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Soyal Momin MS, MBA September 23, 2008

Predictive Modeling 2008: The BlueCross BlueShield of Tennessee Experience. Soyal Momin MS, MBA September 23, 2008. Outline. Maximizing the Value of Predictive Modeling: A Health Plan Perspective Care Management Challenges: Understand Population Care Management Needs Identify Stratify

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Soyal Momin MS, MBA September 23, 2008

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  1. Predictive Modeling 2008: The BlueCross BlueShield of Tennessee Experience Soyal Momin MS, MBA September 23, 2008

  2. Outline • Maximizing the Value of Predictive Modeling: A Health Plan Perspective • Care Management Challenges: • Understand Population Care Management Needs • Identify • Stratify • Triage • Care Management Model, Implementation, Process Efficiencies • Intervene • Care Management Programs • Evaluate • Conclusions

  3. Care Management Challenges: Understand Population Care Management Needs • Cost distribution and trend over time • Quantitative assessment • Population assessment • Qualitative assessment – clinical cost drivers based on healthcare cost (direct cost) • Total cost assessment – direct & indirect costs • Qualitative assessment – clinical cost drivers based on healthcare cost and personnel cost (indirect cost)

  4. Understand Population Care Management NeedsCost Distribution and Trend Over TimeCumulative Total Healthcare Cost

  5. Cost Distribution and Trend Over TimeCumulative Professional and Outpatient Cost

  6. Cost Distribution and Trend Over TimeCumulative Pharmacy Cost

  7. Cost Distribution and Trend Over TimeCumulative Inpatient Cost

  8. Understand Population Care Management NeedsPopulation Assessment Population Assessment is an analysis of claims and membership data to determine characteristics of a given population (Network, Region, Group) that might affect the population’s interaction with the health care system

  9. Population AssessmentMajor Analysis Variables Propensity to Utilize Index – The average number of episodes of illness for a member month Episode Seriousness Index – A measure of the average cost to treat the categories of illness experienced by a population Illness Burden – A measure of the level of illness within a group determined by multiplying the propensity to utilize index by the Episode Seriousness Index

  10. Population AssessmentMajor Analysis Variables, Continued Provider Efficiency Index – A measure of the efficiency to treat a specific episode of illness determined by dividing the cost to treat the specific episode by the average cost for the category of illness PMPM Cost Index – An index that measures the PMPM submitted costs for a population determined by multiplying the Illness Burden by the Provider Efficiency Index

  11. Population AssessmentPopulation Profile

  12. Population AssessmentIllness Burden by Major Practice Category

  13. Population AssessmentProvider Efficiency by Major Practice Category

  14. Population AssessmentPMPM Cost Index by Major Practice Category

  15. Understand Population Care Management NeedsTotal Cost Assessment • Direct costs are dollars paid out for medical treatment • Indirect costs are labor resources lost due to illness Direct Costs= Inpatient + Professional/Outpatient + Pharmacy Indirect Costs= Sick Leave + Presenteeism + Family & Medical Leave + Short Term Disability + Long Term Disability + Turnover + Worker’s Compensation

  16. Total Cost AssessmentAccount Group XYZ Total Healthcare Cost = $23,237,422 Total Healthcare Cost = $23,237,422 Total Healthcare Cost = $23,237,422 Total Healthcare Cost = $23,237,422 $5,631 per FTE $5,631 per FTE $5,631 per FTE $5,631 per FTE Direct $ = Direct $ = Indirect $ = Indirect $ = $13,761,278 $13,761,278 $9,476,144 $9,476,144 $3,334 / FTE $3,334 / FTE $2,296 / FTE $2,296 / FTE 59.2% 59.2% 40.8% 40.8% Inpatient Inpatient Pharmacy Pharmacy Presenteeism Presenteeism STD STD Turnover Turnover Professional/ Professional/ Work Work $376 $376 $804 $804 $318 $318 $220 $220 $74 $74 Outpatient Outpatient Comp Comp 6.7% 6.7% 14.3% 14.3% 5.7% 5.7% 3.9% 3.9% Sick Leave Sick Leave 1.3% 1.3% $2,154 $2,154 $82 $82 FMLA FMLA LTD LTD $1,322 $1,322 38.3% 38.3% 1.5% 1.5% $274 $274 $4 $4 23.5% 23.5% 4.9% 4.9% 0.1% 0.1%

  17. Total Cost AssessmentTop 20 Cost Drivers

  18. Care Management Challenges: Identify & Stratify Members for Care Management • Identifying Members for Care Management • Referrals from • Internal Sources • External Sources • An internally developed ICD9 Trigger list • The ICD9 Trigger list included Asthma, Diabetes, High Risk OB, AIDs, Cancer, CHF, COPD etc • High cost member report • Case managers workload • 103/CM/Month • High predicted cost member report • Stratification index report

