Topic 1

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 information intervention, often provided over the telephone. Includes nurse advice lines and shared decision making.
5. Disease management (DM) - 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 homes - this model returns to the physician the responsibility for 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 - 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 provivde 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.

Duncan Chapter 3, Page 48

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 if 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

Duncan Chapter 3, Page 51

Question 3

Principles of 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

Duncan Chapter 3, Page 56

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 the 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 preventive services will lead to savings as population health improves.
5. Reducing duplication of services
6. Preventing medical errors

Duncan Chapter 3, Page 61

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 / 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

Duncan Chapter 3, Page 62

Question 6

Components of an MTM program for Part D

Answer 6

1. Performing or obtaining necessary (A)ssessments of the patient’s health status
2. (F)ormulating a medication treatment plan
3. Selecting, initiating, modifying, or administering medication (T)herapy
4. Monitoring and (E)valuating the patient’s response to therapy
5. Performing a comprehensive medication (R)eview to identify, resolve, and prevent medication-related problems
6. (D)ocumenting the care delivered and communicating essential information to the patient’s other primary care providers
7. Providing verbal (E)ducation and training designed to enhance patient understanding and appropriate use of medications
8. Providing information, (S)upport services, and resources to enhance patient adherence to drug regimens.
9. Coordinating and (I)ntegrating MTM services with other health care management services

AFTER D ESI

AFTER Documenting, Educate, Support, Integrate

Duncan Chapter 3, Page 64

Question 7

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

Answer 7

1. Retail convenient care clinics - many pharmacies, hospitals, and grocery chains have opened 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.
2. Employer worksite clinics - these are the 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 designated by the federal government to provide health care to the underserved and uninsured. An example is a community health center.

Duncan Chapter 3, Page 69

Question 8

Benefits of being designated an FQHC

Answer 8

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 Services Corps
5. Access to the Vaccine for Children Program
6. Eligibility for various other federal grants and programs

Duncan Chapter 3, Page 72

Question 9

Possible Reasons why DM Studies Show Improved Clinical Outcomes but not Cost Savings

Answer 9

1. S - Measurement of financial outcomes is not stable enough, or measurement techniques are not sensitive enough, to detect positive financial outcomes
2. F - Programs are either not focused on financial outcomes or not structured to optimize financial outcomes
3. O - Program sponsors do not understand the economics of DM programs and therefore do not optimize the programs for financial return
4. I - Improvements in quality of care do not always lead to lower costs. Some improvements may actually increase costs, but still be worth the investment.

Mnemonic Improved Financial OutcomeS?

Duncan Chapter 8, Page 164

Question 10

Financial Measures for Disease Management Programs

Answer 10

Financial Measures for Disease Management Programs:

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
   d) 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

Duncan Chapter 8, Pages 167 and 180

Question 11

Key Metrics in the design of disease management programs

Answer 11

1. The (N)umber and risk-intensity of members to be targeted - this number must be large enough to produce savings that offset implementation costs, but not so large that marginal costs exceed marginal savings
2. (T)ypes of interventions to be used in the program - such as mail or automated outbound dialing
3. The number of nurses and other (S)taff needed for the program, and program costs
4. The (M)etholology for contacting and enrolling members
5. The (R)ules of 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 targeted population if there was no intervention, and the predicted effectiveness of the intervention at modifying that behavior

Duncan Chapter 8, Page 174

Question 12

Components of the Risk Management Economic Model

Answer 12

(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 members and assesses the member’s risk. (See List for Factors that affect re-stratification)

Duncan Chapter 8, Page 176

Question 13

Factors that affect whether the member should be re-stratified

Answer 13

a) Accuracy of the diagnosis
b) Risk Factors present
c) Ability of the DM program to intervene for the condition
d) Patient’s readiness to change
e) Patient’s self-management skills

