Objective 2 - Care Management

Question 1

Types of care management methods

Answer 1

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 a hospital or nursing home
3. 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)
4. Demand management - refers to certain passive forms of informational intervention, often provided over the telephone. Includes nurse advice lines and shared decision making.
5. Disease management - focuses on chronic conditions with certain characteristics that make them suitable for clinical intervention (see separate list for these characteristics)
6. Specialty case management - a care manager who has expertise in a particular area coordinates care for patients in that area
7. 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
8. Patient-centered medical home - this model returns to the physician the responsibility for coordinating all of the patient’s care
9. Accountable Care Organizations (ACO) - a network of doctors and hospitals share responsibility for providing patient care. The 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 (see separate lists)
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
    a) Telehealth encompasses a broad spectrum of technology-enabled health care services
    b) Telemedicine is the electronic transmission of medical information to remote specialists who help diagnose and treat the patient
    c) Automated (or patient) monitoring systems provide patient data to providers. The data can trigger alerts so that the provider can make appropriate interventions.
13. 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 incentive and multiple providers

Question 2

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

Answer 2

1. Once contracted, the disease remains with the patient for the rest of the patient’s life
2. The disease is often manageable with a combination of pharmaceutical therapy and lifestyle change
3. Patients can take responsibility for their own conditions
4. The average annual cost is sufficiently high to warrant spending resources to manage the condition
5. The expected cost of the non-adherent patient is high

Question 3

Principles for establishing a patient-centered medical home

Answer 3

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 improvement
6. Enhanced access through open scheduling, expanded hours, and e-visits
7. Reimbursement structure to support and encourage this model of care

Question 4

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

Answer 4

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 the physician
3. Developing a network of efficient providers for referrals and limiting the use of less efficient and more expensive providers
4. Focusing on quality, which will result in fewer unnecessary services. And emphasizing preventative services will lead to savings as population health improves.

Question 5

Types of interventions conducted by pharmacists

Answer 5

1. 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
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 $4,000 for all covered Part D drugs
3. 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:
   a) 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
   b) Proportion of days covered = number of days of coverage / total number of days in the measurement period

Question 6

Types of clinics that can be used to provide basic health care

Answer 6

1. 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 the evenings and on weekends.
2. 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.
3. 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.
4. Federally qualified health centers (FQHCs) - these are designed by the federal government to provide health care to the underserved and uninsured. An example is a community health center.

Question 7

Benefits of being designated a FQHC

Answer 7

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. Eligibility for various other federal grants and programs

Question 8

Areas where actuaries can be involved with care management programs

Answer 8

1. The economics of care management programs - help with understanding the relationship between care management program inputs and outputs
2. Risk adjustment and predictive modeling
   a) Predictive modeling is used to identify candidates for intervention programs
   b) Risk adjustment is used to assess outcomes
3. Financial outcomes evaluation - help in achieving comparability between the reference and the intervention population

Question 9

Principles for measuring results of care management programs

Answer 9

1. Reference population - any outcome’s measurement requires a reference population against which to evaluate the statistics of interest
2. Equivalence - the 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 measurement - avoid (if possible) 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 (“plausibility analysis”)

Question 10

Issues that affect disease management evaluations for chronic populations

Answer 10

1. Regression to the mean - a high percentage of high-cost patients in one period will not be high cost in the next period, simply because the high-cost event was a one-time event that is not likely to be repeated
2. Identifying patients - due to regression to the mean, it may not be appropriate to use patients’ past data as the comparison group. A common alternative is to use the population approach (uses the entire population)
3. Establishing uniform risk measure for comparability - objective, consistent definitions should be used to identify candidates for the care management program (this will ensure equivalence)
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

Question 11

Considerations when using claims data for evaluating disease management programs

Answer 11

1. Fixed time periods - a one-year time period may be too short for outcomes evaluation
2. Enrollment issues/eligibility - the timeliness of enrollment and disenrollment should be factored into the 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 measures are miscategorized (false positives or false negatives)

Question 12

Benefits of being designated a FQHC

Answer 12

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. Eligibility for various other federal grants and programs

Question 13

Areas where actuaries can be involved with care management programs

Answer 13

1. The economics of care management programs - help with understanding the relationship between care management program inputs and outputs
2. Risk adjustment and predictive modeling
   a) Predictive modeling is used to identify candidates for intervention programs
   b) Risk adjustment is used to assess outcomes
3. Financial outcomes evaluation - help in achieving comparability between the reference and the intervention population

