Sec G Care Management

Question 1

Components of the care management value chain process

Answer 1

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 2

Risk factors for care management studies

Answer 2

• these should be reported with the study, to ensure reproducability 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 for conditions 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 measure whether the manager is able to reach 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 3

Components for designing a care management program using opportunity analysis

Answer 3

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 what does not work
   a) A literature review is done to find programs that are efficacious (the evidence can be trusted), cost-effective (the benefits excee the cost), & 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. Weighing 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 4

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

Answer 4

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 that 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 5

Description of opportunity analysis for care management programs

Answer 5

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 introduce
   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 6

Steps for implementing a care management program using opportunity analysis

Answer 6

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 number of patients identified and engaged
7. Roll out the intervention and enroll patients
8. Operate the program, track outcomes, and modify as necessary

Question 7

Principles for measuring results of care management programs

Answer 7

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, irrelvant, 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 8

Control group methods for estimating care management savings

Answer 8

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
4. The product control methodology - comapres 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 non-participant studies - the experience of those who voluntarily participate is compared to the experience of those who choose not to participate (has selection bias)

Question 9

Description of actuarially-adjusted historical control methodology

Answer 9

• 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 close group (or cohort) method uses the exact same populations 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 for this projection
  b) The actuarl statistic from the measurement period
  3. Formula for calculating savings:
  a) Savings = [ChrUtilpy * (1 + trend) - ChrUtilactual] * Chronic mbrs * Cost/Svc
  i) ChrUtil is the utilization rate per chronic mbr
  ii) The trend rate comes from the health plan’s non-chronic population
  b) Savings PMPM = savings / Mbr months

Question 10

Non-control group methods for estimating care management savings

Answer 10

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 11

Statistical methods for estimating care management savings

Answer 11

1. Time-series methods - a curve is fit to the data over time and a divergence from this 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 e.g.: Yi = Bo + B1Xi + B2Zi+ ei, where:
   a) X = independent variable (yr 1 cost)
   b) Y = dependent variable (yr 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 populations being managed and some benchmark population

Question 12

Requirements for a care management methodology to be valid

Answer 12

1. Familiarity - the purchaser must be familiar with the methodology, or at least be able to grasp it readily
2. Ease of replication and auditability - the methodology must be documented in sufficient detail for another practioner 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 it 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 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 pogram inputs and outputs
2. Risk adjustment and predictive modeling - these processes compare different populations, providing insights on where to devote clinical resources
   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. Also help bridge the gap between the program outcomes and the overall trend in health plan costs.

Question 14

Types of methodologies for estimating care management savings

Answer 14

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

Question 15

Types of care management methods

Answer 15

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
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 form of voluntary intervention program
8. Patient-centered medical home - this model returns to the physician the responsibility of coordinating all of the patient’s care
9. 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
10. Non-traditional provider interventions and care settings - pharamacists and different types of clinics can be used to provide various intenventions
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 payment 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

Question 16

Models typically used to stratify members in a care managment program

Answer 16

1) Stratify members according to the predictive risk score - but at the top of that list are many members who represent a low opportunity for cost savings
2) Condition-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.
3) Rules-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.