1 Gordon Norman, MD, MBA VP, Health Care Quality.…a health and consumer services company making people’s lives better Disease Management

1

Gordon Norman, MD, MBAVP, Health Care Quality

.…a health and consumer services company making people’s lives better

Disease Management

2

DISEASE MANAGEMENTHEALTH IMPROVEMENT

Pre-2000 Era

Population-based

Pre-CY2000 – DM Behind “Veil Of Capitation”


3


Post-2000 Era

HEALTH MANAGEMENT

Post-2000 Era

Population-based Case-based

Post-CY2000 – Risk Shift = Paradigm Shift


4

Catastrophic Care Management Complex case management

Special Population CareFrail members, ER frequentusers, Pre-catastrophic care, Terminally ill members

Chronic Disease ManagementCHF, CAD/stroke, COPD, ESRDDiabetes, Depression, AMI

Acute Episode ManagementIn-/Out-pt. Medical ManagementTransitional, Continuity of Care

Preventive Health ManagementPreventive care/Risk reductionHealth improvement, Member

education

CatastrophicCatastrophic

Special Special PopulationsPopulations

Chronically Ill Chronically Ill

Acutely IllAcutely Ill

WellWell

Me

mb

er

Co

nti

nu

um


“Disease Management” – Spectrum Of Needs

5 .…a health and consumer services company making people’s lives better

Origins of a Bedday

6

ClassicBD/K Mgt.


Classic Utilization Management – ALOS Focus

7

Focused Acute Episode Management

• ALOS Management– managing capitation to shared risk conversions– change from PMG to Pareto group hospital focus– PacifiCare as consultant and resource– “Every Patient, Every Day” mantra– sophisticated informatics and reporting– onsite concurrent review coverage at outlier hospitals – Medical Director-led regional medical teams– Hospitalist programs increasing – achieving Commercial and Medicare utilization results


8

Daily Census – PCC, PHS


MedicareCommercialEnterprise

606

707 713

673

652

680 675

696687

642656

666 663651

676

626

662

636

689

722733

550

600

650

700

750

1/4

1/11

1/18

1/25 2/1

2/8

2/15

2/22 3/1

3/8

3/15

3/22

3/29 4/5

4/12

4/19

4/26 5/3

5/10

5/17

5/24

California

309

326 329

346

386

374 371

343

329

371 368359

379

368 367

349 350346 347

336

397

300

325

350

375

400

425

1/4

1/11

1/18

1/25 2/1

2/8

2/15

2/22 3/1

3/8

3/15

3/22

3/29 4/5

4/12

4/19

4/26 5/3

5/10

5/17

5/24

Enterprise

1,733

1,657

1,5171,560

1,530

1,4591,500

1,5811,559

1,4481,4351,4251,4321,4301,4241,469

1,4141,414

1,3141,338

1,314

1,200

1,300

1,400

1,500

1,600

1,700

1,800

1/4

1/11

1/18

1/25 2/1

2/8

2/15

2/22 3/1

3/8

3/15

3/22

3/29 4/5

4/12

4/19

4/26 5/3

5/10

5/17

5/24

California

488

405

356

391

424 419

460 458

411423

409

388403

422430

398387

355369

382

421

300

350

400

450

500

1/4

1/11

1/18

1/25 2/1

2/8

2/15

2/22 3/1

3/8

3/15

3/22

3/29 4/5

4/12

4/19

4/26 5/3

5/10

5/17

5/24

\

Membership-adjusted, Seasonally-adjusted Average Daily Census Budget

Actual AverageDaily Census

9

ERER

Hippocratic Oath: “primum non nocere”Division of clinical roles, responsibilitiesRescue ethos: active over passive mgt.Little time for discharge planningLegal risks (COBRA, EMTALA)Clinical uncertainty of dx, pxUncertainty of patient F/UFinancial reimbursementFamily/caregiver anxietyDiscretionary gray zoneLimited clinical historyPatient expectationsRelative time, effortHospital economicsPatient advocacyMalpractice riskConvenienceLiability riskHabit

Easy out-pt. coordinationPrimary care continuity

Member disincentivesDiversion alternativesSocial work resourcesHospitalist incentives

Family expectationsQuick, easy HH svcsAvailable SNF beds

24 hr. observationFull hospital beds

Onsite RN triageDSS, protocolsDischargeDischarge AdmitAdmit

Lesson: it’s often too late by the time the member is in ER – avoiding the slippery slope requires upstream medical management

Lesson: it’s often too late by the time the member is in ER – avoiding the slippery slope requires upstream medical management


ER – Slippery Slope to Hospital Admission

10

UpstreamBD/K Mgt.


