Soyal Momin, MS, MBA Sylvia Sherrill, RN, MS Lelis Welch, RNC, CCM Judy Slagle, RN, MPA

1. Application of Predictive Modeling to Identify, Stratify, and Triage Members in Care Management Programs: A Health Plan Case Study Soyal Momin, MS, MBA Sylvia Sherrill, RN, MS Lelis Welch, RNC, CCM Judy Slagle, RN, MPA Terence Shea, PharmD Steven Coulter, MD

2. Outline • Historical View: Case Management at BCBST • Concept: Next Generation Care Management (NGCM) • Implementation and Evaluation of NGCM • Enhancements/Improving Process Efficiency

3. History • Identifying Members for Case 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 • Case managers workload • 103/CM/Month • DCG implementation validation revealed missed opportunities for case management

4. Base Year and Year-2 Risk Profile of Members Referred to Case Management Commercial Line of Business 7,000 6,170 6,000 Current methodology of identifying members for case management (Trigger List) seems to be working 5,000 4,543 4,244 4,124 4,117 4,000 3,000 2,683 2,120 2,087 1,926 2,000 840 1,000 0 Risk Level 1 ($0-1K) Risk Level 2 ($1K-$5K) Risk Level 3 ($5K-$10K) Risk Level 4 ($10K-$25K) Risk Level 5 (>25K) Base Year (04/01-03/02) Year-2 (04/02-03/03)

5. Year-2 Detailed Risk Profile of Members NOT Referred to Case Management Commercial Line of Business 1000 872 907 900 800 700 600 500 Light Touch 400 303 300 200 88 100 27 24 0 $25,000-$30,000 $30,000-$40,000 $40,000-$50,000 $50,000-$60,000 $60,000-$70,000 $70,000-$9,999,999 Year-2 (04/02-03/03)

6. Year-2 Case Mix Index of Members NOT Referred to Case Management Commercial Line of Business 24 22 20 17.04 18 16 14 12 10 6.87 8 6 3.23 4 1.13 2 0.24 0 Risk Level 1 ($0-1K) Risk Level 2 ($1K-$5K) Risk Level 3 ($5K-$10K) Risk Level 4 ($10K-$25K) Risk Level 5 (>25K) Year-2 (04/02-03/03)

7. Next Generation Care Management: One size does not fit all

8. Next Generation Care Management:Triage Guidelines

9. Lifestyle/Health Counseling for Healthy and Worried Well: • Information on disease/condition • Web resources • Pamphlets • Telephonic health library • Encouragement to take more active role/accountability

10. Care Coordinationfor Chronically Ill • Telephonic coordination with members and their providers • Ensures appropriate treatments and pharmaceuticals • Six different programs included in this model

11. Care Coordination Programs • Pharmacy Care Management • Emergency Room (ER) Visits Management • Centers of Excellence (COE) • Transition of Care • Condition Specific Care Coordination • Disease Management

12. Care Coordination Program # 1 • Pharmacy Care Management for Specialty Populations • Pharmacy Case Management Programs: • Hepatitis C • AMI-Beta Blocker • Migraine • Polypharmacy

13. Care Coordination Program # 2 • Emergency Room (ER) Visits Management Program • Monthly report identify ER “frequent flyers” • Contacted by a nurse with psychiatric training • Clinical counseling and guidance • Discuss options of care with goal to reduce ER Visits

14. Care Coordination Program # 3 • Centers of Excellence (COE) Program • Identify providers based on utilization and quality of care indicators (CQI using ETGs) and input from regional staff • Asthma • Diabetes • CHF • COPD • CAD • Can be used to refer/steer members to providers considered COE

15. Care Coordination Program # 4 • Transition of Care Program • Formerly known as discharge planning, make sure members are in appropriate setting for treatment • Assist facility, physician, and member with transition • Lower ALOS for per diem admissions • Better outcome for DRG admissions • Reduce re-admissions • Smooth transition of care

16. Care Coordination Program # 5 • Condition Specific Care Coordination • Assess and advise program with one time follow-up • CAD • CHF • COPD • Asthma • Diabetes • Hypertension • GI disorders

17. Care Coordination Program # 6 • Disease Management programs • Carved out to LifeMasters Supported SelfCare, Inc. • CAD • CHF • COPD • Asthma • Diabetes

18. Next Generation Care Management:Catastrophic Case Management • Directed to members with • Terminal illness • Major trauma • Cognitive/physical disability • High-risk condition • Complicated care needs • Systematic process of assessing, planning, coordinating, implementing, and evaluation of care

19. Next Generation Care Management:Implementation • MCSource • Predictive Modeling Using • DCG • ETG • Rolling 12 Months DCG Explanation Prospective Model • ETG Cost to Supplement DCG Prediction

20. Better Understanding of Predictive Modeling • Do Predictive models work like a crystal ball? • Models do not predict a disease (ICD-9) • Helps quantify a disease • Provides early warning for certain diseases with high future resource requirements

21. Example of Predictive Modeling • Clinical Profile of Member XYZ • Diagnosed with CHF (Date: 10/01/2002) • Diagnosed with Diabetes (Date: 10/30/2002) • Our traditional methods might refer this member for Case Management (CM) some time in 2003 • DCG/ETG approach will identify this member for CM in 11/2002 or 12/2002

22. Next Generation Care Management:Program Evaluation • Medication cost avoidance and members’ compliance • Hepatitis C ($1.5M/Year) • Beta Blockers post AMI ($1.3M/Year) • Migraine care management • Member and provider satisfaction • CM staff turnover • Triaging efficiencies

23. Next Generation Care Management:Program Evaluation Total Number of Members (04/03 - 03/04) • Lifestyle/Health Counseling - 1,555 • Care Coordination - 7,229 • Catastrophic Case Mgmt. - 13,622 • Number of Cases/CM/Month=76/CM/Month

24. Next Generation Care Management:Program Enhancements • Developed SQL database containing DCG and ETG information • Improved processes/workflow • Easy and continuous access • Better documentation

25. Next Generation Care Management:Program Enhancements

26. Next Generation Care Management:Program Enhancements

27. Conclusions • More scientific/standardized approach • Able to touch more lives efficiently • Well accepted by our case managers • NGCM has helped • streamline our processes • better manage case managers case load • Provide “Peace of Mind” to our members and clients