  19. Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report (Y1Y2) Experience in 2006 Commercial LOB 2005 Allowed >= $50K GROUP B N = 1,968 (22%) PMPM: $10,706 PMPY: $128,469 Average MM: 11.12 IP PFO Rx $3,107 $6,686 $913 $37,280 $80,232 $10,957 Allowed >= $50K GROUP A N = 9,017 (100%) PMPM: $9,025 PMPY: $108,305 Average MM: 10.98 IP PFO Rx $4,379 $4,211 $441 $52,543 $50,534 $5,289 N = 2,011,903 PMPY: $2,979 ? N = 7,049 (78%) Eligible Members With < $50K GROUP C N =5,180 (57%) PMPM: $1,414 PMPY: $16,966 Average MM: 10.44 Members Not Eligible N = 1,723 (19%) Eligible Members W/O Claims$ N = 146 (2%)

  20. Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report (Y2Y1) Experience in 2005 Commercial LOB 2006 Allowed >= $50K GROUP B N = 1,969 (19%) PMPM: $10,155 PMPY: $121,857 Average MM: 11.60 IP PFO Rx $3,285 $6,082 $761 $39,426 $72,990 $9,131 Allowed >= $50K GROUP A N = 10,194 (100%) PMPM: $8,772 PMPY: $105,258 Average MM: 11.09 IP PFO Rx $4,110 $4,196 $467 $49,316 $50,358 $5,608 N = 2,091,256 PMPY: $2,995 ? N = 8,225 (81%) Eligible Members With < $50K GROUP C N =6,651 (65%) PMPM: $1,095 PMPY: $13,134 Average MM: 11.14 Members Not Eligible N = 1,166 (11%) Eligible Members W/O Claims$ N = 408 (5%)

  21. Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report (Y1Y2Y3) Year 2004 Year 2005 Year 2006 Allowed >= $50K N = 7,404 (100%) PMPM: $8,910 PMPY: $ 106,921 Average MM: 10.94 Allowed >= $50K N = 1,635 (22%) PMPM: $10,251 PMPY: $ 123,006 Average MM: 11.47 Allowed >= $50K GROUP D N = 650 (9%) PMPM: $9,493 PMPY: $ 113,915 Average MM: 11.24 Commercial LOB 2004 N = 1,837,214 PMPY: $2,836

  22. Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report: Cost Drivers

  23. Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report: Cost Drivers

  24. Identify & Stratify Members for Care ManagementDeveloping a Stratification Index (SI) • Why? • 1) To reliably identify higher cost, highly impactable members • 2) To enhance prioritization of members for nurse-intervention management • How? • Use predictive output from MEDai • Select key MEDai measures to construct a composite score • Use the composite score as an index to stratify members • Focus on members with the highest index scores

  25. Validating SI ScoreChronic & Acute Impact: Break Down by SI Score

  26. Validating SI ScoreChronic & Preventative Gaps: Break Down by SI Score

  27. Validating SI ScoreForecasted Cost Risk: Break Down by SI Score

  28. Validating SI ScoreMover Identification • Movers are members who are likely to make the transition from low or moderate to high risk • Movers can be identified by comparing current vs. forecasted cost risk level • if a member’s current cost is less than $1,000 (Risk Level I) and is predicted to cost more than $25,000 (Risk Level V) • Do movers have higher index scores?

  29. Validating SI ScoreIndex Scores for Movers

  30. Validating SI ScoreDistribution of Index Scores Commercial LOB 10/2005 High Scores: >=11 (10.2%) Moderate Scores: 6-10 (18.4%) Low Scores: <=5 (71.4%)

  31. Care Management Challenges:Triage & Intervene Members for Care Management NeedsCare Management Model

  32. Care Management ModelLifestyle/Health Counseling for Healthy and Worried Well • Information on disease/condition • Web resources • Pamphlets • Telephonic health library • 24/7 Nurse Line • HRA/PHR • Encouragement to take more active role/accountability

  33. Care Management ModelCare Coordination for Chronically Ill • Telephonic coordination with members and their providers • Ensures appropriate treatments and pharmaceuticals • Five different programs included in this model

  34. Care Management ModelCare Coordination Programs • Pharmacy Care Management • Emergency Room (ER) Visits Mgmt. • Transition of Care • Condition Specific Care Coordination • Disease Management

  35. Care Management ModelCatastrophic Case Management • Directed to members with • Terminal illness (HOPE) • Major trauma • Cognitive/physical disability • High-risk condition • Complicated care needs • Systematic process of assessing, planning, coordinating, implementing, and evaluation of care

