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102903KeenanDMSummit:swh-1 Disease Management Programs Health Care Summit October 29, 2003 Caring is Good. Doing Something is Better. Sam Ho, M.D. SVP,

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Presentation on theme: "102903KeenanDMSummit:swh-1 Disease Management Programs Health Care Summit October 29, 2003 Caring is Good. Doing Something is Better. Sam Ho, M.D. SVP,"— Presentation transcript:

1 102903KeenanDMSummit:swh-1 Disease Management Programs Health Care Summit October 29, 2003 Caring is Good. Doing Something is Better. Sam Ho, M.D. SVP, Chief Medical Officer

2 102903KeenanDMSummit:swh-2 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

3 102903KeenanDMSummit:swh-3 Health & Disease Management Catastrophic Care Management –Complex cases Special Population Care –Frail member, End of Life, Centralized Transplant Unit Disease Management –CHF, CAD/stroke, COPD, ESRD, Diabetes, Depression, Cancer, Asthma, Neonatal, Orthopedics Care Coordination Model –Pareto analysis of outlier hospitals –Onsite & telephonic concurrent review, Continuity of Care Preventive Health Management –HRA, immunization programs, cancer screening, smoking cessation, member education Catastrophic Special Populations Chronically Ill Acutely Ill Well Member Continuum

4 102903KeenanDMSummit:swh-4 Focused Medical Management Care coordination model –State-of-the-art clinical decision support – MUSA –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

5 102903KeenanDMSummit:swh-5 Care Management Special Population Care –Frail Member – Coordinating fragmented needs –End of Life Patients – Compassionate care –Transplant Care – Narrow national network of benchmark quality facilities and services Catastrophic Case Management –Coordination of complex services –Integration of multiple providers of care Coordination with DM Continuity of Care – transitional services Employer-specific CM

6 102903KeenanDMSummit:swh-6 Population-based Case Management – Frail Member Program

7 102903KeenanDMSummit:swh-7 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

8 102903KeenanDMSummit:swh-8 Taking Charge of Diabetes sm Taking Charge of Your Heart Health sm Taking Charge of Depression sm Case-based Orthopedics Case-based CHF Case-based CVD/Stroke Case-based ESRD Case-based COPD Taking Charge of Asthma sm Case-based Cancer Case-based NICU Disease Management Continuum

9 102903KeenanDMSummit:swh-9 Disease Management - Opportunity Analysis High prevalence High total costs and pmpm costs –High cost Pareto groups Impact potential on quality –Evidence-based medicine, standardized metrics, feasibility Wide variation in medical performance –Clinical quality and patient safety outcomes Impact potential on savings –Literature review, industry due diligence –In-source and out-source –Short-term and sustainable ROI

10 102903KeenanDMSummit:swh-10 Institutional Cost by Diagnoses 2001 Top 5% of Commercial members PC DM Programs Non-DMOther

11 102903KeenanDMSummit:swh-11 Institutional Cost by Diagnoses 2001 Top 5% of M+C members Non-DMOtherPC DM Programs

12 102903KeenanDMSummit:swh-12 Institutional Costs* for Top 5% Members *Costs for Mbrs who received Institutional Svcs **Excludes OB/Neonatal

13 102903KeenanDMSummit:swh-13 Disease Management Programs In-sourced DM (population-based) –Taking Charge of Your Heart Health sm (CAD, CHF) –Taking Charge of Diabetes sm –Taking Charge of Depression sm –Taking Charge of Asthma sm Out-sourced DM (case-based) –CAD/stroke – Cancer – Orthopedics –CHF – Neonatal care –COPD – ESRD In-sourced Care Management Programs –End-of-life care, Frail Members All DM/CM programs are available to HMO & PPO members Modules available for self-funded accounts

14 102903KeenanDMSummit:swh-14 PHS Cardiovascular Disease Management Congestive Heart Failure -- M+C (ACEI Rx) Coronary Artery Disease (BB Rx)

15 102903KeenanDMSummit:swh-15 Stroke – Intermediate Clinical Outcomes Improvements over baseline for 384 members with prior CVA, TIA with >2 evaluations through 6/30/03

16 102903KeenanDMSummit:swh-16 Note: HgbA1C -- poor control is an inverse measurement; a lower rate is better PHS-Wide Diabetes Comprehensive Care Measures  22%  13%  29%  17%

17 102903KeenanDMSummit:swh Disease Management Results Incurred claims through February 2003, paid through June 2003 Enterprise savings from baseline for most recent 12 months *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

18 102903KeenanDMSummit:swh-18 DM Savings – e.g., large group 11% of members account for 81% of costs

19 102903KeenanDMSummit:swh-19 DM Program Savings Last 12 Months CHF = $62.6M COPD = $37.5M ESRD = $9M CAD = $4.3M Cancer = $3.7M Cumulative DM Savings since 12/00 = $163.1M

20 102903KeenanDMSummit:swh-20 Innovation InformationIntegration Quality


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