All GH Specialty Flashcards
Types of care management methods
- Pre-Authorization - requires a provider to obtain approval before performing a service
- Concurrent review - monitoring a member’s care while the member is still receiving care in a hospital or nursing home
- Case Management - typically involves a health care professional who coordinates the care of a patient with a serious disease or illness (such as stroke, AIDS, or cancer)
- Demand management - refers to certain passive forms of informational intervention, often provided over the telephone. Includes nurse advice lines and shared decision making
- Disease management - focuses on chronic conditions with certain characteristics that make them suitable for clinical intervention
- Specialty case management - a care manager who has expertise in a particular area coordinates care for patients in that area
- Population health management - the 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
- Patient-centered medical home - this model returns to the physician the responsibility for coordinating all of the patient’s care
- Accountable Care Organization (ACO) - a network of doctors and hospitals share responsibility for providing patient care. The PCP is accountable for providing quality care and reducing utilization
- Non-traditional provider interventions and care settings - pharmacists and different types of clinics can be used to provide various interventions
- 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
- Telehealth, telemedicine, and automated monitoring systems
> Telehealth encompasses a broad spectrum of technology-enabled health care services
> Telemedicine is the electronic transmission of medical information to remote specialists who help diagnose and treat the patient
> Automated (or patient) monitoring systems provide patient data to providers. The data can trigger alerts so that the provider can make appropriate interventions - Bundled payment initiatives - these initiatives bundle payments for multiple services across a single episode of care. The goal is to improve coordination and quality of care and lower costs by aligning the financial incentives of multiple providers
Duncan Ch. 3
Characteristics of chronic conditions that make them suitable for disease management programs
- Once contracted, the disease remains with the patient for the rest of the patient’s [L]ife
- The disease is often [M]anageable with a combination of pharmaceutical therapy and lifestyle change
- Patients can take [R]esponsibility for their own conditions
- The average [A]nnual cost is sufficiently high to warrant spending resources to manage the condition
- The expected cost of the non-[A]dherent patient is high
LAMAR
Duncan Ch. 3
Principles for establishing a patient-centered medical home
- Personal physician - each patient has a personal physician trained to provide comprehensive care
- Physician-directed medical practice - consists of a team of individuals taking responsibility for the patient’s ongoing care
- Whole-person orientation - appropriately arranging care with other qualified professionals
- Care coordinated and integrated across all elements of the health care system and the patient’s community
- Quality and safety - includes patient-centered outcomes, evidence-based medicine, and continuous quality improvement
- Enhanced access through open scheduling, expanded hours, and e-visits
- Reimbursement structure to support and encourage this model of care
RAW PIPS
Duncan Ch. 3
Ways in which provider group-based ACOs are expected to generate savings
- Implementing care coordination to manage the care of the patients who need additional services
- Reducing the need for tests via access to integrated medical records and consistent management by the physician
- Developing a network of efficient providers for referrals and limiting the use of less efficient and more expensive providers
- Focusing on quality, which will result in fewer unnecessary services, and emphasizing preventative services will lead to savings as population health improves
- Reducing duplication of services
- Preventing medical errors
Duncan Ch. 3
Types of interventions conducted by pharmacists
- Drug utilization review - these programs manage price by substituting lower-cost alternatives for higher-cost drugs, and they manage utilization by requiring prior authorization for certain drugs
- 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 $4,000 for all covered Part D drugs.
- Pharmacist-delivered care management programs - pharmacists can collaborate with PCPs on medication optimization and medication safety. These programs often focus on drug adherence, which is measured in one of two ways:
> Medication possession ratio = number of days supply in the patient’s possession / number of days during the measurement period during which the patient could have had the drug
> Proportion of days covered = number of days of coverage / total number of days in the measurement period
CUM
Duncan Ch. 3
Components of an MTM program for Part D
- Performing or obtaining necessary [A]ssessments of the patient’s health status
- Formulating a medication treatment [P]lan
- Selecting, initiating, modifying, or administering medication {T}herapy
- Monitoring and evaluating the patient’s [R]esponse to therapy
- Performing a comprehensive medication [R]eview to identify, resolve, and prevent medication-related problems
- [D]ocumenting the care delivered and communicating essential information to the patient’s other primary care providers
- Providing verbal [E]ducation and training designed to enhance patient understanding and appropriate use of medications
- Providing information, support services, and resources to enhance patient [A]dherence to drug regimens
- [C]oordinating and integrating MTM services with other health care management services
TRADE CARP
Duncan Ch. 3
Types of clinics that can be used to provide basic health care
- Retail convenient care clinics - many pharmacies, hospitals, and grocery chains have opened retail clinics staffed by nurse practitioners. These clinics offer care on a walk-in basis for common, non-urgent illnesses and are generally open during evenings and on weekends.
- Employer worksite clinics - these are most common at very large employers. They may cover various types of care, such as preventative services, acute care, primary care, pharmacy, disease management, and wellness
- Urgent care clinics - freestanding centers that are staffed by a full range of clinicians, who are directed by physicians. They are generally open longer than physician practices and they offer a full range of ambulatory services, including many that are offered at hospital emergency departments
- Federally qualified health centers (FQHCs) - these are designated by the federal government to provide health care to the underserved and uninsured. An example is a community health center.
