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24 Cards in this Set
- Front
- Back
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Reasons why plausibility factors may be a poor validator of care management savings calculations |
Plausibility factors - disease specific admissions per 1,000 in the program year divided by that same statistic in the baseline year. 1. They are calculated based on the entire condition-specific population so they don't exclude members who are not eligible for or managed by the program 2. They are calc'd based only on admissions and ER visits for primary diagnoses which represent a small % of all admissions/costs 3. They do not account for population changes 4. They do not account for risk profile of population 5. They do not account for volatility in admission rates 6. They do not account for existing trends in population |
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Types of care management methods |
1. Pre-authorization - requires a provider to obtain approval before performing a service 2. Concurrent review - monitoring a member's care while the member is still receiving care in hospital or nursing home 3. Case management - typically involves health care professional who coordinates care of a patient with serious disease or illness 4. Demand management - refers to certain passive forms of informational intervention, often provided over phone 5. Disease management - focuses on chronic conditions with certain characteristics that make them suitable for clinical intervention 6. Specialty case management - care manager who has expertise in particular area coordinates care for patients in that area 7. Population health management - entire membership of a health plan is evaluated using statistical tools to identify potential high-cost patients who can benefit from some type of voluntary intervention program 8. Patient-centered medical home - this model returns responsibility to the physician for coordinating all patient's care 9. Accountable Care Organization - network of doctors and hospitals share responsibility for providing patient care. PCP is accountable for providing quality care and reducing utilization 10. Non-traditional provider interventions and care settings - pharmacists and different types of clinics can be used to provide various interventions 11. Gaps in care and quality improvement programs - improving clinical quality and addressing gaps in care is a major focus of ACOs and the Electronic Health Record meaningful use initiative 12. Telehealth, telemedicine, and automated monitoring systems 13. Bundled payment initiatives - initiatives bundle payment for multiple services across a single episode of care |
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Characteristics of chronic conditions that make them suitable for disease management programs |
1. Once contracted, the disease remains with the patient for the rest of their life 2. Disease is often manageable with combination of pharmaceutical therapy and lifestyle change 3. Patients can take responsibility for their own conditions 4. The avg annual cost is sufficiently high to warrant spending resources to manage the condition 5. Expected cost of the non-adherent patient is high |
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Principles for establishing a patient-centered medical home |
1. Personal physician - each patient has a personal physician trained to provide comprehensive care 2. Physician-directed medical practice - consists of a team of individuals taking responsibility for the patient's ongoing care 3. Whole person orientation - appropriately arranging care with other qualified professionals 4. Care coordinated and integrated across all elements of the health care system and the patient's community 5. Quality and safety - includes patient-centered outcomes, evidence-based medicine, and continuous quality improvements 6. Enhanced access through open scheduling, expanded hours, and E-visits 7. Reimbursement structure to support and encourage this model of care |
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Ways in which ACOs are expected to generate savings |
1. Implementing care coordination to manage the care of patients who need additional services 2. Reducing the need for tests via access to integrated medical records and consistent management by physician 3. Developing a network of efficient providers for referrals and limiting the use of less efficient more expensive providers 4. Focusing on quality, which will result in fewer unnecessary services. emphasizing preventive services |
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Types of interventions conducted by pharmacists |
1. Drug utilization review - these programs manage price by substituting lower-cost alternatives for higher-cost drugs, manage utilization by requiring prior authorization for certain drugs 2. Medication Therapy Management (MTM) - Part D plans are required to have MTM programs, which aim to improve medication use and reduce adverse events for beneficiaries that have multiple chronic conditions, are taking multiple Part D drugs, and are likely to incur annual costs of at least $4k for all covered Part D drugs 3. Pharmacist-delivered care management programs - pharmacists can collaborate with PCPs on medication optimization and medication safety. They focus on drug adherence which is measured in one of two ways: a) Medication possession ratio = number of days supply in patient's possession / number of days during measurement period during which the patient could have had the drug b) Proportion of days covered = number of days of coverage / total number of days in the measurement period |
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Types of clinics that can be used to provide basic health care |
