Claims and Disease Management

Question 1

Care Mangement Programs and Interventions

Answer 1

1. Pre-Authorization
2. Concurrent Review
3. Case Management: coordinates care of a patient with serious illness
4. Demand Management: Passive information intervention
5. Disease Management: focuses on chronic conditions with certain characteristcs that make them suitable for clinical intervention
6. Specialty Case Management
   
   • Care manager responsible for coordinating patient’s care
   • Financial responsibility along with service responsibility
7. Population Health Management: Emphasis on wellness, prevention
8. Care coordination and other intervention model enhancements: chronic care model, medical home, embedded care manager, transition models, external care manager, palliative care, care coordination demonstrations
9. PCMH and P4P
10. ACOs
11. Non-traditional providers and care settings: Pharmacists as healthcare providers
    
    • Advantages: There are more pharmacists than PCPs, some pharmacies are open 24/7, patients interact with their pharmacist more often.
12. Non-traditional providers and care settings: Clinics
    
    • Retail (convenient care) clinics (CCCs)
    • Employer worksite clinics
    • Urgent care clinics
    • FQHCs
13. Gaps in care and quality improvement programs
14. Telemedicine, telehealth, and automated monitoring
15. Bundled payment initiatives

Question 2

ACO Description

Answer 2

• Structure and organization of ACO’s
  • ACO: a network of doctors and hospitals responsible for caring for patients
  • To be allowed to share savings with CMS, must report on quality metrics and surpass savings hurdle rate
  • A Medicare Shared Savings Program (MSSP) ACO will manage health care needs (not financially at risk for drug utilization) of 5,000+ Medicare beneficiaries for at least 3 years
  • ACOs are not limited to Medicare
• ACO model overlooks some key learnings of DM programs
  • Need data analytics, as close to real-time as possible
  • Economics. For there to be a net savings, cost must be less than savings
  • Plan the number of interactions, with which patients

Question 3

Ways in which provider group-based ACOs are expected to generate savings

Answer 3

1. Care Coordination
2. Reducing the need for tests via access to integrated records and consistent management by the physician
3. Developing a network of efficient providers
4. Focusing on quality, which will result in fewer unnecessary services.
5. Reducing duplication of services
6. Preventing medical errors

Question 4

Priniciples for establishing a patient-centered medical home (PCMH)

Answer 4

1. Personal physician for each patient
2. Physician-directed medical practice
3. Whole person orientation
4. Care coordinated and integrated across all elements of health care system
5. Quality and safety
6. Enhanced access through open schedule, expanded hours, and E-visits
7. Reimbursement structure to support and encourage this model of care

Question 5

Types of interventions conducted by pharmacists

Answer 5

1. Drug Utilzation Review (DUR) - manage price by subsituting lower-cost alternatives and manage utilization by requiring prior authorization for certain drugs
2. Medication Therapy Management (MTM) - aim to improve medication use and reduce adverse events for beneficiaries with mutliple drugs. Required by Part D.
3. Pharmacist-delivered care management programs - pharmacists collaborate with PCPs. Focus on drug adherence, which is measured one of two ways
   
   1. Medication possession ratio = Number of days supply in the patient’s possession / Number of days during the measurement period the patient could have had the drug
   2. Portion of days covered (PDC) = Number of days of coverage / Total number of days in the measurement period

Question 6

Benefits of being designated an FQHC

Answer 6

1. Reimbursement for services provided under Medicare and 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. Eligibliity for various other federal grants and programs

Question 7

Three factors to resolve inconsistency between health improvements and financial savings

Answer 7

1. A better understanding of economics of DM programs
2. Rigorous measurement of financial outcomes
3. Reconciliation between program savings and cost increase trends

Question 8

Describe the Risk Management Economic Model

Answer 8

1. Examine link between DM program risk, cost, and savings.
2. Quantify savings at different points in the risk distribution.
3. Components:
   
   • Risk stratification
   • Prevalence of different chronic diseases
   • Chronic disease cost
   • Payer risk
   • Targeting and risk
   • Estimated event cost
   • Contract rate
   • Engagement rate
   • Member re-stratification rates

Question 9

Designing a DM Program - Metrics that should be explicitly recognized

Answer 9

1. Number and risk-intensity of members to be targeted
2. Types of interventions to be used
3. Number of staff, their cost, and other program costs
4. Methodology for contacting and enrolling members
5. Rules for integrating program with rest of care system
6. Timing and numbers of members to be contacted
7. Predicted behavior absent intervention and predicted effectiveness at modifying that behavior

Question 10

Chronic diseases addressed by disease management programs

Answer 10

1. Ischemic heart disease
2. Heart failure
3. Chronic obstructive pulmonary disease (COPD)
4. Asthma
5. Diabetes

Question 11

Characteristics of chronic conditions that make them suitable for disease management programs

Answer 11

1. Disesase remains the rest of the patient’s life
2. Mangeable with pharmaceutical therapy and lifestyle
3. Patient can take responsibility for their own condition
4. Average cost sufficiently high to warrant expenditure
5. Expected cost of non-adherent patient is high

