Telehealth Management: Can a new paradigm in managing chronic illness control costs and

improve quality?

presented by

Maria Lopes, MD, MS

Doreen Salek, BS, RN, CCS/CPC October 26, 2010

Speaker Bios

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Maria Lopes, MD, MS, Chief Medical Officer

Dr. Lopes is an OBGYN by training, but has been serving in senior medical management positions in managed care since 1996. Prior to joining AMC in 2008, she spent 4 years as Senior Vice President and Chief Medical Officer for GHI, New York State’s then largest commercial payor, and before that served in senior positions for 7 years at Horizon Blue Cross Blue Shield of New Jersey. Dr. Lopes received her MD from The University of Connecticut School of Medicine, and an MS in Administrative Medicine from The University of Wisconsin.

Doreen Salek, BS, RN, CCS/CPC Ms. Salek is the Director of Business Operations of Health Services for Geisinger Health Plan in Danville, Pennsylvania.  She is responsible for leading business planning and Health Services innovation project teams with medical home, medical management, care coordination, quality improvement and clinical reporting as well as strategic implementation and evaluation of outcomes.  In her current role she is focused on transitions of care across the continuum, as well as strategies around enhancing quality and reducing readmissions, including telemonitoring. Ms. Salek earned her BS from Colorado State University and nursing diploma from the Geisinger School of Nursing. She holds certifications as a Certified Coding Specialist and Certified Professional Coder. 

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What is TeleHealth?

Remote Telemonitoring or Telehealth:

the process of collecting daily biometric and other health-related information from where patient is and transmitting data to clinicians who manage care

• Two forms of data collection

1. “Hard” biometric data

2. “Soft” self-reported symptom information

• “Telemedicine” has become a universal term for industry

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• Telemedicine has been around since early 60’s when NASA developed

monitoring methods for the space program

• The majority of activity described as “Telemedicine” surrounds two-way

televideo for clinical consultation

• In the last 10 years remote physiological monitoring from the home has

become a recognized and affordable component of chronic care

Evolution

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How It Works: Data Collection and Integration

Self-reported symptom information

via IVR

Biometric information via telemonitoring

devices

“Live” virtual diagnostic assessment

via televideo

Medication compliance data via dispensing/reporting

appliances

AMC collects, sorts and verifies raw data and presents it as critical, actionable information on the secure web portal

Data integration platform captures timely information from patients when they cannot be physically in front of clinicians

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The Problem Telehealth Seeks to Address

• Acute exacerbation occurs outside clinical scrutiny. It is often preceded by incremental and insidious deterioration whose expression occurs in the home, away from clinical eyes.

• Existing information systems do not cross boundaries of care settings

• Electronic Health Records (EHR’s) illuminate what was done to patients (i.e. tests ordered, hospitalizations, Rx written, etc.) but don’t clarify the outcome.

• “Are their biometrics improving? Are they at reduced risk because of these actions? Are their medications having the right effect? Have barriers to compliance been identified?”

As a result, care is often duplicated, applied too late, or in the worst setting due to incomplete clinical information

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• Knowing what is going on with a patient’s course of illness, in between visits, when he or she cannot be physically in front of the clinician

• Detecting pre-acute conditions early enough to bring resources to bear before the patient clinically decompensates

• Not waiting for the call from the ER before knowing that a patient is trending in the wrong direction

How TeleHealth is Advancing Patient Care

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Not Traditional Disease Management

• Telemonitoring uses real-time information from the patient’s home to empower them with knowledge of how they are progressing in the context of their personal disease progression and care plans, and how their behaviors are indeed affecting their health

• Thus, unlike traditional DM, which can educate a patient about what can and usually happens, telemonitoring can tell them what is happening, and how they—and their doctors and caregivers—can react to these events to change course if necessary

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Value Proposition

Marketing: differentiate

through value-added features

Quality: improve compliance & HEDIS metrics

Financial: reduce re-

hospitalization & optimize ROI

Operational: enhance

productivity & care coordination

Clinical:Improve

outcomes

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Support for Medical Home

• Empower the clinician through technology

provide critical information to electronic health records (EHR’s)

• Through daily data collection, PCP can continually monitor patient

between doctor visits

increases efficiencies in care by allowing PCP to be alerted when

intervention is most needed

• Greater frequency of targeted patient education

continual data collection provides physician with real-time quality

measures for benchmarking and improvement

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Challenges

“There is a tendency to overemphasize the technological

aspects of telehealth and indeed to equate it with its

technology … Telemedicine is not software or hardware,

although it employs both. Nor is it ‘clinicianware’ or

‘econoware’ despite its value to clinicians and administrators

and payors. When it’s all said and done, it is ‘patientware’, as it

should not be defined in terms of its technical components but

in terms of utility in reinforcing the clinician-patient bond.”