Duncan Chapter 8, Page 176

Question 14

Common Chronic Diseases Addressed by disease management programs

Answer 14

1. Ischemic Heart Disease
2. Heart Failure
3. Chronic Obstructive Pulmonary Disease
4. Asthma
5. Diabetes

Duncan Chapter 8, Page 176

Question 15

Description of Opportunity Analysis for Care Management Programs

Answer 15

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 prospective. Once a profile of an opportunity population is identified, all current members meeting that profile can be included in the program

Duncan Chapter 9, Page 183

Question 16

Models typically used to stratify members in a care management program

Answer 16

1. Stratify members according to their 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 theses models)

Duncan Chapter 9, Page 184

Question 17

Components for designing a care management program using opportunity analysis

Answer 17

1. Analytics - members are segmented by medical conditions into sub-populations 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 exceed 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. 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 which point in the risk ranking it is economically feasible to intervene

Duncan Chapter 9, Page 185

Question 18

Steps for implementing a care management program using opportunity analysis

Answer 18

1. Develop a (P)redictive model to populate the risk distribution
2. Establish a (P)roduction analysis and reporting unit. Develop the necessary reports and a reporting application
3. Determine the (L)ikely number of care managers required
4. Develop a (B)udget for the program, accounting for all required resources
5. (H)ire and train care managers to conduct interventions and manage patients
6. Develop a (P)lan, including estimates of the numbers of patients identified and engaged
7. (R)oll out the intervention and enroll patients
8. (O)perate the program, track outcomes, and modify as necessary.

Mnemonic - PPL BH PRO (PeoPLe BeHave like PROs)

Duncan Chapter 9, Page 195

Question 19

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

Answer 19

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 sub-populations re 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

Duncan Chapter 9, Page 196

Question 20

Description of Propensity Score Matching

Answer 20

1. Propensity Score matching is a technique used for making a participant (intervention) group comparable to a nonparticipant 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
2. Each member in the participant group is matched with a member of the nonparticipant group based on propensity scores
3. The propensity score, p, is the probability that the member will be in the participant group.
   a) It is calculated using a logistic regression based on the member’s values for the independent variables (such as age and gender)
   b) This process reduces a large number of variables into a single score
   c) Members with similar scores can then be matched, even if they are not matched exactly on the independent variables
   d) There should still be relatively close matches on those other variables

Duncan Chapter 11, Page 211

Question 21

Steps for Applying Propensity Score Matching to a Study

Answer 21

1. 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 participant in the program
   a) The regression equation is ln[p/(1-p] = α + βX + e
   b) So the propensity score, p = exp (α + βX) / ( 1+exp[α + βX])
2. Use propensity scores to match each participant to a nonparticipant using one of the following techniques:
   a) Nearest Neighbor Matching - the first member of the comparison population with the closest propensity score is selected, either with or without replacement
   b) Caliper matching - a match is made if the member and match’s propensity scores are within a fixed distance
   c) Mahalanobis metric matching - this metric i s used to measure the dissimilarity between two vectors
   d) Stratification matching - observations are stratified and then matched by stratum
3. 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 use only the minimum number of variables necessary to achieve a stable model).

Duncan Chapter 11, Page 212

Question 22

Comparison of Propensity Scoring and Risk Adjustment

Answer 22

Similarity:
1. Both reduce the effect of multiple risk factors (such as age, sex, and diagnoses) to a single score, using multiple regression

Differences:

1. 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
2. Risk adjustment uses the entire population while propensity matching can result in many members of the population being discarded

Duncan Chapter 11, Page 214

Question 23

Description of the Actuarially-Adjusted Historical Control Methodology

Answer 23

1. Objective Criteria are used to determine which member 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) Both 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 from the difference between:
   a) An estimated statistic projected from the baseline period. They key component is the health care trend factor used for this projection.
   b) the actual statistic from the measurement period
3. Formulas for calculating savings:
   a) [ChrUtil(prior year) * (1 + trend) - ChrUtil(Actual) ] * Chronic members * Cost per service
   i) ChrUtil is the utilization rate per chronic member
   ii) Trend rate comes from the health plan’s non-chronic population
   b) Savings PMPM = savings / member months

