Disease Management Programs Health Care Summit October 29, 2003

PacifiCare Update for Deloitte & ToucheSam Ho, M.D.
Pedigree = Quality & Accountability
Since 1991 – commitment to NCQA Accreditation. 99% of commercial HMO members in NCQA Excellent Accredited plans. 100% of PBH members in NCQA Full Accredited MBHO.
Since 1997 – exemplary disease management programs
Since 1998 – first consumer-disclosed report cards on providers and rewards to best practices – QUALITY INDEX profiles
Since 2002 – first tiered networks based on clinical quality and costs
Since 2002 – augmented existing market share rewards to better performing providers, with Quality Incentive Program (QIP)
2003 – Health Credits for members engaged in healthier & cost effective behavior
2003 – DMAA’s Best Disease Management Program Award and FACCT’s Innovator Award for Health Financing
Corporate legacy of leadership in, and commitment to, NCQA accreditation, provider report cards, tiered networks on the basis of costs and quality
Will highlight results and distinctions in our disease management programs and analytical capabilities
102903KeenanDMSummit:swh-*
Disease Management
Care Coordination Model
Onsite & telephonic concurrent review, Continuity of Care
Preventive Health Management
Catastrophic
Focus on 20% of hospitals with 85% of outlier days
PacifiCare as consultant and resource
Integrated informatics and reporting – census, auth, claims
Integrated onsite and telephonic concurrent review
Hospitalist programs – 24/7 care managers
Medical director-led regional medical teams
Referrals to DM/CM programs
End of Life Patients – Compassionate care
Transplant Care – Narrow national network of benchmark quality facilities and services
Catastrophic Case Management
Coordination with DM
Employer-specific CM
End Of Life CM
Active, early engagement of terminal patients for hospice, palliative care yields $1.9M reduction in paid claims per death episode in latest rolling 12 months
Chart1
&LPrepared by: Medical Informatics&C&P of &N&R&D
CHF - CO
&LPrepared by Medical Informatics&C&P of &N&R&D
COPD - SH
ESRD - SH
ESRD - CO
ESRD - SH_DL Not Cap
ESRD - SH_DL Cap
ESRD - CO_DL Not Cap
ESRD - CO_DL Cap
CANCER - CO
CAD_CA
3) POD4 Year1 (01/02-2/03);
CAD_TX
Enterprise Summary
Enterprise Summary
PM CA
California
Year 1 (11/00-10/01)
Year 2 (11/01-10/02)
Utilization
Utilization
Texas
Year 1 (04/02-03/03)
Utilization
CHF - CO
COPD - SH
ESRD - SH
ESRD - CO
ESRD - SH_DL Not Cap
ESRD - SH_DL Cap
ESRD - CO_DL Not Cap
ESRD - CO_DL Cap
CANCER - CO
CAD_CA
3) POD4 Year1 (01/02-2/03);
CAD_TX
Enterprise Summary
Enterprise Summary
PM CA
California
Year 1 (11/00-10/01)
Year 2 (11/01-10/02)
Utilization
Utilization
Texas
Year 1 (04/02-03/03)
Utilization
High cost Pareto groups
Impact potential on quality
Clinical quality and patient safety outcomes
Impact potential on savings
In-source and out-source
PC DM Programs
Commercial
Disease
91.3%
93.3%
93.6%
Disease
2001
Cum
SH
Secure Horizons
73.5%
73.5%
73.4%
Final_01_alldz
plan_id
disease
mems
tot_paid
ip_days
ip_admits
mm
paid_pmpm
CO
ESRD
270
10112305.436452
1929
301
2569
3936.2808238427
CO
CHF
902
27702664.380815
8016
1364
8580
3228.7487623328
CO
COPD
453
7185756.626332
1811
365
4313
1666.069238658
CO
CANCER
3896
52182912.566333
11282
2210
36784
1418.6307244001
CO
CAD_STRK
3708
47255705.604232
11316
3262
36702
1287.5512398298
CO
RARE_DZ
2112
17901773.414747
3232
733
19942
897.691977472
CO
DIABETES
3306
28145329.711605
7083
1511
31389
896.6621973177
CO
ASTHMA
2994
18224053.2364019
4425
1309
28194
646.3805503441
CO
GASTROINTESTINAL
8565
48992423.0738843
10593
2624
80690
607.1684604522
CO
DEPRESSION
4236
21246614.443095
3760
994
39360
539.8021962168
CO
OTHER
24679
100219717.874461
18414
5554
210799
475.4278619655
CO
ARTHRITIS
7373
30394383.8673351
4614
1567
68846
441.4836572544
SH
ESRD
821
40213799.262399
8887
1480
7651
5256.0187246633
SH
CHF
4982
173307695.86104
65389
11098
41763
4149.7903852942
SH
COPD
1040
29441159.841481
11938
1979
8614
3417.8267751893
SH
DIABETES
1181
34479326.575884
12256
1860
10111
3410.0807611397
SH
CANCER
1889
51881041.5575679
16828
2603
16010
3240.539759998
SH
CAD_STRK
3798
106764325.824924
34337
6271
33860
3153.1106268436