1. Retail convenient care clinics - retail clinics staffed by nurse practitioners 2. Employer worksite clinics - most common at large employers, may cover various types of care (preventive, acute, primary, etc) 3. Urgent care clinics - staffed by full range of clinicians, directed by physicians. 4. Federally qualified health centers (FQHCs) - these are designated by federal gov't to provide health care to underserved and uninsured, such as a community health center |
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Benefits of being designated an FQHC |
1. Reimbursement for services provided under Medicare/Medicaid 2. Medical malpractice coverage 3. Eligibility to purchase medications for outpatients at reduced cost 4. Access to National Health Service Corps 5. Access to the Vaccine for Children Program 6. Eligibility for various other federal grants and programs |
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Areas where actuaries can be involved with care management programs |
1. Economics of care management programs - help with understanding the relationship between care management program inputs and outputs 2. Risk adjustment and predictive modeling - used to identify candidates for intervention programs, adjustment used to assess outcomes 3. Financial outcomes evaluation - help in achieving comparability between the reference and intervention population |
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Principles for measuring results of care management programs |
1. Reference population - any outcome's measurement requires a reference population against which to evaluate statistics of interest 2. Equivalence - reference population should be equivalent to the intervention population 3. Consistent statistics - the same statistic should be measured in the same way in the reference and intervention populations 4. Appropriate measurements - if possible, avoid extraneous irrelevant or confounding variables 5. Exposure - the exposure group must be clearly defined and all members who meet the definition should be included in the appropriate group 6. Reconcile the results - reconcile the outcomes of a small population with those of the entire health plan |
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Issues that affect disease management evaluations for chronic populations |
1. Regression to the mean - a percent of high-cost patients in one period will not be high-cost in the next period because it was a one time event 2. Identifying patients - due to mean regression, it may not be appropriate to use patients' past data as the comparison group, common alternative is to use entire population 3. Establishing uniform risk measure for comparability - objective, consistent definitions should be used to identify candidates for the care management program 4. Patient selection bias - this results when a study is based on those volunteering for a program 5. Patient drop outs - drop outs may also create a bias (e.g. those feeling better may drop out) 6. General vs. specific population - some interventions are performed on an extremely small population, making some methodologies inappropriate for measuring results |
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Considerations when using claims data for evaluating disease management programs |
1. Fixed time periods - a one-year time period may be too short for outcome evaluation 2. Enrollment issues/eligibility - timeliness of enrollment and disenrollment should be factored into study 3. Claims run-out - due to claims lag, program results may not be known for up to two years after the program begins 4. Outlier claims - these may distort the study's results 5. Special problems with claims data - when using claims data to identify chronic members, some members are miscategorized (false positives/negatives) |
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Risk factors for care management studies |
1. Demographic variables 2. Exclusionary conditions that exclude certain members - such as conditions that imply the member is not a good candidate for care management 3. Exclusionary conditions that exclude certain claims - exclude claims for conditions that disease management does not try to affect 4. Persistency - understand the terms under which a member may enter or leave group 5. Chronic prevalence and risk classification - chronic prevalence is defined as % of individuals in a population with the condition 6. Severity of illness - severity affects claims cost, and therefore the potential for savings 7. Contactability - measures whether the manager is able to reach and engage the member 8. Operational issues - number of eligible members; the number of chronic patients identified, contacted, and enrolled; the graduation rates; methodologies used |
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Components of the care management value chain process |
1. Data warehousing - integrate membership and claims data, and identify member conditions 2. Predictive modeling - apply models to determine members to target for interventions 3. Intervention development - develop campaigns to deliver interventions to target populations 4. Outreach and enrollment - contact members and enroll them in the program, includes follow up 5. Member coaching and assessment - including maintaining enrollment and graduating members from the program 6. Outcomes assessment - including clinical, financial, and operational outcomes |
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Reasons for measuring health care quality |
1. Improving health of population 2. Monitoring services rendered 3. Evaluating outcomes 4. Shaping provider behavior 5. Meeting requirements of government regulations, business partners, or accreditation agencies |
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Challenges when using codes to measure quality |
