Presentation Transcript

1. Sample CompanyIntegrated HealthManagement Analysis

   Prepared by Highmark Blue ShieldPeriod Ending December 31
2. Introduction Report Overview: The Integrated Health Plan Performance Review is intended to demonstrate a holistic view of Sample Company’s health plan performance using aggregate financial, clinical and wellness data. It offers recommendations which are aimed at helping Sample Company mitigating cost increases by improving the health of employees and their families. Report Time Frame: This report provides a retrospective analysis of Sample Company’s performance based on incurred plan experience from January 1, 2005 through December 31, 2006 Incurred & Paid Claims: The data included in this report includes a comparison of claims incurred January 2005 through December 2005 (paid through March 2006) to claims incurred January 2006 through December 2006 (paid through March 2007). Benchmarks: In a number of the exhibits, Sample Company’s experience is compared to normative data. This normative data is typically a national average based on claims from XX million member lives from Highmark’s National PPO product. Several pages in the reports include external benchmarks from various sources which are documented on each exhibit.
3. Table of Contents Executive Summary Overview 4 Health Care Cost and Utilization Dashboard 5 Personalized Health Management Dashboard 6 Cost and Utilization Financial Analysis 8 Network Utilization and Discounts 9 PMPM Change Analysis 10 Demographics 11 Distribution of Members and Claims 12 PMPM by Type of Service 13 Pharmacy Management 15 Behavior Health Management 17 Population Health Risk 18 Personalized Health Management Highmark’s Personalized Health Management Model 20 Process Overview 21 Selected Conditions/Interventions Summary 22 Intensive (Case) Management 23 Disease Management 24 Health Risk Management & Decision Support 27 Wellness & Health Promotion 29 Absence Management 32 Summary of Findings & Recommendations 35 Appendix 36 Glossary 38
4. Executive SummaryHealth Care Costs and Utilization Dashboard2005- 2006 - Incurred Basis
5. Executive SummaryPersonalized Health Management Dashboard2006 (2005 included in Chronic Condition Compliance)
6. Cost and Utilization Outline Financial Analysis Network Utilization & Average Discounts PMPM Change Analysis Demographics Distribution of Members & Claims Medical Expense by Major Type of Service Pharmacy Management Behavioral Health Management Population Health Risk
7. Financial AnalysisOverview Key Findings Blue Shield’s negotiated discounts have saved ABC Company nearly $74 million over the past two years. While ABC Company’s eligible charges increased 4.8% PMPM from 2005 to 2006, paid expense only increased by 3.0% due to increased member cost sharing and improved discounts.
8. Financial AnalysisNetwork Utilization and Average Discount Key Findings The in-network utilization for ABC Company improved from 2005 to 2006 and remains greater than the Highmark PPO network average. The favorable network utilization was at least in part due to the vast Blue Cross Blue Shield network. Overall discounts as a percentage of charges increased slightly from 45.0% in 2005 to 45.2% in 2006. Negotiated discounts as a percent of charges increased for both professional and pharmacy services while the facility discounts declined. * Optional Major Medical claims excluded (if applicable)
9. PMPM Change Analysis Key Findings ABC Company’s combined Medical/Rx claims PMPM increased by 6.6% from 2005 to 2006. This increase is significantly lower than the account adjusted benchmark of 12.6% for the same time period. ABC Company’s Medical only PMPM increase was 4.2% from 2005 to 2006. ABC Company’s 2006 PMPM of $239.47 was 2.9% below the adjusted benchmark of $246.70 The minor change due to demographics is due to changes in the age and gender distribution of ABC Company from the prior year. There were no benefit design changes implemented during the 2006 plan year. The 7.3% price increase was in line with the healthcare industry’s average
10. Demographics Key Findings ABC Company’s membership grew by 21% from 2005 to 2006. Still the age and gender distribution remained relatively stable. The average age of ABC Company subscribers is 41.6 years. This is 2.4 years younger than the Highmark average. ABC Company’s average member age is only slightly below the Highmark average. Despite the growth, ABC Company’s contract size (members per subscriber) stayed the same between 2005 and 2006 at 2.0. By comparison, the Highmark average contract size was slightly higher at 2.1. * See page 18 for Population Risk
11. Add information from shock claim analysis regarding program status for members above $50,000 Distribution of Membersand Claims Key Findings Members with claims over $100,000 accounted for 8.2% of overall claims in 2006, about the same level as in 2005. The percentage of claims incurred by members over $50,000 increased from 14.2% in 2005 to 15.5% in 2006. This was still well below the Highmark average of 19.6%. The percent of members with claims under $10,000 declined from 96.6% to 95.0%. Aggregated claims incurred in 2006 and paid through March 31st for each member
12. Medical ExpensePMPM Change by Claim Type by Service Type Key Findings The biggest driver of the increase in the inpatient PMPM was the Other Category, which includes behavioral health, rehabilitation and skilled nursing facilities. The Outpatient surgery PMPM increased by 33%. This was the big driver, along with radiology, of the overall increase in the outpatient PMPM. Many of the professional service categories showed PMPM increases from the prior period. Of particular note was radiation therapy, which showed a 80% increase.