Question 14

Principles for measuring results of care management programs

Answer 14

1. Reference population - any outcome’s measurement requires a reference population against which to evaluate the statistics of interest
2. Equivalence - the 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 measurement - avoid (if possible) 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 (“plausibility analysis”)

Question 15

Issues that affect disease management evaluations for chronic populations

Answer 15

1. Regression to the mean - a high percentage of high-cost patients in one period will not be high cost in the next period, simply because the high-cost event was a one-time event that is not likely to be repeated
2. Identifying patients - due to regression to the mean, it may not be appropriate to use patients’ past data as the comparison group. A common alternative is to use the population approach (uses the entire population)
3. Establishing uniform risk measure for comparability - objective, consistent definitions should be used to identify candidates for the care management program (this will ensure equivalence)
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

Question 16

Considerations when using claims data for evaluating disease management programs

Answer 16

1. Fixed time periods - a one-year time period may be too short for outcomes evaluation
2. Enrollment issues/eligibility - the timeliness of enrollment and disenrollment should be factored into the 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 measures are miscategorized (false positives or false negatives)

Question 17

Risk factors for care management studies

Answer 17

(these should be reported with the study, to ensure reproducibility of results)

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 that disease management does not try to affect (e.g., maternity)
4. Persistency - understand the terms under which a member may enter or leave the group
5. Chronic prevalence and risk classification - chronic prevalence is defined as the percentage of individuals in a population with the condition
6. Severity of illness - severity affects claims cost, and therefore the potential for savings.
7. Contactability - this measures whether the manager is able to reach out and engage the member
8. Operational issues - such as the number of eligible members; the number of chronic patients identified, contacted, and enrolled; the graduation rates; and the methodologies used

Question 18

Components of the care management value chain process

Answer 18

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

Question 19

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

Answer 19

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 be worth the investment.

Question 20

Financial measures for disease management programs

Answer 20

1. Return on investment - this is the most common metric. DM programs typically use Gross ROI.
   a) Net ROI = (gross savings - cost) / cost
   b) Gross ROI = gross savings / cost
   c) Program costs generally include direct costs (such as salaries), indirect costs of supporting activities, management costs, overhead costs and set-up costs. Gross savings come from decreased utilization as a result of the DM program or intervention.
2. Total savings - this metric may be more useful, since it represents the dollar savings for the plan.
   a) Average savings equals total savings net of program cost, divided by the 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

Question 21

Key metrics in the design of disease management programs

Answer 21

1. The 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 numbers of contacts, enrollments, and interventions
7. The predicted behavior of the target population if there were not intervention, and the predicted effectiveness of the intervention at modifying that behavior

Question 22

Components of the Risk Management Economic Model

Answer 22

(these are the factors that contribute to the financial outcomes of the program)

1. Prevalence of different chronic diseases
2. The 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 costs
4. Targeting 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
5. Estimated cost of the targeted event
6. Contact rate - the rate at which the company is able to make contact with targeted members
7. Engagement (or enrollment) rate
8. Member re-stratification rates - the initial risk rank 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.

Question 23

Common chronic diseases addressed by disease management programs

Answer 23

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

Question 24

Description of opportunity analysis for care management programs

Answer 24

1. Definition: a data driven analytical process that extends traditional predictive modeling by matching opportunities within a population to care management programs and services
2. To perform the analysis, the following components are required:
   a) Knowledge of member benefit design
   b) Information on any evidence-based care management programs currently in place or that could reasonably be introduced
   c) Eligibility and claims data for the past 2-3 years
3. Is retrospective. It looks at past data to identify pockets of opportunity.
4. Is applied prospectively. Once a profile of an opportunity population is identified, all current members meeting that profile can be included in the program

Question 25

Components for designing a care management program using opportunity analysis

Answer 25

1. Analytics - 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.
2. Searching the evidence base for knowledge of what works and does not work
   a) A literature review is done to find programs that are efficacious (the evidence can be trusted), cost-effective (the benefits exceeded the cost), and generalizable to the population to be managed
   b) A three-step approach is used: search for relevant publications, assess the quality of evidence, and determine generalizability
3. Weighting the economics
   a) The population is risk ranked using a predictive model, which also determines the expected cost for each person
   b) This cost is compared to the person’s cost without the intervention to determine savings
   c) The savings is compared to the cost of the intervention to determine at what point in the risk ranking it is economically feasible to intervene

