1 Soyal Momin MS, MBA December 14 th, 2007 Maximizing the Value of Predictive Modeling: The BlueCross BlueShield of Tennessee Experience

1

Soyal Momin MS, MBA

December 14th, 2007

Maximizing the Value of Predictive Modeling: The BlueCross BlueShield of

Tennessee Experience

2

Outline• Understanding Population Needs

• Historical View: Care Management at BCBST

• Concept: Next Generation Care Management (NGCM)

• Implementation of NGCM

– Improving the

• Process Efficiency

• Information Shared with CM

• Using Predictive Modeling to Evaluate Care Mgmt. ROI

• Conclusions

3

Understanding Population Needs

• Utilization distribution– Total healthcare cost and its components

• Population assessment

• Total cost assessment – direct & indirect costs

4

Cumulative Total Healthcare Cost

5

Cumulative Professional and Outpatient Cost

6

Cumulative Pharmacy Cost

7

Cumulative Inpatient Cost

8

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

9

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

Major Analysis Variables

10

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

Major Analysis Variables, Continued

11

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

0

0.5

1

1.5

2

2.5

Propensity to Utilize Episode SeriousnessIndex

Provider Efficiency PMPM Cost Index


12

Illness Burden by Major Practice Category

00.020.040.060.08

0.10.120.140.16

Infe

ctio

us Dis

ease

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Endocr

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Hemat

ology

Psych

iatry

Chem

ical

Dep

enden

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Neuro

logy

Ophthal

mol

ogy

Cardi

ology

Otola

ryngo

logy

Pulm

onology

Gastro

ente

rolo

gy

Hepat

ology

Nephro

logy

Urolo

gy

Obstet

rics

Gynec

ology

Derm

atolo

gy

Ortho &

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um

Neonat

ology

Major Practice Category

Illn

es

s In

de

x


00.020.040.060.08

0.10.120.140.16

Infe

ctio

us Dis

ease

s

Endocr

inolo

gy

Hemat

ology

Psych

iatry

Chem

ical

Dep

enden

cy

Neuro

logy

Ophthal

mol

ogy

Cardi

ology

Otola

ryngo

logy

Pulm

onology

Gastro

ente

rolo

gy

Hepat

ology

Nephro

logy

Urolo

gy

Obstet

rics

Gynec

ology

Derm

atolo

gy

Ortho &

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um

Neonat

ology


Illn

es

s In

de

x


13

00.5

11.5

22.5

33.5

44.5


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00.5

11.5

22.5

33.5

44.5


Pro

vid

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Eff

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nc

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de

x


Provider Efficiency by Major Practice Category

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PMPM Cost Index by Major Practice Category

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Infe

ctio

us Dis

ease

s

Endocr

inolo

gy

Hemat

ology

Psych

iatry

Chem

ical

Dep

enden

cy

Neuro

logy

Ophthal

mol

ogy

Cardi

ology

Otola

ryngo

logy

Pulm

onology

Gastro

ente

rolo

gy

Hepat

ology

Nephro

logy

Urolo

gy

Obstet

rics

Gynec

ology

Derm

atolo

gy

Ortho &

Rhe

um

Neonat

ology


Co

st

Ind

ex


0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Infe

ctio

us Dis

ease

s

Endocr

inolo

gy

Hemat

ology

Psych

iatry

Chem

ical

Dep

enden

cy

Neuro

logy

Ophthal

mol

ogy

Cardi

ology

Otola

ryngo

logy

Pulm

onology

Gastro

ente

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gy

Hepat

ology

Nephro

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Urolo

gy

Obstet

rics

Gynec

ology

Derm

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gy

Ortho &

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um

Neonat

ology


Co

st

Ind

ex


15

Total Cost Assessment

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

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Total Cost Assessment: Company XYZ

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 / FTE

40.8%

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 / FTE

40.8%

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%

17

$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 N

EOPLASM

GASTRO INFEC/IN

FLAM

HYPERTENSION

DEPRES & A

NXIETY D

IS

ORTHO DERANGE/T

RAUMA

PREG & D

ELIVERY W

/ C-S

EC

MALIG

NANT NEOPLASM

DIABETES

RHINIT

IS/S

INUSIT

IS

PREG & D

ELIV N

O C-S

EC

ASTHMA

CORONARY DIS

EASE

OTHER CARDIA

C DIS

COND ASSOC M

ENST/INFERT

GALL BLADDER D

ISEASE

VISUAL D

ISTURBANCES

HYPERLIPID

EMIA

HEREDITARY/C

ONGEN DIS

MIN

OR ORTHO D

IS

Direct Costs Indirect Costs

Top 20 Cost Drivers

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History

• Identifying Members for Case 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