13. Pharmacy Management Key Findings ABC Company’s Pharmacy PMPM decreased by 3.3%. The 10.1% increase in utilization was more than offset by a 4.9% decrease in the average cost per prescription. The generic utilization rate increase to 58.1% in 2006, singificantly greater than the network average of 52.8%. This was a driver of the decrease in average cost. Mail utilization increaed modestly to 2.8% of prescriptions, but remains well below the network average of 8.3%. Anti-infective agents accounted for 22.4% of Rx payments for ABC Company. This was much higher than the 8.6% network rate. This class of drugs includes X, Y, and Z.
14. Pharmacy Management Tools & Programs Clinical programs Formulary List of FDA approved drugs Highmark’s independent Pharmacy and Therapeutics (P&T) Committee Selected based on safety, efficacy, quality and cost to the plan. Care Management Programs Managed Rx Coverage – real-time, online, automated – promotes appropriate dose, duration of therapy and utilization while limiting member disruption Quantity Per Co-payment – promotes appropriate use, prevent stockpiling Managed Prior Authorization – promotes appropriate use of high cost products Concurrent/Retro DUR – promotes patient health/safety MD Programs Profiling – educates physicians on best practices Dose Optimization – simplifies dosage regimens and increases compliance Generic Sampling – increases utilization of generic medication Retail Exclusivity Program Streamlined program through which physicians can order certain injectable drugs. Program is aimed at: Enhancing integrated care and utilization management for patients who use these drugs to help ensure that these drugs are administered in the most appropriate and effective manner Simplifying the precertification process for these medications to save physicians time and members receive these medications promptly and directly to their home Reducing cost by minimizing waste MEDVANTX Point of Care Delivery Network Automated dispensing system to control generic samples and OTC products in physician office Participating physicians can offer initial course of medication therapy to all their patients free. There is no cost to either the physician or patient.
15. Behavioral Health Management Behavioral Health Referral and Management Model Surveys – Inpatient & Outpatient BH Continued Stay IP Reviews Medical Case Management Referral Distribution Checklist Key Findings Client ABC’s average cost per prescription of $29.77 was 13% lower than the network average of $34.46 as a result of: Increased generic utilization Lower per script prices Higher employee cost sharing A large percentage (7.9%) of Rx costs were part of the Miscellaneous Endocrine class of drugs, the majority of which were infertility drugs. Outreach (Brief telephonic outreach) Depression Management Program (Maximum of 1 year) Complex Case Management (Maximum of 90 days)
16. Population Health RiskConcurrent Risk Scores and Risk Distribution Something like this: DxCG has developed a rigorous methodology for assigning weights to relative health risks of a member or population. Each medical diagnosis is assigned a relative weight, or risk score. A risk score is calculated for each member based on the diagnoses incurred during the specified time period. The overall risk score for ABC Company is the average of all member scores. Please see the Appendix for additional explanation of the DxCG methodology. Key Findings ABC Company’s aggregate risk score declined from 2005 to 2006. This reflects a relative improvement in the health of the ABC company population. Similarly the ABC Company risk score for 2006 was below the Highmark average. This is consistent with the claims PMPM also being lower than the Highmark average.
17. Personalized Health Management Outline Highmark’s Personalized Health Management Model: Continuum of Care Clinical Cost Drivers and Intervention Summary Highmark Patient Identification and Stratification Process Wellness and Health Promotion Health Risk Management & Decision Support and Advocacy Disease Management Intensive Management Highmark’s Personalized Health Management program objectives: Keep healthy people healthy and productive – actively involve members Provides support to making health-related decisions Reduces health risk over time Actively manages those with chronic conditions to avoid costly complications Coordinates care for intensive-case patients
18. Highmark’s Personalized Health Management Model Continuum of Health Healthy At Risk Acute Condition Chronic Disease Complex/Disabling (Risk) Low Moderate Elevated High Extreme Health Promotion and Disease Prevention Health Risk Management Decision Support & Advocacy Disease Management Intensive Management Symptom Support Episodic Case Management Chronic Condition Management Case Management Health Risk Assessment Educational Resources such as Healthwise Knowledgebase Audiotapes & Literature Evidence-based Criteria and Guidelines Physician Involvement in assessment & planning Management of Co-morbidities Lifestyle Improvement Interventions Depression Management Shared Decision Making Maternity Program Address clinical, psychosocial, and financial issues Screenings Self Management Skills Targeted Behavior Modificaition Discharge Planning Wellness Coaching Pharmacy Benefit Management Utilization Management Integrated Absence Management Health Advocacy and Wellness and Lifestyle Behavior Modification Programs Personal Health Records
19. Highmark Patient Identification & Stratification ProcessProgram Process Overview Identification Medical and Rx claims Readiness to change (HRA) Authorizations Health Coach case findings Likelihood of hospitalization High Cost Claimants Stratification Financial risk Clinical risk Predictive modeling Predicted clinical risks Predicted financial risks Health Risk Assessment Healthy At Risk Acute Condition Chronic Disease Complex/Disabling
20. Selected Clinical Conditions and Intervention Summary