– Jay Sanders, MD, former President, American Telemedicine Association

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It can never be about the technology:

• This has to be about putting accurate and meaningful information in front of the clinician, regardless of the means of collection

• Must be seamlessly embedded into a care management workflow to maximize efficiency

• Data must be timely, meaningful and actionable and not simply contribute to the ‘noise’

Challenges (continued)

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PCMH & Telehealth Platform Evolution

AMC-Geisinger Strategic Partnership

A mutual investment to strategically impact and enhance each other’s core competencies and business models

AMC Health:Telemonitoring And IVR ServicesReal-time Data & Clinical Decision Support Tools

Geisinger:Subject Matter

Expertise forPredictive Analytics

Clinical Content & Decision Support

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AMC’s Telehealth program doubled the ratio of CHF Patients that

Geisinger Case Managers were able to cover in complex case management:

1. Track patients in real-time 2. Uncover proactive intervention opportunities3. Receive unbiased, reliable patient data4. Reduce the need for clinicians to initiate outreach

96% of Geisinger Case Managers reported AMC

technology improved efficiency in monitoring HF

patients

85% of Geisinger Case Managers reported telehealth solution prevented patient

hospitalization

Geisinger Health Plan Outcomes

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Looking Forward

New technologies are constantly being assessed for integration potential

Motion Analysis and Access Detection Technologies

GPS Tracking and Communications

Exercise Monitoring

Wearable Sensors for Recording Events Over Time

Smart Bandages and ClothingBringing the Lab Home

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• Comprehensive, cross-setting, interdisciplinary care coordination models that utilize Extended Care Pathways

• ACO models

• Less comprehensive care management models housed within the payor or community-based care entity

Synthesis with New HIT Priorities

Patient at Home

Data Collection Technologies

Webportal for Shared Reporting & Analytics

Telecare Management Nurse Call Center

Data Mining and Population Analytics

Thread telehealth technology unobtrusively into best-of-breed

care coordination models that best fit each unique structure, including:

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The Goal: Open-Ended Integration

Universally-Accessible Webportal with Decision-Support Analytics

EHR’s

PBM & Other Pharma Data

External Care Management Data

Claims

Telehealth Data

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Impact of Telecare Management (TCM) on Medicare Advantage (MA) Members after 8 months:

Study Parameters: Results:•TCM Intervention Group N=69 •8 Month Period •Random Selection• Intervention and control cohorts had similar claims histories•CHF, Hypertension, Diabetes, COPD, CAD , Atrial Fibrillation •66% >3 diagnoses

Cost Intervention Group

Control Group

Total ↓ 23% ↑ 6%

Inpatient ↓ 20% ↑ 16%

Outpatient ↓64% ↓17%

ER ↓14% ↓8%

ROI 3:1If ESRD is included, 43% reduction in total costs compared to control

represents ROI 6:1

Outcomes

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Comparison of Total Costs (8 Months) Care Management vs. Care Management + Telemonitoring*

* MEMBER MONTHS: Control Group – pre: 5,106, post: 4,698 , Telemonitored Group - pre: 538, post: 543

High-Risk Pre-Intervention High-Risk Post-Intervention$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$2,457 $2,608

$2,378

$1,839

control group (n=641)

telemonitored patients (n=69)

Impact of Telecare Management (TCM) on MA Members after 8 months (continued):

Outcomes

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PM

PM

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• Majority of non-diabetics reached BP goals, as did nearly half the diabetics

• Improvement in BP translates into 29% reduction in risk of

cardiac events and 21% reduction in risk of stroke • 83% of diabetics reached blood glucose targets • Average blood sugar reduction equates to a 1.7 point drop in

HbA1c:63% reduction in risk of microvascular complications 73% reduction in risk of peripheral vascular disease

Impact of Telecare Management (TCM) on MA Members after 8 months (continued):

Outcomes

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Impact of Telemonitoring Combined with Home Care Case Management (Medicare Advantage Plan):

Study Parameters Results

•N = 47, •Intervention period > 12 months•Longitudinal •Primary Dx CAD, CHF, COPD or DM•Control members in Case Management without Telemonitoring

TM Group Control Group

Hospital Admissions

↓ 50% ↑ 8%

Total Costs ↓ 55% ↑ 6%

Total Claims Savings

TM Group > Control Group for All Diagnosis

CHF ↓ 37% ↑ 43%

COPD ↓ 70% ↓ 16%

Outcomes

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High Risk - Pre Intervention High Risk - Post Intervention

control group (n=132) 1919.70802919708 2067.99531066825

telemonitored pts (n=47) 2395.90443686007 1205.4794520548

250

750

1250

1750

2250

2750

Comparison of Acute Care Admissions (12 Months):Case Management vs. Case Management + Telemonitoring*

Ad

mis

sio

ns

per

100

0 M

emb

ers

per

Yea

r

* MEMBER MONTHS: Control Group - pre 1644, post 853 , Telemed Group - pre 586, tele 219

Impact of Telemonitoring Combined with

Home Care (cont.)

