

100%

$0-999 $1000-4999 $5000-9999 $10000-24999

>$25000

Forecasted Cost Level

Perc

ent o

f Mem

bers

High Index ScoresModerate Index ScoresLow Index Scores

Validating SI Score Forecasted Cost Risk: Break Down by SI Score

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• Movers are members who are likely to make the transition from low or moderate to high risk

• Movers can be identified by comparing current vs. forecasted cost risk level

• if a member’s current cost is less than $1,000 (Risk Level I) and is predicted to cost more than $25,000 (Risk Level V)

• Do movers have higher index scores?

Validating SI Score Mover Identification

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Current Risk Level

Forecasted Risk Level Frequency Mean Index

ScoreI II 430,312 4.52I III 11,370 9.87I IV 451 12.75I V 2 11.00II III 96,352 10.26II IV 7,737 13.03II V 51 13.04III IV 22,492 13.47III V 225 13.95IV V 2,142 14.85

Validating SI Score Index Scores for Movers

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Commercial LOB 10/2005

High Scores: >=11(10.2%)

Moderate Scores: 6-10(18.4%)

Low Scores: <=5(71.4%)

Validating SI Score Distribution of Index Scores

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Segmentation Risk Level Management Type

Healthy Group; Worried Well

Low

Lifestyle/Health

Counseling

Chronically Ill Moderate Refer to Care Coordination Unit

Catastrophic

High

Refer to Catastrophic Case Management

Care Management Challenges: Triage & Intervene Members for Care Management NeedsCare Management Model

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• Information on disease/condition– Web resources– Pamphlets– Telephonic health library– 24/7 Nurse Line– HRA/PHR

• Encouragement to take more active role/accountability

Care Management ModelLifestyle/Health Counseling for Healthy and Worried Well

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• Telephonic coordination with members and their providers

• Ensures appropriate treatments and pharmaceuticals

• Five different programs included in this model

Care Management ModelCare Coordination for Chronically Ill

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• Pharmacy Care Management

• Emergency Room (ER) Visits Mgmt.

• Transition of Care

• Condition Specific Care Coordination

• Disease Management

Care Management ModelCare Coordination Programs

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• Directed to members with– Terminal illness (HOPE)– Major trauma– Cognitive/physical disability– High-risk condition– Complicated care needs

• Systematic process of assessing, planning, coordinating, implementing, and evaluation of care

Care Management ModelCatastrophic Case Management

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Triage & Intervene Members for Care Management Needs Implementation

• Predictive modeling using– MEDai, DCG, ETG

• Rolling 12 months DCG explanation prospective model

• ETG cost to supplement MEDai prediction • Developed SQL database containing MEDai, DCG,

and ETG information• Improved processes/workflow• Easy and continuous access• Better documentation

37

38

39

40

41

42

43

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Triage & Intervene Members for Care Management Needs Implementation: Future Enhancements

• Accreditation Analytics • Member non-compliance for HEDIS measures• Satisfaction profile

• Geo-spatial Analytics (imputed race, vicinity to Centers of Excellence (COE) or efficient/quality providers)

• Data Mining Analytics• Probability of engagement, segmentation profile

• Psychosocial Profile

• Speech Analytics

• Indirect Cost Profile

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• Basic research problem: measuring what would have happened vs. what actually happened

• Methodologies:• Randomized Control Group• Population-Based Pre-Post Methodology• Predictive Modeling• Control Group Matching • Combination

Care Management Challenges: Evaluate Care Management Interventions

46

Predictive Modeling with Inflation FactorsYr1 Yr2

Net Savings 12,606$ 72,811$ ROI 1.43 3.72

Group's Inflation Factor 5% 7%

CM Mbrs Actual PMPM 574$ 542$ CM Mbrs Predictive Modeling PMPM 629$ 638$ Inflated CM Mbrs Predictive Modeling PMPM 659$ 682$

CM Savings PMPM 85$

140$

Total CM Savings 42,005$ 99,560$ Admin Cost 29,399$ 26,749$

Evaluate Care Management InterventionsPredictive Modeling

47

Predictive Modeling w/Inflation Factors and AdjustmentsYr1 Yr2

Non CM Mbrs Actual PMPM 225$ 217$ Non CM Mbrs PMPM Predictive Modeling 205$ 232$ Inflation Adjusted Non CM Mbrs PMPM Predictive Modeling 214$ 248$ Adjustment for Actual to Predictive Modeling 5% -13%