Upstream Medical Management – Admits/K Focus

11

California 1999 Commercial Top 5% Cost Members Summarized by Disease

Disease Paid Paid PMPM % of Paid Cumm %% of Total

Paid Cumm %ALL OTHER $21,704,015 $618.28 22.9% 22.9% 16.5% 16.5%CANCER $14,761,009 $1,806.95 15.6% 38.5% 11.2% 27.7%COPD $13,517,550 $1,566.71 14.3% 52.8% 10.3% 37.9%CAD/STROKE $12,478,244 $1,208.78 13.2% 66.0% 9.5% 47.4%GASTROIN $7,816,471 $758.14 8.3% 74.3% 5.9% 53.3%ESRD $7,784,755 $6,969.34 8.2% 82.5% 5.9% 59.2%ARTHRITS $4,959,525 $501.01 5.2% 87.7% 3.8% 63.0%CHF_1 $3,575,329 $2,019.96 3.8% 91.5% 2.7% 65.7%DEPRESSN $2,678,225 $561.94 2.8% 94.3% 2.0% 67.7%RARE_DZ $2,254,391 $2,314.57 2.4% 96.7% 1.7% 69.4%DIABETES $1,601,938 $756.34 1.7% 98.4% 1.2% 70.7%ASTHMA $1,502,728 $762.42 1.6% 100.0% 1.1% 71.8%

$94,634,180

Pareto Analysis – Top 5% Most Costly Members

12

• Outsourcing preferred

– major focus is primary disease driving majority of members’ utilization/costs

– specialized skills not easily developed or recruited

– use of proprietary tools

– economies of scale, scope

– performance data available

– performance risk accepted

• Insourcing preferred– major task is support,

integration of many unmet member needs that result in excessive health care resource consumption

– generalist, social mgt more critical than specialist skills

– integrating community resources important

– no proprietary tools needed


Disease Management – Sourcing Preferences

13

• Most promising choices for outsourced DM

– ESRD – cancer

– CHF – rare complex disease medley

– CAD/stroke – neonatal care

– COPD – asthma

• Appealing insourced CM candidates

– End-of-life care (cancer, chronic diseases, HH services, family support, hospice, AMDs, palliative care)

– Frail members (chronic disease, disabled, homebound)

– ER frequent utilizers (chronic disease, access, compliance)

DM Opportunity Analysis – Conclusions


14

$0

$500

$1,000

$1,500

$2,000

$2,500

Pai

d P

MP

M

Enrolled Not Enrolled

Baseline Intervention

Congestive Heart Failure – California

0

2000

4000

6000

8000

10000

Day

s P

TM

PY



$0

$500

$1,000

$1,500

$2,000

Pai

d P

MP

M



0

2000

4000

6000

8000

10000

Day

s P

TM

PY



SHNet Savings $6.3M

CONet Savings $2.3M

-55% 0%

-62% -10%

-51% 1%

-49% -11%

Baseline Period: 12/1/99 - 11/30/00 Intervention Period: 12/1/00 - 11/30/01

Mem Mos11,741 66,297

1,069 6,408 Mem Mos

11,741 66,297

1,069 6,408

15

Chronic Obstructive Pulmonary Disease – California

0

2000

4000

6000

8000

Day

s P

TM

PY



$0

$400

$800

$1,200

$1,600

Pai

d P

MP

M



-37% -4% -28% -3%


SHNet Savings $2.9M

Mem Mos11,395 15,815 11,395 15,815

16

End Stage Renal Disease – California

0

2000

4000

6000

8000

10000

12000

14000

Day

s P

TM

PY

Disease Population


$0

$1,000

$2,000

$3,000

$4,000

$5,000

Pa

id P

MP

M

Disease Population


0

2000

4000

6000

8000

Da

ys

PT

MP

Y

Enrolled


$0

$1,000

$2,000

$3,000

$4,000

$5,000

Pa

id P

MP

M

Enrolled


-26% -8%

-43% 8%


SHNet Savings $0.7M

CONet Savings ($0.4M)

Mem Mos4,238

Mem Mos875

4,238

875

17

0

5000

10000

15000

20000

25000

Day

s P

TM

PY



$0

$1,000

$2,000

$3,000

$4,000

$5,000

Pai

d P

MP

M



-29% -1% -17% 0%

Frail Member Care – PCC

0

5000

10000

15000

20000

25000

30000

Day

s P

TM

PY



$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

Pai

d P

MP

M



-10% -8% -16% 4%

Baseline Period: 11/99 - 10/00 Intervention Period: 11/00 - 11/01

SHNet Savings $4.8M

CO Net Savings $0.4M

Mem Mos5,121 13,654

1,072 2,228 Mem Mos

5,121 13,654

1,072 2,228

18

End of Life Care – PCC

0%

5%

10%

15%

20%

25%

30%

% In

-pt.