Outcomes

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High Risk - Pre Intervention High Risk - Post Intervention

control group (n=132) 2290.64576034063 2160.86902696366

telemonitored pts (n=47)

2344.4327133106 969.159726027398

$250

$750

$1,250

$1,750

$2,250

Co

sts

PM

PM

Comparison of Total Costs (12 Months) Case Management vs. Case Management + Telemonitor-

ing*

* MEMBER MONTHS: Control Group - pre 1644, post 853 , Telemed Group - pre 586, tele 219

Impact of Telemonitoring Combined with

Home Care (cont.)

Outcomes

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Costs PMPM Admits per 1000 Members per Year0

500

1000

1500

2000

2500

3000

969

12051109

1234

Results sustainable for up to 6 months post-telemonitoring*

Telemonitoring Period After Discharge from Telemonitoring

* MEMBER MONTHS: Telemed Group tele 219, post 107

Pre-Intervention Levels

* MEMBER MONTHS: Telemed Group tele 219, post 107

Impact of Telemonitoring Combined with

Home Care (cont.)

Outcomes

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Value of Telemonitoring in Achieving A1c and Blood Pressure Goals in Medicaid Managed Care Population

• N= 440 on telehealth for a minimum of 40 days

• Identified through outpatient clinics

Glycemic Control79% sustained improvement

% hypertensive at baseline who improved BP

69% improved by an average of 6mmHg

diastolic

Reduction of cardiac risk 25%

Reduction of risk of stroke 18%

• For the 21% with no glycemic improvement, 66% of those hypertensive at baseline improved by an average of 5mmHg diastolic

Outcomes

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Results

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Value of Telemonitoring in Achieving A1c and Blood Pressure Goals in Medicaid Managed Care Population (cont.)

Of the group with improvement, the higher the baseline HgA1c, the greater the improvement:

Those with Improvement (79%)

Baseline HbA1c TierBaseline HbA1c Mean

Latest HbA1c Mean

Point Improvement

< 7.0 (n=13) 6.4 5.8 0.67.0 to 8.9 (n=129) 8.0 7.0 1.0

9.0 to 9.9 (n=60) 9.4 7.6 1.810.0 to 11.9 (n=91) 10.9 8.3 2.6

³12.0 (n=53) 14.0 9.3 4.7

For the subset of members with a minimum of 12 mos of claims both pre-telemonitoring and for 12 mos of telemonitoring (n=77):

• 36% reduction in hospitalization• 47% reduction in emergency room visits

Outcomes

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Impact of Telemonitoring (TM) Post-Discharge from Acute Care Setting Fee-for-Service Medicare Home Care:

Study Parameters

• Pre/Post intervention study

• N = 1,451 for 2 years

Results:

Subsequent Controlled Study:

• N= 510 for 18 months

• Result: ↓34% reduction in 30-day readmission compared to control

Pre-TM Post TM

60-day Readmission Rate

27% 11%

RN Weekly Visits ↓50%Cost/ Home Care Episode ↓ $750ER Visits ↓ 40%

Outcomes

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Impact of Telecare Management on Biometric Outcomes – 1st 90 Days

Medicaid (SSI, non-Medicare Eligible) Diabetes Pilot

Average PMPM costs prior to pilot: $1,943

Reductions in average blood pressure:17% reduction in risk of cardiac events 12% reduction in stroke risk

Blood sugar reductions for 25% most severe at baseline = 2 pt reduction in HbA1c:10% reduction in overall health care costs80% reduction in risk of eye, kidney and nerve disease complications*

* Source: National Diabetes Clearinghouse

Goals Reached

Average Blood Glucose 67%

Systolic BP 26%

Diastolic BP 39%

Outcomes

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Impact of Telecare Management on Biometric Outcomes – 1st 120 Days

Medicaid (SSI, ABD & Medicare Eligible) Telehealth Pilot

Average PMPM costs prior to pilot: $2,893

High risk, rural population COPD, Diabetes, Heart Failure,

Hypertension, Renal Failure

:

Reductions in average blood pressure for 25% most severe non-diabetics: 43% reduction in risk of cardiac events 27% reduction in stroke

Blood sugar reductions for 25% most severe at baseline = >1.2 pt reduction in HbA1c:

24% reduction in overall health risk for Sources: Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies . Lancet. 2002;360:1903-1913 and Heart Disease and Stroke Statistics – 2007 Update Dallas, TX: American Heart Association 2007. e million adults in

Goals Reached

Systolic BP

Diastolic BP

Blood Glucose

Non-diabetics

60% 82% N/A

Diabetics 40% 54% 70%

Outcomes

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Metoprolol

Case Study

Patient • 54 year old female • TIA, CAD; Hx of palpitations, dizziness

Intervention •Telehealth initiated 7/15/09

•Pulse above 100 daily as high as 120 bpm

•RN notified physician and presented data

•RN monitoring daily B/P and pulse

•BP within normal range.

•Started Metoprolol

Outcome •Pulse average 98 bpm •Continue to follow medication effects

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