soyal momin ms, mba september 23, 2008
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
1
Soyal Momin MS, MBASeptember 23, 2008
Predictive Modeling 2008: The BlueCross BlueShield of
Tennessee Experience
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 Time Cumulative Professional and Outpatient Cost
6
Cost Distribution and Trend Over Time Cumulative Pharmacy Cost
7
Cost Distribution and Trend Over Time Cumulative Inpatient Cost
8
Understand Population Care Management Needs Population 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
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
Population Assessment Major Analysis Variables
10
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
Population Assessment Major Analysis Variables, Continued
11
Population Assessment Population Profile
0
0.5
1
1.5
2
2.5
Propensity to Utilize Episode SeriousnessIndex
Provider Efficiency PMPM Cost Index
Population A Population B
12
00.020.040.060.08
0.10.120.140.16
Infectio
us Dise
ases
Endocri
nology
Hemato
logy
Psych
iatry
Chemica
l Dep
enden
cy
Neuro
logy
Ophthalmolo
gy
Cardiology
Otolar
yngo
logy
Pulmonolo
gy
Gastro
enter
ology
Hepato
logy
Nephro
logy
Urology
Obstetri
cs
Gynec
ology
Dermato
logy
Ortho &
Rhe
um
Neonato
logy
Major Practice Category
Illne
ss In
dex
Population A Population B
Population Assessment Illness Burden by Major Practice Category
13
00.5
11.5
22.5
33.5
44.5
Major Practice Category
Prov
ider
Effi
cien
cy In
dex
Population A Population B
Population Assessment Provider Efficiency by Major Practice Category
14
00.05
0.10.15
0.20.25
0.30.35
Infectio
us Dise
ases
Endocri
nology
Hemato
logy
Psych
iatry
Chemica
l Dep
enden
cy
Neuro
logy
Ophthalmolo
gy
Cardiology
Otolar
yngo
logy
Pulmonolo
gy
Gastro
enter
ology
Hepato
logy
Nephro
logy
Urology
Obstetri
cs
Gynec
ology
Dermato
logy
Ortho & R
heum
Neonato
logy
Major Practice Category
Cos
t Ind
ex
Population A Population B
Population Assessment PMPM Cost Index by Major Practice Category
15
Direct costs are dollars paid out for medical treatment Indirect costs are labor resources lost due to illness
Direct CostsDirect Costs = Inpatient + Professional/Outpatient + Pharmacy
Indirect CostsIndirect Costs = Sick Leave + Presenteeism + Family & Medical Leave + Short Term Disability + Long Term Disability
+ Turnover + Worker’s Compensation
Understand Population Care Management Needs Total Cost Assessment
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Total Healthcare Cost = $23,237,422Total Healthcare Cost = $23,237,422$5,631 per FTE$5,631 per FTE
Direct $ = $13,761,278$3,334 / FTE
59.2%
Indirect $ = $9,476,144
$2,296 / FTE40.8%
Inpatient
$376
6.7%
Professional/Outpatient
$2,154
38.3%
Pharmacy
$804
14.3% Sick Leave
$1,322
23.5%
Presenteeism
$318
5.7%
FMLA
$274
4.9%
STD
$220
3.9%
LTD
$4
0.1%
Turnover
$74
1.3%
Work Comp
$82
1.5%
Total Healthcare Cost = $23,237,422Total Healthcare Cost = $23,237,422$5,631 per FTE$5,631 per FTE
Direct $ = $13,761,278$3,334 / FTE
59.2%
Indirect $ = $9,476,144
$2,296 / FTE40.8%
Inpatient
$376
6.7%
Professional/Outpatient
$2,154
38.3%
Pharmacy
$804
14.3% Sick Leave
$1,322
23.5%
Presenteeism
$318
5.7%
FMLA
$274
4.9%
STD
$220
3.9%
LTD
$4
0.1%
Turnover
$74
1.3%
Work Comp
$82
1.5%
Total Cost AssessmentAccount Group XYZ
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$0
$200,000
$400,000
$600,000
$800,000
$1,000,000
$1,200,000
$1,400,000
$1,600,000
$1,800,000
$2,000,000
JOIN
T DEGEN/IN
FLAM
BENIGN NEOPLASM
GASTRO INFEC/IN
FLAM
HYPERTENSION
DEPRES & ANXIETY D
IS
ORTHO DERANGE/TRAUMA
PREG & DELIVERY W
/ C-S
EC
MALIGNANT N
EOPLASM
DIABETES
RHINITIS/SINUSITIS
PREG & DELIV N
O C-S
EC
ASTHMA
CORONARY DISEASE
OTHER CARDIAC D
IS
COND ASSOC M
ENST/INFERT
GALL BLADDER DISEASE
VISUAL DISTURBANCES
HYPERLIPIDEMIA
HEREDITARY/CONGEN D
IS
MINOR O
RTHO DIS