Question 26

Steps for implementing a care management program using opportunity analysis

Answer 26

1. Develop a predictive model to populate the risk distribution
2. Establish a production analysis and reporting unit. Develop the necessary reports and a reporting application
3. Determine the likely number of care managers required
4. Develop a budget for the program, accounting for all required resources
5. Hire and train care managers to conduct interventions and manage patients
6. Develop a plan, including estimates of the numbers of patients identified and engaged
7. Roll out the intervention and enroll patients
8. Operate the program, track outcomes, and modify as necessary

Question 27

Reasons for using opportunity analysis for identifying patients for care management interventions

Answer 27

1. Studies have shown that clinicians are not particularly good at identifying high-risk patients
2. The economics of program planning cannot be ignored in a system with limited resources
3. This structured approach is important for understanding which subpopulations are amenable to intervention and the likely value of the intervention
4. The structured financial model provides a framework against which actual outcomes may be compared, identifying areas where the program needs to be corrected or improved

Question 28

Considerations when evaluating results of disease management studies

Answer 28

1. Has the measurement been performed according to a valid methodology?
2. How has that methodology been applied in practice?
3. Are the results arithmetically correct?

Question 29

Requirements for a care management methodology to be valid

Answer 29

1. Familiarity - the purchaser must be familiar with the methodology, or at least able to grasp it readily
2. Ease or replication and auditability - the methodology must be documented in sufficient detail for another practitioner to replicate the analysis
3. The results upon applying the methodology must be consistent with the client’s savings expectations, and must be plausible
4. Results should be stable over time and between clients
5. The methodology must be practical (possible to implement cost-effectively)
6. Inherent validity - lack of obvious bias
7. Scientific rigor
8. Market acceptance - how the method is perceived in the market
9. Application - how the methodology is applied in practice

Question 30

Types of methodologies for estimating care management savings

Answer 30

1. Control group methods - these attempt to match the study subjects with other subjects that are not part of the study (see separate list)
2. Non-control group methods - population methods that do not use control groups (see separate list)
3. Statistical methods - these use purely statistical techniques, rather than constructing an explicit reference population (see separate list)

Question 31

Control group methods for estimating care management savings

Answer 31

1. Randomized - compares equivalent samples drawn randomly from the same population (the preferred method)
2. Geographic - compares equivalent populations in two different locations
3. Temporal - comparing equivalent samples drawn from the same population before and after the intervention program
4. The product control methodology - compares samples drawn from the same population at the same point in time, but differentiates between members who have different products.
5. “Patient as their own control” - patients are used as their own control group
6. Participant vs. nonparticipant studies - the experience of those who voluntarily participate is compared to the experience of those who choose not to participate (has selection bias)

Question 32

Non-control group methods for estimating care management savings

Answer 32

1. Services avoided methods - savings are calculated as the estimated cost of a service requested through pre-authorization minus the actual cost after the intervention
2. Clinical improvement methods - the change in a clinical measure is observed and the resulting improved health and reduced utilization is estimated from outside studies

Question 33

Statistical methods for estimating care management savings

Answer 33

1. Time series methods - a curve is fit to the data over time and a divergence from the best-fit line can be observed once the intervention is applied
2. Regression discontinuity - a line is fitted to data that relates pre- and post-intervention experience. A dummy variable is used to test whether the intervention produced a change. For example: Yi = B0 + BiXi + BxZi + ei where
   a) X = independent variable (year 1 cost)
   b) Y = dependent variable (year 2 cost)
   c) Z = dummy variable for the intervention in question
   d) B = regression coefficients and e = random error
3. Benchmark methods - the values of certain key statistics are compared between the population being managed and some benchmark population

Question 34

Description of the actuarially-adjusted historical control methodology

Answer 34

This is a temporal control group method

1. Objective criteria are used to determine which members will be included in the baseline and intervention populations
   a) 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.
   b) But the populations are comparable, and assumed to be equivalent, because the same selection criteria is used in each period
2. Savings are not directly measured. They are derived as the difference between:
   a) An estimated statistic projected from the baseline period. The key component is the health care trend factor used in this projection
   b) The actual statistic from the measurement period
3. Formulas for calculating savings:
   a) Savings = {ChrUtilPriorYear * (1+trend) - ChrUtilActual] * Chronic members * cost per services
   i) ChrUtil is the utilization rate per chronic member
   ii) The trend rate comes from the health plan’s non-chronic population
   b) Savings PMPM = savings / member months