Dea

thss



$0

$5,000

$10,000

$15,000

$20,000

Pai

d p

er D

eath



-24% 12% -6% 1%

Baseline Period: 1/00 - 12/00 Intervention Period: 1/01 - 11/01

SH

Mem Mos579 8,241 579 8,241

19

• Outsourced DM

– original 4 outsourced: CHF, CAD/stroke, ESRD, COPD

– launching commercial Oncology DM

– design “middle tier” diabetes pilot

– pursue pediatric asthma

– reconsider rare disease medley

– maximize appropriate, early provider referrals

– promote successful programs to capitated providers

– increase penetration in non-capitated provider groups

– implement DM programs for PPO, ASO business


Disease Management Portfolio – 2002

20


• Insourced DM– Frail members– End of Life members – selective catastrophic case management– comorbid, EOL patients from outsourced DM programs– maximize appropriate, early provider referrals– integrate workflow with outsourced vendors– pre-catastrophic case management as predictive modeling

allows (DCG, RxGroups, ACG, CRG, CRxG, Ingenix, Medical Scientists, M&R, RxSols)

– combine predictive modeling with HRA stratification


21


• Apply DM learnings to other outsourced service providers

– Hospitalist contracting for in-pt. care management, ER intervention

– neonatal/NICU management

• Improve integration – across comorbidities, vendors and PHS, providers

• Subject our DM performance to rigorous challenges

– CMS Disease Management Demonstration Program

– CMS PPO Demonstration Program

– external validation of savings methodology

– external audits of DM capabilities, effectiveness


22

CAD Programs


Taking Charge of Your Heart HealthSM

Evidence-based management of CAD

DM vendor

Includes all members with CAD

Member and Provider Interventions

Member Testing, Provider Intervention

Lower Risk Higher Risk


Double-Barreled Approach – CAD

23

Diabetes Programs


Taking Charge of DiabetesSM

Coronary artery diseaseCongestive heart failureEnd-stage renal disease

Manage diabetes-related end-organ conditions

4 DM vendors

Includes all members with diabetes

Member and Provider Interventions

Case-based*

Intensive MemberCase Management

Diabetics with worst control, highest risk, readiness to change

1 DM vendor

Low Risk Moderate Risk High Risk

*pilot program in negotiation.…a health and consumer services company making people’s lives better

Triple-Barreled Approach – Diabetes

24 .…a health and consumer services company making people’s lives better

Newest DM Program – Cancer

• Why cancer?– Shortage of medical oncologists (cancer doctors), all “too busy”– MDs unfamiliar with oversight of total patient care– Technical, sophisticated treatment emphasized over education,

empathy, preparation for end of life– MDs tend to use most convenient setting for them, not the

patient– Difficulty discussing, dealing with death– Futile and unwanted treatment not uncommon within

commercial populations– Preparation for end of life is variable, late, or neglected

25

Fatigue Management

Anticancer Treatment

Palliative Care

Diagnosis Primary Treatment

End-of-Life

Psychosocial Counseling

Nutrition Services

Pain Management

Cancer Rehabilitation

Advanced Care

Planning

Hospice Referral

Ongoing Symptom

Management

Cancer DM

Approach

Cancer DM

Approach

Curative Anticancer TreatmentCurative Anticancer Treatment

Palliative CarePalliative Care

Traditional Practice

Traditional Practice Palliative CarePalliative Care

-End-of-Life

< 1 Month

Curative Anticancer TreatmentCurative Anticancer Treatment

Pain

Management HospiceReferral

Diagnosis Primary Treatment

(Futile Treatment)

(Unwanted Treatment)

What’s Different about Cancer DM?


26


HEALTH MANAGEMENT


Today – Full Service Health Management


27

Disease Management – “Baked Into” Our...

• Brand Promise

• Quality Initiatives

• HEDIS Performance

• NCQA Accreditation

• Medical Management

• Member, Provider Satisfaction

• Competence/Achievement Culture

• Financial Performance & Membership Growth

CatastrophicCatastrophic

Special Special PopulationsPopulations

Chronically Ill Chronically Ill

Acutely IllAcutely Ill

WellWell

Me

mb

er

Co

nti

nu

um


Documents

1 Gordon Norman, MD, MBA VP, Health Care Quality.…a health and consumer services company making people’s lives better Disease Management