CURE
Duncan Ch. 3
Benefits of being designated an FQHC
- [R]eimbursement for services provided under Medicare and Medicaid
- Medical [M]alpractice coverage
- Eligibility to purchase medications for [O]utpatients at reduced cost
- Access to [N]ational Health Service Corps
- [A]ccess to the Vaccine for Children Program
- Eligibility for various other federal grants and [P]rograms
PRO MAN
Duncan Ch. 3
Possible reasons why DM studies show improved clinical outcomes but not cost savings
- The [M]easurement of financial outcomes is not stable enough, or measurement techniques are not sensitive enough, to detect positive financial outcomes
- Programs are either not [F]ocused on financial outcomes, or not structured to optimize financial outcomes
- Program sponsors do not understand the [E]conomics of DM programs and therefore do not optimize the programs for financial returns
- Improvements in quality of care do not always lead to [S]avings. Some improvements may actually increase costs, but still be worth the investment
FEMS
Duncan Ch. 8
Financial measures for disease management programs
- Return on investment - this is the most common metric. DM programs typically use Gross ROI
> Net ROI = (gross savings - cost)/cost
> Gross ROI = gross savings/cost
> Program costs generally include direct costs, indirect costs, management costs, overhead costs, and set-up costs
> Gross savings come from decreased utilization as a result of the DM program or intervention - Total savings - this metric may be more useful, since it represents the dollar savings for the plan
> Average savings = Total Savings net of Program Cost / Total Population
> 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
Duncan Ch. 8
Key metrics in the design of disease management programs
- The number and [R]isk-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
- Types of [I]nterventions to be used in the program - such as mail or automated outbound dialing
- The number of nurses and other [S]taff needed for the program, and program costs
- The methodology for contacting and [E]nrolling members
- The [R]ules for integrating the program with the rest of the care management system
- The [T]iming and number of contacts, enrollments, and interventions
- The [P]redicted behavior of the target population if there were no intervention, and the predicted effectiveness of the intervention at modifying that behavior
STRIPER
Duncan Ch. 8
Components of the Risk Management Economic Model
- [P]revalence of different chronic diseases
- the [C]ost of the chronic disease
- [P]ayer risk - the most savings for the plan will come when the plan is at financial risk for all of the patient’s costs
- [T]argeting and risk - members should be prioritized based on the probability of experiencing the targeted event. Those with the highest risk ranks will be selected for the program
- [E]stimated cost of the target event
- [C]ontact rate - the rate at which the company is able to make contact with targeted members
- [E]ngagement or enrollment rate
- Member [R]e-stratification rates - the initial risk of the member will be re-stratified after the nurse interacts with the member and assesses the member’s risk. Factors that affect whether the member should be re-stratified include the accuracy of the diagnosis, risk factors present, the ability of the DM program to intervene for the condition, the patient’s readiness to change, and the patient’s self-management skills
CREPT PEC
Duncan Ch. 8
Common chronic diseases addressed by disease management programs
- Ischemic heart disease
- Heart failure
- Chronic obstructive pulmonary disease
- Asthma
- Diabetes
I CHAD
Duncan Ch. 8
Description of opportunity analysis for care management programs
- Definition: a data-driven analytical process that extends traditional predictive modeling by matching opportunities within a population to care management programs and services
- To perform the analysis, the following components are required:
> Knowledge of member benefit design
> Information on any evidence-based care management programs currently in place or that could reasonably be introduced
> Eligibility and claims data for the past 2-3 years - Is retrospective, it looks at past data to identify pockets of opportunity
- Is applied prospectively, once a profile of an opportunity population is identified, all current members meeting that profile can be included in the program
Duncan Ch. 9
Models typically used to stratify members in a care management program
- Stratify members according to the predictive risk [S}core - but at the top of that list are many members who represent a low opportunity for cost savings
- [C]ondition-specific model - focus on members with a specific condition, such as diabetes. But any program targeted at a specific condition may miss the greater opportunity of addressing the co-morbid conditions of that population
- [R]ules-based approach - clinicians use a set of rules to identify patients for care management. But the literature suggests that clinicians are not particularly good at identifying patients for management
Opportunity analysis is designed to address the shortcomings of these models.
SRC
Duncan Ch. 9
Components for designing a care management program using opportunity analysis
- [A]nalytics - members are segmented by medical conditions into subpopulations that are amenable to different types of interventions. Utilization data is compared to a benchmark to highlight areas with the most potential for utilization management savings.