Question 12

Describe DM ROI Calculations

Answer 12

1. In other applications, return expressed on a Net basis.
   
   • In Disease Management express return in gross terms.
2. Program cost (denominator)
   
   • Direct costs (salaries of internal staff; vendor fees)
   • Indirect costs of internal support
   • Management costs
   • Overhead and other allocated costs
   • Set-up costs: one-time expenses
3. Savings due to the program (numerator)
   
   • Savings result from decreased resource utilization

Question 13

Components of an MTM program for Part D

Answer 13

1. Performing or obtaining necessary assessments of the patient’s health status
2. Formulating a medication treatment plan
3. Selecting, initiating, modifying, or administering medication therapy
4. Monitoring and evaluating the patient’s response to therapy
5. Performing a comprehensive medication review to identify, resolve, and prevent medication-related problems
6. Documenting the care delivered and communicating essential information to the patient’s other primary care providers
7. Providing verbal and written education to enhance understanding of medications
8. Coordinating MTM services with other health care management services

Question 14

Possible reasons why DM studies show improved clinical outcomes but not cost savings

Answer 14

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.

Question 15

What is Opportunity Analysis

Answer 15

1. Demonstrates improvements that could result from applying evidence-based CM programs
2. Apply programs to members likely to achieve the Triple Aim (advancing health of populations, improving individual patients experiences, reducing per capita health care costs)
3. Several basic components are required:
   
   • Knowledge of member benefit design
   • Information on any evidence-based care management programs
   • Eligibility and claims data for the prior 2 or 3 years
4. While an Opportunity Analysis is retrospective, the results are applied prospectively to identify members meeting the profile of opportunity population

Question 16

Member Stratification For Opportunity Analysis vs. Care Management

Answer 16

1. Care Management program planning follows one of several typical models:
   
   1. Model 1: Run a predictive model stratifying members by their risk score.
      
      • Disadv: prevalence of members who are minimally intervenable
      • Disadv: operation problems if population is very diverse in term of conditions and needs
   2. Model 2: A condition-specific model.
      
      • Prevalence of co-morbidities means ultimately need to address all conditions of the high risk population
   3. Model 3: A rules-based approach.
      
      • Often relies on clinicians for identifying candidates; but clinicians are not good at identifying candidates.
2. ​Opportunity analysis addresses a number of shortcomings with these models.
   
   • It maintains stratification of model 1, but assigns lower priority to less intervenable patients
   • favors programs targeting members with common risk profiles.

Question 17

Designing a Program (a.k.a. The Opportunity Analysis Process)

Answer 17

1. Analytics
   
   1. Group conditions by intervention type
   2. Also consider comorbidities
   3. Requires further drill down analysis
   4. Further segmentation by cost and frequency
2. Searching the Evidence Base
   
   1. Step 1: Search for relevant publications
   2. Step 2: Assess the quality of evidence
   3. Step 3: Determine generalizability
   4. Step 4: Develop a suggested program
3. Weighing the Economics
   
   1. Expected cost per risk-ranked patient
   2. The cost of alternative treatment from which we derive potential savings.
   3. The expected accuracy of our identification algorithm
   4. Apply a timing factor
   5. Not all patients offered a program will engage, due to:
      
      • Difficulty reaching the patient
      • Cognitive impairment
      • Unwillingness to cede hope of recovery

Question 18

Implementing a Program Following Opportunity Analysis

Answer 18

1. Develop a predictive model to populate the risk distribution
2. Establish a production analysis and reporting unit
3. Determine the number of care managers required
4. Develop a budget accounting for all required resources
5. Hire and train care managers to conduct interventions
6. Develop a plan. Estimate numbers of patients identified, engaged, and transferred
7. Roll out intervention and enroll first patients
8. On an ongoing basis, track outcome and modify as necessary

Question 19

The Value of Opportunity Analysis (a.k.a. Reasons for taking this alternative, more structured approach)

Answer 19

1. Clinicians are not particularly good at identifying high-risk patients
2. The economics of program planning cannot be ignored
3. Resources are devoted to patients where they can have the most beneficial effect.
4. Understanding which sub-populations are intervenable and the value of that intervention
5. Plan for the number of patients, the number of care-givers, and the estimated financial return
6. Provides a specific plan with targets for comparing actual outcomes

Question 20

What is a Propensity Score?

Answer 20

1. Summarizes mutliple characteristics into a single value, allowing matches on the score rather than directly on characteristics.
2. The score should not be the only criterion on which members are matched
3. Disadvantage: it controls only for observable and not unobservable variables (e.g. willingness to change behavior)

Question 21

General Approach to Propensity Score Matching

Answer 21

1. Run logistic regression to create a propensity score
   
   • Assign a value of 1 to participants (the treatment group) and 0 to nonparticipants
   • ln[p/(1-p)]=a+B*X +e. p is the probability of the member being in the treatment group, p/(1-p) is the odds ratio
   • Solve for p, propensity score. p= (e^a+B*X)/(1+e^a+B*X​)
2. Match each participant based on propensity score
   
   • A target member may be matched to one or many comparison members
   • Important considerations for matching include:
     