SH
ASTHMA
283
7518030.263902
2652
427
2438
3083.6875569737
SH
ARTHRITIS
327
9025167.068144
2537
397
3044
2964.9037674586
SH
OTHER
921
21627576.424695
7250
1036
7297
2963.8997430033
SH
RARE_DZ
804
20499582.50605
6935
1199
6918
2963.2238372434
SH
DEPRESSION
318
7370533.915461
3268
432
2693
2736.9231026591
SH
GASTROINTESTINAL
826
18849617.873608
6546
1096
7007
2690.1124409316
&A
Non-DM
Other
Commercial
Disease
91.3%
93.3%
93.6%
Disease
2001
Cum
CO
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
&A
Secure Horizons
73.5%
73.5%
73.4%
Disease
Percent
Cum
Depression
1%
1%
Asthma
1%
3%
Arthritis
2%
5%
Gastrointestinal
4%
8%
Final_01_alldz
plan_id
disease
mems
tot_paid
ip_days
ip_admits
mm
paid_pmpm
CO
ESRD
270
10112305.436452
1929
301
2569
3936.2808238427
CO
CHF
902
27702664.380815
8016
1364
8580
3228.7487623328
CO
COPD
453
7185756.626332
1811
365
4313
1666.069238658
CO
CANCER
3896
52182912.566333
11282
2210
36784
1418.6307244001
CO
CAD_STRK
3708
47255705.604232
11316
3262
36702
1287.5512398298
CO
RARE_DZ
2112
17901773.414747
3232
733
19942
897.691977472
CO
DIABETES
3306
28145329.711605
7083
1511
31389
896.6621973177
CO
ASTHMA
2994
18224053.2364019
4425
1309
28194
646.3805503441
CO
GASTROINTESTINAL
8565
48992423.0738843
10593
2624
80690
607.1684604522
CO
DEPRESSION
4236
21246614.443095
3760
994
39360
539.8021962168
CO
OTHER
24679
100219717.874461
18414
5554
210799
475.4278619655
CO
ARTHRITIS
7373
30394383.8673351
4614
1567
68846
441.4836572544
SH
ESRD
821
40213799.262399
8887
1480
7651
5256.0187246633
SH
CHF
4982
173307695.86104
65389
11098
41763
4149.7903852942
SH
COPD
1040
29441159.841481
11938
1979
8614
3417.8267751893
SH
DIABETES
1181
34479326.575884
12256
1860
10111
3410.0807611397
SH
CANCER
1889
51881041.5575679
16828
2603
16010
3240.539759998
SH
CAD_STRK
3798
106764325.824924
34337
6271
33860
3153.1106268436
SH
ASTHMA
283
7518030.263902
2652
427
2438
3083.6875569737
SH
ARTHRITIS
327
9025167.068144
2537
397
3044
2964.9037674586
SH
OTHER
921
21627576.424695
7250
1036
7297
2963.8997430033
SH
RARE_DZ
804
20499582.50605
6935
1199
6918
2963.2238372434
SH
DEPRESSION
318
7370533.915461
3268
432
2693
2736.9231026591
SH
GASTROINTESTINAL
826
18849617.873608
6546
1096
7007
2690.1124409316
&A
*Costs for Mbrs who received Institutional Svcs
**Excludes OB/Neonatal
Taking Charge of Diabetessm
Taking Charge of Depressionsm
Taking Charge of Asthmasm
Modules available for self-funded accounts
(ACEI Rx)
Stroke – Intermediate Clinical Outcomes
Improvements over baseline for 384 members with prior CVA, TIA with >2 evaluations through 6/30/03
PHS-Wide Diabetes Comprehensive Care Measures
Note: HgbA1C -- poor control is an inverse measurement; a lower rate is better
D 22%
D 13%
D 29%
D 17%
*Change is contract period versus baseline
CAD includes CA and TX performance incurred through January 2003; CAD eligibility/enrollment is not applicable
ESRD all eligible members are enrolled; results for membership with eligibility greater than 100 members
Frail Member includes CA and TX performance incurred through March 2003 and March 2003 enrollment
DM Enterprise
Enterprise savings from baseline for most recent 12 months
Claims incurred through February 2003, paid through June 2003
M+C
*Change is contract period versus baseline
CAD includes CA and TX performance incurred through January 2003; CAD eligibility/enrollment is not applicable
ESRD all eligible members are enrolled; results for membership with eligibility greater than 100 members
Frail Member includes CA and TX performance incurred through March 2003 and March 2003 enrollment
&LPrepared by: Medical Informatics&R7/28/03
MBD003FC518.bin
11% of members account for 81% of costs
Innovation
Information
Integration
Quality
CADn/a15,342n/an/a$21924.3%n/a189.2%
Frail Member85274687.6%34.8%$1,34434.1%34.0%7,64335.3%
Commercial
2003
Eligible
Members
2003
Enrolled
Members
CADn/a3,825n/an/a$1719.9%n/a229.8%
Frail Member29723579.1%29.6%$2,18831.9%34.0%9,33540.7%
72
51
55
88
64
67
22
25
22
0
20
40
60
80
100

Disease Management Programs Health Care Summit October 29, 2003

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Transcript of Disease Management Programs Health Care Summit October 29, 2003