CM Mbrs Actual PMPM 574$ 542$ CM Mbrs Predictive Modeling PMPM 629$ 638$ Inflated CM Mbrs Predictive Modeling PMPM 659$ 682$ Adjusted Predictive Model 692$ 597$

Adjusted CM Savings PMPM $ 117 $ 55 Adjusted CM Savings $ 57,819 $ 39,113 Admin Cost 29,399 26,749$$

Adjusted Net Savings 28,296$ 12,364$ Adjusted ROI 1.96 1.46

Evaluate Care Management InterventionsPredictive Modeling w/Adjustments

48

Evaluate Care Management InterventionsTotal Cost Approach

Direct CostsDirect Costs by SI Score – 2007 Commercial Subscribers

Median 2007 Direct Costs by SI Score - Commercial Subscribers Enrolled in 2007

0

10,000

20,000

30,000

40,000

50,000

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score

Num

ber o

f Sub

scrib

ers

$0

$6,000

$12,000

$18,000

$24,000

$30,000

$36,000

Med

ian

Dire

ct C

osts

Number of Subscribers Median 2007 Direct $

Percent of Direct Costs & Commercial Subscribers by SI Score - Subscribers Enrolled in 2007

0%

2%

4%

6%

8%

10%

12%

14%

16%

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score

% of Total Subscribers % of Direct $ in 2007

80% of Members 20% of Members

49

Evaluate Care Management InterventionsTotal Cost Approach

Indirect CostsIndirect Costs by SI Score – 2007 Commercial Subscribers

Median 2007 Indirect Costs by SI Score - Commercial Subscribers Enrolled in 2007

0

10,000

20,000

30,000

40,000

50,000

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score

Num

ber o

f Sub

scrib

ers

$0

$4,000

$8,000

$12,000

$16,000

$20,000

Med

ian

Indi

rect

Cos

ts

Number of Subscribers Median 2007 Indirect $

Percent of Indirect Costs & Commercial Subscribers by SI Score Subscribers Enrolled in 2007

0%

2%

4%

6%

8%

10%

12%

14%

16%

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score

% of Total Subscribers % of Indirect $ in 2007

80% of Members 20% of Members

50

Evaluate Care Management InterventionsTotal Cost Approach

Total CostsTotal Costs by SI Score – 2007 Commercial Subscribers

Median 2007 Total Healthcare Costs by SI Score - Commercial Subscribers Enrolled in 2007

0

10,000

20,000

30,000

40,000

50,000

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score

Num

ber o

f Sub

scrib

ers

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

Med

ian

Tota

l Hea

lthca

re C

osts

Number of Subscribers Median 2007 THC $

Percent of Total Healthcare Costs & Commercial Subscribers by SI Score - Subscribers Enrolled in 2007

0%

2%

4%

6%

8%

10%

12%

14%

16%

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score

% of Total Subscribers % of THC $ in 2007

80% of Members 20% of Members

51

Evaluate Care Management InterventionsTotal Cost Approach

-$14,000

-$12,000

-$10,000

-$8,000

-$6,000

-$4,000

-$2,000

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10

EBI Score Change From December 2006 to 2007

Median Change in Indirect $ (06 vs. 07)Median Change in Direct $ (06 vs. 07)

Change in SI Score vs. Change in Median THC Change in SI Score vs. Change in Median THC for Commercial Subscribers in 2006 & 2007for Commercial Subscribers in 2006 & 2007

SI Score Reduced

SI Score Increased

Each 1 point reduction in Score = $775 in THC savings PMPY

Each 1 point increase in Score = $750 THC increase PMPY

Med

ian

Chan

ge in

Co

sts

SI Score Change From December 2006 to 2007

52

Conclusions

• More scientific/standardized approach• Able to touch more lives efficiently• Well accepted by our care managers• PM approach has helped

– Streamline our processes– Better manage case managers case load

• Provide “Peace of Mind” to our members and clients