     • With or without replacement decision
     • What determines closeness of a match
     • What constitutes a satisfactory percentage of matched members
   • There is a trade-off between the number of matches and closeness of the score.
3. Testing the Results
   
   • Testing for bias is difficult because propensity score only adjusts for observable variables
   • Models should use the minimum number of variables necessary
   • Validate that the matched sample adjusts for observed differences

Question 22

Propensity Score Matching Methods

Answer 22

1. Nearest neighbor matching - the first member of the comparison population with the closest propensity score is selected, with or without replacement
2. Caliper matching - a match is made if the member and match’s propensity scores are within a fixed distance
3. Mahalanobis metric matching - this metric is used to measure the dissimilarity between two vectors
4. Stratification matching - observations are stratified and then matched by stratum

Question 23

Compare propensity scores and risk adjustment

Answer 23

1. Similarity: Both reduce the effect of multiple risk factors (such as age/sex/diagnosis) to a single score, using multiple regression
2. Diff: Propensity score is usually based on a wider range of independent variables, but risk score takes into account more detailed diagnosis variables.
3. Diff: Risk adjustment uses entire population, propensity matching can result in many members being discarded

Question 24

Describe the Actuarially-Adjusted Historical Control Methodology

Answer 24

1. Objective criteria define inclusion in reference or intervention population
   
   • Trend is derived from “index” population
   • Methodology is “open group”, comparable population selected each period using same selection criteria
2. Savings are not directly measured, but derived as difference between actual and projected cost

Question 25

Issues related to determining and controlling exposure for a disease management study

Answer 25

1. Managed vs. Measured populations - populations need not be the same
2. Eligible members - eligibility is first determined for health plan membership, then for DM services
3. Member month counts - category determined monthly
4. Chronic and non-chronic (index) members - assignment determined monthly
5. Excluded members
6. Measured and non-measured members
7. Outcomes should be measured for all targeted members to avoid bias in results

Question 26

Conditions that would exclude a member from a disease management program

Answer 26

1. ESRD
2. Transplants
3. HIV/AIDs or mental health
4. Members who are institutionalized
5. Members with catastrophic claims
6. Members eligible for other management programs

Question 27

Challenges when calculating disease management savings

Answer 27

1. Applying the proper trend rate - trend must be risk adjusted
2. Demonstrating equivalence between the baseline and measurement periods - must account for the change in mix of new, continuing, and terminating members

Question 28

Leading indicators of savings for EHM programs

Answer 28

1. Identification, stratification, and targeting (outreach)
2. Program enrollment and use of tools
3. Continuing engagement or program completion
4. Behavior change
5. Behavior maintenance
6. Process of care
7. Medication adherence
8. Achieving clinical targets
9. Patient activation
10. Satisfaction with EHM
11. Well-being

Question 29

Lagging indicators of savings for EHM programs

Answer 29

1. Functional status
2. Quality of life and well-being
3. Absenteeism and presenteeism
4. Morbidity (ER, hospital, procedures)
5. Healthcare claims cost

Question 30

When should an EHM model be used in place of measurement for savings calculations?

Answer 30

1. When population is less than 25,000 members
2. When fully adjudicated medical and pharmacy claims are not available
3. When frequency of reporting is more frequent than annual
4. Additional comments on model building
   
   • Build the model using factors similar to those in the studies upon which the model is based
   • Model as much of the population as possible
   • Determine what savings to model (e.g. health care savings, absenteeism, presenteeism)

Question 31

Two key questions in Care Management

Answer 31

1. Will this drive better clinical outcomes for the member?
2. How much money can we save by doing this?

Question 32

Ways vendors can impact medical cost (in context of care management)

Answer 32

1. Utilization management
   
   • Assess medical necessity/appropriateness of care, etc.
2. Site of care
   
   • Shift some types of care to less expensive venues
3. Diagnosis or patient type
   
   • Savings measured on all covered care to patient, not a subset
4. Severity/downcoding
   
   • Identify and reverse inappropriate upcoding

Question 33

Methods to measure Medical Savings Initiative

Answer 33

1. Pre/Post analysis
2. Participating/nonparticipating analysis
3. Regression/trend line analysis
4. Matched cohort analysis
5. Propensity score matching
6. Coarsened exact matching

Question 34

Considerations/Adjustments for Care Management populations

Answer 34

1. Scope
2. Trend
3. Risk adjustment
4. Overlap
5. Delay in claim impact
6. Episodic care
7. Seasonality
8. Class of Claims
9. Care shifting
10. Credibility

HINT: STRODES CCC

Question 35

Forms of Reimbursement to Care Management Vendor

Answer 35

1. Fee paid per eligible PMPM
2. Capitation - payer pays vendor a fixed PMPM, vendor takes on all risk
3. Risk Share - vendor awarded a percentage of savings achieved

Question 36

Four main program components of palliative care program

Answer 36

1. Patient identification through predictive analytics
2. Specially trained nurses/social workers performing in-home and telephonic visits
3. Caregiver support
4. Goals-of-care discussions and documentation of plans