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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Section (III) Cost Analysis

Cost Trends using Look-Back Periods

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$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

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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)

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Comparing Reports Between PopulationsMental Health Clinics Substance Abuse Clinics

Clinic Comparisons

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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

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Health Care Cost Comparisons (PMPM)

Total PMPM$1278

Total PMPM$2285

Health Care Cost Comparisons

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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

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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

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Questions?

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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.