• Case managers workload– 103/CM/Month

• PM implementation validation revealed missed opportunities for case management

19

Next Generation Care Management:Triage Guidelines

Segmentation DxCG Risk Level

Management Type

Healthy Group; Worried Well

1 – 2

Lifestyle/Health

Counseling

Chronically Ill 3 – 4 Refer to Care Coordination Unit

Catastrophic

5

Refer to Catastrophic Case Management

20

Lifestyle/Health Counseling for Healthy and Worried Well

• Information on disease/condition– Web resources– Pamphlets– Telephonic health library

• Encouragement to take more active role/accountability

21

Care Coordinationfor Chronically Ill

• Telephonic coordination with members and their providers

• Ensures appropriate treatments and pharmaceuticals

• Five different programs included in this model

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Care Coordination Programs

• Pharmacy Care Management

• Emergency Room (ER) Visits Mgmt.

• Transition of Care

• Condition Specific Care Coordination

• Disease Management

23

Catastrophic Case Management

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

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

24

Next Generation Care Management:Implementation

• Predictive Modeling Using– DCG

– ETG

• Rolling 12 Months DCG Explanation Prospective Model

• ETG Cost to Supplement DCG Prediction

25

Next Generation Care Management:Process Enhancements

• Developed SQL database containing DCG and ETG information

– Improved processes/workflow– Easy and continuous access– Better documentation

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27


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• Under prediction at all risk levels

• Use pharmacy data for prediction

– NDCs

• Prediction of utilization

• Provide information to help prioritize

members for interventions

• Evidence-based guideline gaps

Care Management Staff Feedback

29

MEDai RNC

Prediction of utilization

Evidence-based guideline gaps

Use pharmacy data for prediction

Provide information to help prioritize members for interventions

• Forecasted cost–Overall–Pharmacy

• ER and IP LOS prediction

• Mover identification• Impact index

–Acute–Chronic

• Risk drivers

• Gaps in care

30

Improving the Information Shared with Care Management Staff

• Enhancing SQL database with RNC information

ETG Low/Med/High Amount

MEDai forecasted costs (total and Rx)ER and IP LOS prediction Impact indexCare management historyActive PCP

- Risk drivers - Latest Rx data

- Gaps in Care - Risk History

31

32

33

34

35

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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

Developing a Stratification Index (SI)

38

0%

20%

40%

60%

80%

100%

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

Chronic Impact Level

Pe

rce

nt

of

Me

mb

ers

High Index Scores

Moderate Index Scores

Low Index Scores

Chronic Impact: Break Down by SI Score

39

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

Pe

rce

nt

of

Me

mb

ers

High Index Scores


Low Index Scores

40

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 1 - 2 3 - 4 > = 5

Number of Chronic Gaps

Per

cen

t o

f M

emb

ers

High Index Scores


Low Index Scores

Chronic Gaps: Break Down by SI Score

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 1 - 2 > = 3

Number of Preventative Gaps

Per

cen

t o

f M

emb

ers

High Index Scores


Low Index Scores

Preventative Gaps: Break Down by SI Score

42

0%

20%

40%

60%

80%

100%

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

>$25000

Forecasted Cost Level

Per

cen

t o

f M

emb

ers

High Index Scores


Low Index Scores

NGCM Risk Levels: Break Down by SI Score

43

• 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 NGCM 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?

Mover Identification

44

Current Risk Level

Forecasted Risk Level

FrequencyMean Index

Score

I II 430,312 4.52

I III 11,370 9.87

I IV 451 12.75

I V 2 11.00

II III 96,352 10.26

II IV 7,737 13.03

II V 51 13.04

III IV 22,492 13.47

III V 225 13.95

IV V 2,142 14.85

Index Scores for Movers

45

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%)

Distribution of Index Scores

46

• 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

How Do We Measure Care Management (CM) Impact?

47

Predictive Modeling

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$

48

Predictive Modeling w/Adjustments

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

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Conclusions of DM Evaluations

• A statistically valid predictive model should be incorporated in lieu of randomized control group

• Adjustments (inflation factors, inaccuracy of predictive models, etc.) should be made to the model information

50

Conclusions

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

– Streamline our processes– Better manage case managers case load

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

Documents

1 Soyal Momin MS, MBA December 14 th, 2007 Maximizing the Value of Predictive Modeling: The BlueCross BlueShield of Tennessee Experience