Question 35

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

Answer 35

1. Managed versus measured populations - the population to be measured does not need to be the same population that is being managed
2. Eligible members - eligibility is first determined for health plan membership, then for DM services
3. 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
4. Chronic and non-chronic (index) members - the assignment of chronic status is determined monthly
5. Excluded members - some members are eligible for health plan membership, but are not eligible for inclusion in the DM program (see separate list)
6. Measured and non-measured members - tests for inclusion in the measurement population may include the continuous coverage test and a claim-free period
7. 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)

Question 36

Reasons a member may be excluded from a disease management program

Answer 36

1. The member class is not receptive to disease management
2. The member is a candidate for a program administered by another vendor (such as mental health)
3. The pattern of claims that the member exhibits is subject to sharp discontinuity, and can thus distort a trend calculation
4. The member’s claims are significant, and the experience is likely to dominate the group, or introduce noise in the calculation

Question 37

Conditions that would exclude a member from a disease management program

Answer 37

1. End-stage renal disease (ESRD) - this condition is excluded because management of the condition may delay cost, but it cannot ultimately reduce or postpone those costs
2. Transplants - claims are high up to a period shortly after the transplant, at which point the claims are reduced and stabilized
3. HIV, AIDS, mental health - privacy issues make it difficult or impossible for a vendor to receive complete data feed, or manage the member
4. Members who are institutionalized - these members may not be reachable, or may not benefit from disease management interventions
5. Members with catastrophic claims - these members are not manageable by the DM program, and are often subject to management by another program.
6. Members who are eligible for other management programs

Question 38

Challenges when calculating disease management savings

Answer 38

(when using the acturially-adjusted historical control design)

1. Applying the proper trend rate - the trend of the non-chronic population is typically used because the chronic trends are impacted by the disease management efforts. This non-chronic trend must be adjusted for the average risk of the population
2. Demonstrating equivalence between the baseline and measurement periods - must account for the change in the mix of new, continuing, and terminating members and any changes in conditions and co-morbidities. This can be done by re-weighting the claim costs that are used in the savings calculations.

Question 39

Methods for calculating trend to use in evaluating a disease management program

Answer 39

1. Group-specific trend - most savings calculations use trends based on the employer’s non-chronic population. But his trend is subject to random fluctuation, even for large groups (a study showed a 3.6% standard deviation for groups of 40,000 members)
2. Population trend - to reduce the random fluctuation, a very large trend source should be considered, such as the health plan’s trend for all groups combined
3. Truncated trend - random fluctuation can also be reduced by truncating claims at $50,000. But then savings for these larger claims don’t get counted because of the truncation.
4. Utilization trend - could calculate the reduction in admissions instead of the reduction in claim costs. This results in credibility being achieved at much smaller group sized
   a) A claim cost savings can be calculated if a reasonable cost per admission can be estimated
   b) But this approach doesn’t count savings that result from reducing length of stay

Question 40

Approaches and interventions for ACOs to optimize care and achieve performance targets

Answer 40

1. Care redesign to improve the delivery and coordination of care - includes establishing patient-centered medical homes and improving transitions in care from hospitals to post-acute or community settings
2. Care management of patients with costly, complex needs - including an individualized approach to identify and address unmet needs
3. Patient and family engagement and patient activation initiatives - engaging patients in care management to identify personal goals for lifestlye change and educate them about their treatment options
4. Integrated data and analytics - developing capabilities to identify patients who could benefit from more intensive care management
5. Supportive payment models and financial incentives - capitation provides the greatest flexibility for engaging providers in novel ways. But it may be easier to layer a shared-savings or shared-risk model on top of existing reimbursement arrangements, at least initially.

