Mary Kay Owens - Understanding and Addressing Medicaid Hot Spots Critical for Bending the Cost Curve

7/31/2019 Mary Kay Owens - Understanding and Addressing Medicaid Hot Spots Critical for Bending the Cost Curve

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Understanding and AddressingHot Spots

Critical Approaches For Bending theMedicaid Cost Curve

Mary Kay Owens, R.Ph., C.Ph.

Executive Director, Institute for Healthcare Innovation Strategies

Associate Professor, University of Florida College of Pharmacy

National Alliance for Integrated Medication Management (AIMM) Exec. Board

May 31, 2012

PFCD Hill Briefing, Washington, DC


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Identifying the Targets:

Hot Spots include Patients with

Uncoordinated Care, Lack of

Appropriate Medication Use, andUnmet Treatment Goals for Chronic

Conditions


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State Medicaid Chronic Disease Treatment

Uncoordinated Care10-30% of pop. & account for 30-50% costs

Low Drug Adherence rates

40-65% for major chronic drug classes

Lack of Treatment for Chronic Conditions

Hundreds of thousands with no drug treatment yetincurred $ hundreds of millions in medical costs forconditions (cholesterol, hypertension, MH)

Clinical Goals Unmet

50-80% of patients are not at clinical goals


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Goals of Intelligent ClaimsAnalysis Model

Use clinically and statistically validated algorithms toidentify subset of patients that exhibit utilizationpatterns consistent with uncoordinated andinappropriate care Hot Spot Patients.

Algorithms based on common indicators such as:uncoordinated care from multiple prescribers/pharmacies,accessing the ER for primary care,avoidable ER and hospitalization visits,duplicative medical and drug services from various providers

random drug changes within therapeutic classes by differentprescribers, drug switchinginconsistent drug usage, treatment gaps and non-adherencelack of appropriate treatments/services based on guidelines


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State Medicaid Examples andStrategies

Identify Uncoordinated Care andCreate Solutions to Improve Quality

and Reduce Unnecessary Costs


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Average Contribution of Cost Components forUncoordinated Care vs. Coordinated Care Patients

$2,001

$5,295

$4,907

$1,669

$1,039

$189

$506$1,340

$714 $287

$222$46

$0

$2,000

$4,000

$6,000

$8,000$10,000

$12,000

$14,000

$16,000

Uncoordinated Care

Patients $15,100

Coordinated Care

Patients $3,116

Lab

Out Pt/Hm HlthER

Pharmacy

Practioner

Hospital


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State Example: Utilization and Cost Summaryfor Uncoordinated Care Medicaid Patients

PercentPatients

PercentPrescription

Costs

PercentPrescriptions

45%46%

10%

Uncoordinated Care Utilization and Cost Percentages

32%

PercentMedicalCosts

36%

PercentAll Costs

(drug + medical)

Approx 35% of red bar

costs are avoidable

$1.8B


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State Example: Pre-Medicare Duals Population(Ages 55-64 pop. group)

PercentPatients

PercentPrescription

Costs

PercentPrescriptions

70%71%

28%

Uncoordinated Care Utilization and Cost Percentages

44%

PercentMedicalCosts

52%

PercentAll Costs

(drug + medical)

Approx 35% of red barcosts are avoidable


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Comparison of Uncoordinated Care vs. Coordinated Care Patients

by Cost Groups (Percentage and Amount of Total Costs)

State Example:

Savings Across All Patient Cost Groups(Low to High)

$500-

$999

$1,000-

$4,999

$5,000-

$9,999

$10,000-

$19,999

$20,000-

$29,999

$30,000-

$49,999

$50,000-

$99,999

$100,000

TotalDollarA

mount

$74 M

Total Cost Groups (Annual Medical and Drug Costs)

$19 M

$130 M

$82 M

47%

53%

$61 M

$97 M

$87 M

$123 M

58%

42%

59%

41%

57%

43%

58%

42%

69%

31%10%97%3%

90%

Uncoordinated Care Patients

Coordinated Care Patients

Approx 35% of red bar

costs are avoidable


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SEC Published Study: Institute of Medicine *National Cost Savings Estimates

Public Programs (Medicaid and Medicare)Avg. of $133.5 billion per year

Private Programs

Avg. of $106.6 billion per yearTotal Public and Private

Avg. of $240.1 billion per year

*Web Link: The Healthcare Imperative: Lowering Costs and Improving Outcomes.The Institute of Medicine. 2010. Washington, DC: The National Academies Press.Owens, MK.Chapter 3: Inefficiently Delivered Services, Costs of Uncoordinated Care,pgs 131-138. http://books.nap.edu/openbook.php?record_id=12750&page=131
http://books.nap.edu/openbook.php?record_id=12750&page=131http://books.nap.edu/openbook.php?record_id=12750&page=131


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Creating the Path to Success:Utility of New Analytical Approach to

Identify and Address Hot Spots

For Achieving Savings


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What are the solutions?1. Conduct baseline and periodic analysis of claims

data to identify the Hot Spots - subset of patients totarget that have high risk and uncoordinated care.

2. Conduct geographical mapping of these patients totarget specific areas and providers.

3. Focus intensive efforts in utilization managementand coordination on the targeted patients andproviders.

4. Create hybrid FFS payment models with incentive forsavings and improved outcomes.

5. Implement comprehensive medication managementin targeted patients to achieve appropriate use &adherence to medications. (AIMM Model)

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Contact Information

Mary Kay Owens, R.Ph., C.Ph.Executive Director, Institute for Healthcare Innovation Strategies

National Alliance for Integrated Medication Management (AIMM) Board

3019 N. Shannon Lakes Dr., Suite 202Tallahassee, Florida 32309

(850) 668-8524

[email protected]

www.ihis-health.org
mailto:[email protected]://www.sec-rx.com/http://www.sec-rx.com/http://www.sec-rx.com/http://www.sec-rx.com/mailto:[email protected]:[email protected]:[email protected]

Documents

Mary Kay Owens - Understanding and Addressing Medicaid Hot Spots Critical for Bending the Cost Curve