  36. Triage & Intervene Members for Care Management NeedsImplementation • Predictive modeling using • MEDai, DCG, ETG • Rolling 12 months DCG explanation prospective model • ETG cost to supplement MEDai prediction • Developed SQL database containing MEDai, DCG, and ETG information • Improved processes/workflow • Easy and continuous access • Better documentation

  37. Triage & Intervene Members for Care Management NeedsImplementation: Future Enhancements • Accreditation Analytics • Member non-compliance for HEDIS measures • Satisfaction profile • Geo-spatial Analytics (imputed race, vicinity to Centers of Excellence (COE) or efficient/quality providers) • Data Mining Analytics • Probability of engagement, segmentation profile • Psychosocial Profile • Speech Analytics • Indirect Cost Profile

  38. Care Management Challenges: Evaluate Care Management Interventions • Basic research problem: measuring what would have happened vs. what actually happened • Methodologies: • Randomized Control Group • Population-Based Pre-Post Methodology • Predictive Modeling • Control Group Matching • Combination

  39. Group's Inflation Factor 5% 7% CM Mbrs Actual PMPM $ 574 $ 542 CM Mbrs Predictive Modeling PMPM $ 629 $ 638 Inflated CM Mbrs Predictive Modeling PMPM $ 659 $ 682 CM Savings PMPM $ 85 $ 140 Total CM Savings $ 42,005 $ 99,560 Admin Cost $ 29,399 $ 26,749 Evaluate Care Management InterventionsPredictive Modeling

  40. Non CM Mbrs Actual PMPM $ 225 $ 217 Non CM Mbrs PMPM Predictive Modeling $ 205 $ 232 Inflation Adjusted Non CM Mbrs PMPM Predictive Modeling $ 214 $ 248 Adjustment for Actual to Predictive Modeling 5% -13% CM Mbrs Actual PMPM $ 574 $ 542 CM Mbrs Predictive Modeling PMPM $ 629 $ 638 Inflated CM Mbrs Predictive Modeling PMPM $ 659 $ 682 Adjusted Predictive Model $ 692 $ 597 Adjusted CM Savings PMPM $ 117 $ 55 Adjusted CM Savings $ 57,819 $ 39,113 Admin Cost $ 29,399 $ 26,749 Adjusted Net Savings $ 28,296 $ 12,364 Adjusted ROI 1.96 1.46 Evaluate Care Management InterventionsPredictive Modeling w/Adjustments

  41. Median 2007 Direct Costs by SI Score - Percent of Direct Costs & Commercial Subscribers by SI Score Commercial Subscribers Enrolled in 2007 - Subscribers Enrolled in 2007 50,000 $36,000 16% Number of Subscribers Median 2007 Direct $ % of Total Subscribers % of Direct $ in 2007 14% $30,000 40,000 80% of Members 20% of Members 12% $24,000 10% 30,000 8% $18,000 Number of Subscribers Median Direct Costs 20,000 6% $12,000 4% 10,000 $6,000 2% 0% 0 $0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 SI Score SI Score Evaluate Care Management InterventionsTotal Cost Approach Direct Costs by SI Score – 2007 Commercial Subscribers

  42. Percent of Indirect Costs & Commercial Subscribers by SI Score Median 2007 Indirect Costs by SI Score - Subscribers Enrolled in 2007 Commercial Subscribers Enrolled in 2007 16% 50,000 $20,000 % of Total Subscribers % of Indirect $ in 2007 Number of Subscribers Median 2007 Indirect $ 14% 40,000 $16,000 80% of Members 20% of Members 12% 10% 30,000 $12,000 Number of Subscribers Median Indirect Costs 8% 20,000 $8,000 6% 4% 10,000 $4,000 2% 0 $0 0% 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 SI Score SI Score Evaluate Care Management InterventionsTotal Cost Approach Indirect Costs by SI Score – 2007 Commercial Subscribers

  43. Median 2007 Total Healthcare Costs by SI Score - Percent of Total Healthcare Costs & Commercial Subscribers by SI Score - Subscribers Enrolled in 2007 Commercial Subscribers Enrolled in 2007 50,000 $60,000 16% Number of Subscribers Median 2007 THC $ % of Total Subscribers % of THC $ in 2007 14% $50,000 40,000 80% of Members 20% of Members 12% $40,000 10% 30,000 Median Total Healthcare Costs Number of Subscribers $30,000 8% 20,000 6% $20,000 4% 10,000 $10,000 2% 0 $0 0% 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 SI Score SI Score Evaluate Care Management InterventionsTotal Cost Approach Total Costs by SI Score – 2007 Commercial Subscribers

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