21. Intensive Management SummaryCase Management Activity Intensive Management Description of Care Management Program Who?: Provided to members who require in-depth care coordination, community service, education and advocacy due to major illness, injury, or certain types of surgery How?: Case managers work with members, their families, physicians and hospitals to provide proactive, comprehensive assessment, issue identification, goals setting, and targeted interventions to guide members to appropriate health care services (e.g., home health services, community resources, or Employee Assistance Programs Why?: The goal is to enable the member to reach optimum recovery in a timely manner Key Findings Client XYZ currently has 1.2% of its population under some form of case management compared to 1.0% for Highmark’s book-of-business average Readmission rates and ER visit rates are 4 times higher for those who patients who were targets, but opted out of Highmark’s case management programs * See Appendix XX for more detailed metrics on Case Management program
22. Disease Management Prevalence and Outreach Activity Disease Management Disease Management Outreach: Highmark’s Disease Management programs assist members with specific chronic diseases to better understand their conditions, including the risks, complications and co-morbidities that can create potential unfavorable outcomes if not monitored and treated appropriately. DM support is provided by licensed professionals trained specifically for each managed condition. These professionals provide education and counseling through targeted outreach and condition monitoring. Key Findings ABC Company’s aggregate risk score declined from 2005 to 2006. This reflects a relative improvement in the health of the ABC company population. Similarly the ABC Company risk score for 2006 was below the Highmark average. This is consistent with the claims PMPM also being lower than the Highmark average.
23. Health Risk Management and Decision Support & AdvocacySymptom Support and Outreach Decision Support & Advocacy Blues on Call is a component of Highmark’s integrated care management solution. Through Blues on Call, members have access to a range of programs and services providing education, advocacy and support with the goal of improving the quality of care. Resources and services include the following: Health coaching (registered nurses) available 24 hours per day to answer questions and provide educational materials regarding medical conditions, symptoms, treatment options, and medications Pre-admission and post-discharge counseling Targeted outreach to at-risk or newly diagnosed members On-demand audio and video materials targeted to specific medical conditions and treatment decisions Healthwise Knowledgebase, on online source for information on diagnoses, symptoms, medications and the latest medical technologies Key Findings Only 54 members attempted calls to a Health Coach. This represents only 2.7% of members and is well below the 4.9% Highmark average. Better communication of this service to members would provide opportunities for improved decision making for members of ABC company 35 out of the 135 members identified for targeted member outreach were not available. Typical reasons include outdated phone numbers or addresses. This information should be kept up to date with Highmark to maximize the value of the Blues on Call resources.
24. Wellness and Health PromotionPreventive Screening Tests Wellness & Health Promotion Health Risk Management Program Premise Evidence exists to prove that people who get preventive healthcare - screening tests, immunizations, and health counseling and advice - enjoy better health overall Many studies have substantiated that preventive care helps people live longer and improve their quality of life Key Findings In general, preventive screening for XYZ Company improved from 2005 to 2006 and compared favorably with the benchmark Because of the relatively low rate of prostate screening and the low percentage of males in the ABC Company population this may be a target area for education. Prostate cancer is an extremely preventable cancer with early detection. The mammogram screening rate for ABC Company compares favorably to the benchmark The Highmark Blue Shield preventive schedule can be found at highmarkbcbs.com.
25. Highmark Productivity Management Highmark experts collaborate with Company ABC on management of the risks and financial exposure associated with health-related absenteeism and presenteeism. Productivity management specialists analyze your existing and future risks and will develop appropriate interventions to alter the course of anticipated health risk and disease progressions. Highmark Productivity Management provides an outsourced corporate medical department which can be used by Company ABC in setting key HR policies and procedures, as well coordinating medical services for executives and other personnel. Physicians are on call 24 hours per day, 365 days per year to provide support and intervention for any health-related issue. “First Report of Absence” intervention is provided for work and non-work related issues. Physicians will work directly with providers through closure. Productivity Management Presenteeism and Indirect Health-Related Costs ProductivityManagement Presenteeism is defined as lost productivity occurring when an employee is present for work, but is not performing at full capacity. Unlike absenteeism, the costs of presenteeism can be difficult to quantify, but the costs of health-related presenteeism are significant. Recent studies1 have shown that medical costs account for only a portion of total health and productivity-related expenditures that employers face. Presenteeism costs, along with the indirect health-related costs of absenteeism and disability, highlight the need for broad and proactive management of employee health risk factors as well as chronic and disabling conditions. 1 Goetzel, Ron et al. Health and Productivity Cost Estimates. Journal of Occupational and Environmental Medecine. April 2004: 398-412 2 Presenteeism cost estimates assume average wage of $23.15 per hour.
26. Recommendation Summary Opportunity Areas Based on Highmark’s analysis, below is a three-pronged integrated strategy to address ABC Company’s overall health care costs through targeted communication and program investment. Additionally, ABC Company should monitor previous plan design changes to ensure intended results.