- Searching the [E]vidence base for knowledge of what works and does not work
> A literature review is done to find programs that are efficacious, cost-effective, and generalizable to the population to be managed
> A three-step approach is used: search for relevant publications, assess the quality of evidence, and determine generalizability - [W]eighing the economics
> The population is risk ranked using a predictive model, whch also determines the expected cost for each person
> This cost is compared to the person’s cost without the intervention to determine savings
> The savings are compared to the cost of the intervention to determine at what point in the risk ranking it is economically feasible to intervene
AWE
Duncan Ch. 9
Steps for implementing a care management program using opportunity analysis
- Develop a predictive [M]odel to populate the risk distribution
- Establish a production analysis and [R]eporting unit. Develop the necessary reports and a reporting application
- Determine the likely [N]umber of care managers required
- Develop a [B]udget for the program, accounting for all required resources
- Hire and [T]rain care managers to conduct interventions and manage patients
- Develop a plan, including [E]stimates of the numbers of patients identified and engaged
- Roll out the [I]ntervention and enroll patients
- [O]perate the program, track outcomes, and modify as necessary
MINT ROBE
Duncan Ch. 9
Reasons for using opportunity analysis for identifying patients for care management interventions
- [S]tudies have shown that clinicians are not particularly good at identifying high-risk patients
- The [E]conomics of program planning cannot be ignored in a system with limited resources
- This structured approach is important for [U]nderstanding which subpopulations are amenable to intervention and the likely value of that intervention
- The structured financial model provides a [F]ramework against which actual outcomes may be compared, identifying areas where the program needs to be corrected or improved
FUSE
Duncan Ch. 9
Description of propensity score matching
- Propensity score matching is a technique used for making a participant (intervention) group comparable to a non-participant group. It can control for observable variables such as age, gender, and geography, but it does not control for important unobservable influences such as willingness to change behavior
- Each member in the participant group is matched with a member of the non-participant group based on propensity scores
- The propensity score, p, is the probability that the member will be in the participant group
> IT is calculated using logistic regression based on that member’s values for the independent variables (such as age and gender)
> This process reduces a large number of variables to a single score
> Members with similar scores can then be matched, even if they are not matched exactly on the independent variables
> There should still be relatively close matches on those other variables
Duncan Ch. 11
Steps for applying propensity score matching to a study
- Run logistic regression to create a propensity score. Should consider as the independent variables any observable factors that may influence a person’s decision to participate in the program
> The regression equation is ln[p/1-p)] = a + BX + e
> so propensity score, p = exp[a + Bx]/(1 + exp[a + BX]) - Use propensity scores to match each participant to a nonparticipant using one of the following techniques:
> Nearest neighbor matching: the first member of the comparison population with the closest propensity score is selected, either with or without replacement
> Caliper matching: a match is made if the member and match’s propensity scores are within a fixed distance
> Mahalanobis metric matching: this metric is used to measure the dissimilarity between two vectors
> Stratification matching: observations are stratified and then matched by stratum - Test the model for appropriateness and bias: testing for bias is difficult because the propensity score match only adjusts for observable variables. Models should be parsimonious (should only use minimum variables necessary to achieve stability)
RAM
Duncan Ch. 11
Comparison of propensity scoring and risk adjustment
Similarity:
> Both reduce the effect of multiple risk factors (such as age, sex, and diagnoses) to a single score using multiple regressions
Differences:
> The propensity score is usually based on a wider range of independent variables, but the risk score will almost always take into account more detailed diagnosis variables
> Risk adjustment uses the entire population, while propensity matching can result in many members of the population being discarded
Duncan Ch. 11
Description of the actuarially-adjusted historical control method
- Objective criteria are used to determine which members will be included in the baseline and intervention populations
> This is an open group method, since the populations are not identical. A closed group (or cohort) method uses the exact same population in both periods
> But the populations are comparable, and assumed to be equivalent, because the same selection criteria is used in each period - Savings are not directly measured. They are derived as the difference between
> An estimated statistic projected from the baseline period. The key component is the health care trend factor used for this projection.
> The actual statistic from the measurement period - Formulas for calculating savings:
> Savings = [ChrUtilpy * (1 + tr) - ChrUtilact] * ChrMbrs * Cost/Svc
> Trend rate comes form the health plan’s non-chronic population
> Savings PMPM = savings / member months
Duncan Ch. 12
Issues related to determining and controlling exposure for a disease management study
- Managed versus measured populations: the population to be measured does not need to be the same population that is being managed
- Eligible members: eligibility is first determined for health plan membership, then for DM services
- Member months: in any given month, a member is uniquely classified into a single category. Members can move between categories from one month to the next
- Chronic and non-chronic (index) members: the assignment of chronic status is determined monthly
- Excluded members: some members are eligible for health plan membership but are not eligible for inclusion in the DM program
- Measured and non-measured members: tests for inclusion in the measurement population may include the continuous coverage test and a claim-free period
- Enrolled, targeted, and reachable members: to avoid bias in the results, outcomes should be measured for all targeted members (whether enrolled, not enrolled, or unreachable)
Duncan Ch. 12
Reasons a member may be excluded from a disease management program
- The member class is not receptive to disease management
- The member is a candidate for a program administered by another vendor (such as mental health)
- The pattern of claims that the member exhibits is subject to sharp discontinuity, and can thus distort a trend calculation
- The member’s claims are significant, and the experience is likely to dominate the group, or introduce noise to the calculation
Duncan Ch. 12