Question 41

Benefits to stakeholders of using standardized measures for assessing employee health management (EHM) programs

Answer 41

1. Employers and benefit managers - core metrics can facilitate comparisons and provide a basis for developing vendor performance metrics. Employers can use this data to identfiy gaps in their programs
2. Benefits consultants - a standard set of metrics may lead to reliable comparative data for making vendor recommendations and for negotiating performance standards
3. Health management program managers - core metrics will provide data to fine-tune health enhancement interventions
4. Accrediting organizations - metrics can be used to evaluate vendor and health plan compliance
5. National health management policy makers - core metrics will facilitate development of recommendations for use by federal and state policy makers.
6. EHM services vendors - core metrics will create a level playing field for competitors and encourage produce improvements to achieve benchmarks
7. EHM participants - will benefit from product improvements stemming from competition to achieve benchmarks

Question 42

Steps taken to develop a standard set of measures for EHM programs

Answer 42

1. Review the literature to discover what metrics are currently used to measure performance of EHM programs
2. Obtain guidance and advice from subject matter experts
3. Identify and/or develop recommended measures
4. Review the work with key stakeholders to obtain feedback and consensus
5. Release the work through conference presentations, publication and other channels

Question 43

Steps of the EHM value chain

Answer 43

These help in understanding how EHM programs add value

1. Assess all individuals in the population to identify opportunities to maintain or improve health
2. Engage individuals with programs and tools through which they can address these opportunities
3. Continue engagement long enough for them to acquire and sustain healthy behaviors
4. Sustained effective engagement will result in preventing or reducing lifestyle-related risk factors
5. Sustained healthy behaviors and clinical outcomes will result in fewer ER visits, hospitalizations, and procedures related to lifestyle-related risk factors
6. Fewer ER visits, hospitalizations, and procedures yield medical, absenteeism, worker’s compensation, and disability cost savings
7. Improved employee productivity and performance contribute to improved financial outcomes

Metrics for the first five steps are referred to as plausibility metrics. They check whether the EHM programs accomplished enough to make the claim of savings plausible. Plausibility metrics should be reported alongside any financial metrics

Question 44

Recommended measures for assessing EHM programs

Answer 44

The recommendation covers the following seven domains

1. Financial outcomes (see separate list)
2. Health impact
   a) Physical health impact (such as blood pressure and cholesterol)
   b) Mental and emotional health impact (such as depression and anxiety)
   c) Health behaviors that impact physical and mental health (such as physical activity and tobacco use)
   d) Summary of health measures (overall risk reduction and individual risk reduction)
3. Participation - categories are recommended based on the level of interaction needed to produce an outcome:
   a) Telephonic contacts - categories for 1-2, 3-4 and 5+
   b) Web-based contacts - categories for 1-5, 6-10, and 11+
   c) In-person contacts - categories for 1, 2 and 3+
4. Satisfaction (such as overall satisfaction, effectiveness, and member experience)
   a) Patient satisfaction
   b) Client satisfaction
5. Organizational support
   a) Organizational support elements (see separate list)
   b) Employee-perceived level of organizational support
   b) Leaders-perceived organizational support
6. Productivity and performance
   a) Time away from work due to poor health
   b) Productivity loss while at work due to poor health
   c) Objective measures of worker performance (such as employee performance ratings)
7. Value on investment - a comparison of the investment vs. the outcomes
   a) Outcomes may be specific clinical measures of dollar amounts representing the monetized value of outcomes
   b) Investments include direct costs (such as program fees and incentives), indirect costs (such as employee time), and tangential costs (such as employee morale and company reputation)

Question 45

Organizational support elements for EHM programs

Answer 45

These are deliberate steps the employer can take to create an environment that supports health and well-being

1. Company-stated health values
2. Health-related policies
3. Supportive environment
4. Organizational structure
5. Leadership support
6. Resources and strategies
7. Employee involvement
8. Rewards and recognition

Question 46

Leading indicators of savings for EHM programs

Answer 46

These can indicate during the first year whether a program is likely headed for savings later on