Duncan Chapter 12, page 228

Question 24

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

Answer 24

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 (separate list)
6. Measured and non-measured members - tests for inclusion in the measurement population may include 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)

Duncan Chapter 12, Page 231

Question 25

Reasons a member may be excluded from a disease management program

Answer 25

1. The member class ic 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 the trend calculation
4. The member’s claims are significant, and the experience is likely to dominate the group, or introduce noise to the calculation

Duncan Chapter 12, page 234

Question 26

Conditions that would exclude a member from a disease management program

Answer 26

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 feeds, or manage the member
4. Members who are institutionalized - these member 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

Duncan Chapter 12, Page 242

Question 27

Challenges when Calculating Disease Management Savings (Actuarially-Adjusted Historical Control Design)

Answer 27

(when using the actuarially-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

Duncan Chapter 13, Page 251

Question 28

(TIA Card) Transition States: Risk Adjusting for Population Changes

Answer 28

1. Chronic population matures between baseline and intervention periods
2. Small change in transition probabilities results in large change in costs
3. Risk Adj: Trend used from baseline to intervention should be net of population changes
4. May divide the population into risk strata: Continuing, New, Terminated
5. Transition States - changes in mix of subgroups affect chronic trend

TIA Card for Duncan Chapter 13

Question 29

Leading Indicators of Savings for Employee Health management (EHM) programs

Answer 29

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. Processes of care
7. Medical Adherence
8. Achieving Clinical Targets
9. Patient Activation
10. Satisfaction with EHM
11. Well-being

WE AB B C TIPS (WE’re ABout Behavior Change TIPS)

GHS-125-19, Page 12

Question 30

Lagging Indicators of Savings for EHM programs

Answer 30

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

GHS-125-19, Page 12

Question 31

Recommended Financial Metrics for EHM Programs

Answer 31

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 observed and expected trends. The adjusted-expected trend is the product of:
   i) Trend components that are impactible by EHM (utilization and risk net of demographics). These are forecasted before the year.
   ii) Trend components that are non-impactible by EHM (demographics, price per unit, and plan design). These are set equal to observed trend
   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
   c) Comparison with matched controls in a non-exposed population - compares cost trajectories 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 and characteristics of program participants
4. Reduction or prevention of lifestyle-related health risk factors to published evidence on the economics of preventing and reducing such risk factors

GHS-125-19, Pages 11, 13, and 18

Question 32

Definitions of Modeled and Measured Savings for EHM Calculations

Answer 32

1. Modeled savings are estimated by multiplying factors from published studies by the utilization reductions or other results of the EHM program
   a) The use of a savings model is strongly recommended for organizations who do not have the population size and funds required for a valid claims savings measurement study
2. Measured savings are estimated by comparing actual claims to what claims would have been without EHM

GHS-125-19, Page 16

Question 33

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

Answer 33

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 calculations require fully adjudicated claims data. But savings models require only data typically generated through the program, such as demographic, 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

GHS-125-19, Page 17

Question 34

Questions to ask when selecting financial metrics for an EHM program

Answer 34

1. Do we have enough baseline claims data and is it of high enough quality?
2. Do we have fully-adjudicated claims? if not, a dollar-based analysis is not possible.
3. Is our membership size more than approximately 25,000?
4. Do we have the analytic resources available to use a sophisticated methodology?
5. Which EHM components are we implementing?
6. Is the structure of our EHM program reasonably close to those in published savings literature?
7. Does our consultant have a large bench-marking database that includes employers in our industry?
8. Do our leading indicators indicate the program has achieved enough through initial success to make it plausible to detect a sizable enough savings to demonstrate ROI?

GHS-125-19, Page 24