1. Codes (like CPT codes) do not give a complete picture of the care provided 2. Coding errors and coding fraud are prevalent in healthcare 3. Electronic medical records may contain wrong or missing diagnoses 4. The source of the coded data affects the interpretation of it 5. The codes can only indicate if care was provided, not whether the patient complied with physician orders |
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Organizations that measure health care quality in the US |
1. National Quality Forum (NQF) - has lead responsibility for determining which measures should be recognized as national standards in the US 2. Agency for Healthcare Research and Quality - has developed quality indicators which use hospital data to highlight quality concerns and identify areas that need further investigation 3. Joint Commission - primary accrediting body for hospitals, nursing homes, other care facilities 4. CMS - develops measures of quality in various settings and sponsors quality initiatives 5. National Committee for Quality Assurance - develops quality standards for various health care organizations. Develops and updates HEDIS measures 6. Hospital Quality Alliance - develops performance measures of hospital care and produces the Hospital Compare website 7. Measures Applications Partnership - the NQF convened this partnership to identify the best performance measures for specific applications 8. American Medical Association Physician Consortium for Performance Improvement - has developed evidence-based performance measurement sets to facilitate physician analysis of their performance |
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Categories for measuring health care quality |
1. Structure - resources and organizational arrangements are in place to deliver care 2. Process - appropriate physician and other provider activities are carried out to deliver care 3. Outcomes - the results of physician and other provider activities |
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Methodologies for assessing progress of clinical quality initiatives |
1. Percentage compliance - number of times a service was provided divided by the number of times a provider could have performed the measured service 2. Actual vs expected performance - measuring actual outcomes requires careful consideration of: a) how the measure is constructed b) comparability between intervention and comparison populations 3. Performance against a benchmark - a provider's performance is compared to a benchmark in order to determine efficiency |
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Possible reasons why DM studies show improved clinical outcomes but not cost savings |
1. The measurement of financial outcomes is not stable enough, or measurement techniques are not sensitive enough to detect positive financial outcomes 2. Programs are either not focused on financial outcomes or not structured to optimize financial outcomes 3. Program sponsors do not understand the economics of DM programs and therefore do not optimize the programs for financial return 4. Improvements in quality of care do not always lead to lower costs, some improvements may actually increase costs but still are worthwhile investments |
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Financial measures for disease management programs |
1. Return on Investment, most DM programs use Gross ROI a) Net ROI = (gross savings - cost) / cost b) Gross ROI = gross savings / cost c) Program costs generally include direct costs (salaries), indirect costs of supporting activities, management costs, overhead costs, and set-up costs d) Gross savings come from decreased utilization as a result of the DM program 2. Total savings - this metric may be more useful since it represents the dollar savings for the plan a) Avg savings equals total savings net of program cost, divided by total population b) Marginal savings per chronic member equals the increase in savings (net of costs) due to intervention on the marginal population, divided by the number of members in the marginal population |
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Key metrics in the design of disease management programs |
1. Number and risk-intensity of members to be targeted - the number must be large enough to produce savings that offset implementation costs, but not so large that marginal costs exceed marginal savings 2. Types of interventions to be used in the program - such as mail or automated outbound dialing 3. The number of nurses and other staff needed for the program and program costs 4. The methodology for contacting and enrolling members 5. The rules for integrating the program with the rest of the care management system 6. The timing and number of contacts, enrollments, and interventions 7. The predicted behavior of the target population if there were no intervention, and the predicted effectiveness of the intervention at modifying that behavior |
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Components of the Risk Management Economic Model |
1. Prevalence of different chronic diseases 2. Cost of the chronic disease 3. Payer risk - the most savings for the plan will come when the plan is at financial risk for all of the patient's cost 4. Targeting and risk - members should be prioritized based on probability of experiencing targeted event, those with highest risk ranks will be selected for program 5. Estimated cost of the targeted event 6. Contact rate - rate at which the company is able to make contact with targeted members 7. Engagement (or enrollment) rate 8. Member re-stratification rate - initial risk rank of the member will be re-stratified after the nurse interacts with that member and assesses the member's risk |
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Common chronic diseases addressed by disease management programs |
1. Ischemic heart disease 2. Heart failure 3. Chronic obstructive pulmonary disease 4. Asthma 5. Diabetes |