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 47

Lagging indicators of savings for EHM programs

Answer 47

These often improve after sustained high performance on leading indicators

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

Question 48

Recommended financial metrics for EHM programs

Answer 48

1. Directly-monetized claim savings - one of the following metrics should be selected:
   a) Cost trend compared with industry peers - compares trend to peers without EHM
   b) Adjusted-expected compared to actual cost trend - compares expected to observed trend, with trend decomposed into components such as demographics or non-demographic. Credit is taken for EHM-impactible components
   c) Chronic vs. non-chronic trend comparison - used for disease management. Compares expected trend (from the non-chronic population) to observed trend (from the chronic population)
   d) Cost or trend comparison of program participants vs. non-participants - compares cost trajectories of the two groups, after neutralizing the impact of non-EHM differences
   e) Comparison with matched controls in a non-exposed population - compares cost trajectories of members who meet criteria for EHM program targeting in the employer’s population with members who meet criteria in a comparison population that does not have EHM programs
2. The monetized impact on utilization that is potentially preventable by EHM - monetizes a downward trend in ER and hospital visits and procedures that can be prevented by EHM
3. Financial impact based on a model that links to what occurred during the program an characteristics of program participants
4. Reduction or prevention of lifestyle-related health risk factors - relates reduction in or prevention of lifestyle-related health risk factors to published evidence on the economics of preventing and reducing such risk factors

Question 49

EHM value proposition

Answer 49

This is how EHM adds value for the employer

1. Identify opportunities to:
   a) Improve (or maintain) health, and
   b) Mitigate or eliminate current risks or avoid future risks
2. Address these opportunities with effective programs and tools to improve the population’s health status, improve productivity, and lower health-related costs

Question 50

Considerations in choosing whether to use modeled or measured savings for EHM calculations

Answer 50

Modeled savings are estimated by multiplying factors from published studies by the utilization reductions or other results of the EHM program

Measured savings are estimated by comparin actual claims to what claims would have been without EHM

1. Measured savings are not accurate for small populations, so models should be used for them. A common cutoff point is 25,000 members
2. Measured savings calulations require fully-adjudicated claims data. But savings models require only data typically generated through the program, such as demographics, participation, risk factors, diseases, or gaps in care.
3. Measured savings are generally calculated annually, while modeled savings can be run with any desired frequency
4. Measured savings inherently incorporate the organization’s specific data. Modeled savings calculations must incorporate this data to be as accurate.
5. Measured savings are validated (or audited) by a third party. Modeled savings are developed based on published evidence or studies.

Question 51

Dimensions of the triple aim of health care

Answer 51

The triple aim is to simultaneously achieve all three dimensions

1. Improve population health
2. Improve the patient experience of care
3. Reduce per capita cost

Question 52

Role of the integrator in achieving the triple aim

Answer 52

To achieve its purpose, the triple aim needs the cooperation of various entities (such as health care organizations, public health departments, and employers). An integrator is needed to do the following:

1. Accept responsibility and pull together various resources to support the pursuit of the triple aim
2. Create an appropriate governance structure
3. Lead the establishment of a clear purpose for the pursuit of the triple aim
4. Identify projects and investments to support that pursuit
5. Create a set of high-level measures to monitor progress

Question 53

Key measurement principles that apply to the triple aim

Answer 53

1. The need for a defined population - most triple aim measures, such as per capita cost, require a population denominator
2. The need for data over time - tracking data over time helps to gain insight into the relationship between interventions and effects and to better understand time lags between cause and effect
3. The need to distinguish between outcome and process measures, and between population and project measures. Measurement should include top-level population outcome measures, and related outcome and process measures for projects.
4. The value of benchmark or comparison data - this data enables comparisons with other systems

The principles used by the National Quality Forum for evaluating quality measures also can apply to triple aim measurement: importance, scientific acceptability, usability, and feasibility.

Question 54

Menu of trip aim outcome measures from the IHI Triple Aim prototyping initiative

Answer 54

IHI = Institute for Healthcare Improvement

1. Population health measures
   a) Health outcomes
   i) Mortality - years of potential life lost, life expectancy, and standardized mortality ratio
   ii) Health and functional status - single-question assessment (a person rating his or her own health) and multi-domain assessment
   iii) Healthy life expectancy - combines life expectancy and health status into a single measure, reflecting remaining years of life in good health
   b) Disease burden, such as incidence and prevalence of major chronic conditions
   c) Behavioral factors (such as smoking, alcohol consumption, physical activity, and diet) and physiological factors (such as blood pressure, body mass index, cholesterol, and blood glucose)
2. Experience of care measures
   a) Standard questions from patient surveys - for example:
   i) Rating all health care received in the last 12 months
   ii) Likelihood to recommend the provider of care to someone else
   b) Set of measures based on key dimensions, such as the Institute of Medicine’s six aims for improvement: safe, effective, timely, efficient, equitable, and patient-centered
3. Per capita cost measures
   a) Total cost of the population PMPM, including costs by type of service
   b) Hospital and emergency department utilization rate and cost