Direct Costs Indirect Costs
Total Cost AssessmentTop 20 Cost Drivers
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• 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
Care Management Challenges: Identify & Stratify Members for Care Management
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Commercial LOB 2005
Allowed >= $50K GROUP A
N = 9,017 (100%)
PMPM: $9,025PMPY: $108,305
Average MM: 10.98
IP PFO Rx $4,379 $4,211 $441 $52,543 $50,534 $5,289
Experience in 2006
Allowed >= $50K GROUP B
N = 1,968 (22%)
PMPM: $10,706PMPY: $128,469
Average MM: 11.12
IP PFO Rx $3,107 $6,686 $913 $37,280 $80,232 $10,957
?N = 7,049 (78%)
Eligible Members With < $50KGROUP C
N =5,180 (57%)
PMPM: $1,414PMPY: $16,966
Average MM: 10.44
MembersNot
EligibleN = 1,723 (19%)
Eligible MembersW/O Claims$N = 146 (2%)
N = 2,011,903
PMPY: $2,979
Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report (Y1Y2)
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Commercial LOB 2006
Allowed >= $50K GROUP A
N = 10,194 (100%)
PMPM: $8,772PMPY: $105,258
Average MM: 11.09
IP PFO Rx $4,110 $4,196 $467 $49,316 $50,358 $5,608
Experience in 2005
Allowed >= $50K GROUP B
N = 1,969 (19%)
PMPM: $10,155PMPY: $121,857
Average MM: 11.60
IP PFO Rx $3,285 $6,082 $761 $39,426 $72,990 $9,131
?N = 8,225 (81%)
Eligible Members With < $50KGROUP C
N =6,651 (65%)
PMPM: $1,095PMPY: $13,134
Average MM: 11.14
MembersNot
EligibleN = 1,166 (11%)
Eligible MembersW/O Claims$N = 408 (5%)
N = 2,091,256
PMPY: $2,995
Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report (Y2Y1)
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Year 2004
Commercial LOB 2004N = 1,837,214PMPY: $2,836
Allowed >= $50K N = 7,404 (100%)
PMPM: $8,910PMPY: $ 106,921
Average MM: 10.94
Year 2005
Allowed >= $50KN = 1,635 (22%)
PMPM: $10,251PMPY: $ 123,006
Average MM: 11.47
Year 2006
Allowed >= $50KGROUP D N = 650 (9%)
PMPM: $9,493PMPY: $ 113,915
Average MM: 11.24
Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report (Y1Y2Y3)
22
ETGCode ETG Description Allw
%TotalAllw
ETGCode ETG Description Allowed
% TotalAllw
553 Chronic Renal Failure, w ith ESRD $47,923,994 5.4 553 Chronic Renal Failure, w ith ESRD $38,761,827 16.1
721 Joint Degeneration, Local, w / Surgery $35,771,711 4.0 656 Malignant Neoplasm of Breast w /o Surgery $10,600,438 4.4
786 Other major Neonatal d/o perinatal origin $30,891,125 3.5 75 Non-Neoplastic Blood Disease, Major $9,977,285 4.1
73 Neoplastics Disorder Blood & Ly mph, Ex Leuk $30,658,775 3.4 73 Neoplastic Disorder Blood & Ly mph, Ex Leuk $9,880,412 4.1
260 Coronary Disease w /o AMI w / CABG $27,081,959 3.0 72 Leukemia w /o Splenectomy $7,787,074 3.2
655 Malignant Neoplasm Breast, w / Surgery not BMT$21,565,875 2.4 76 Non-Neoplastic Blood Disease, Minor $7,526,867 3.1
251 Coronary Disease w / AMI w /CABG $21,287,899 2.4 991 Orphan Drug Record $5,929,881 2.5
401 Malignant Pulmonary Neoplasm, w /o Surgery $20,113,568 2.2 401 Malignant Pulmonary Neoplasm, w /o Surgery $5,921,153 2.5
72 Leukemia w /o Splenectomy $19,282,495 2.2 478 Malignant Neoplasm Rectum/Anus, w /o Surgery$4,566,464 1.9
75 Non-Neoplastic Blood Disease, Major $17,920,993 2.0 721 Joint Degeneration, Local, w / Surgery $3,616,225 1.5
253 Coronary Disease w /o AMI w / Angioplasty $16,713,020 1.9 373 Bacterial Lung Infection w ith Comorbidity $3,494,225 1.4
477 Malignant Neoplasm Rectum/Anus w /Surgery $16,288,401 1.8 51 Other Metabolic Disorder $3,339,403 1.4
656 Malignant Neoplasm of Breast w /o Surgery $16,052,116 1.8 655 Malignant Neoplasm Breast, w / Surgery not BMT$3,310,015 1.4
262 Coronary Disease w /o AMI w /Angioplasty $15,814,419 1.8 810 Late Effects and Late Complications $3,206,696 1.3
373 Bacterial Lung Infection w ith Comorbidity $11,639,075 1.3 454 Malignant Neoplasm Intest/Abdom w /o Surgery$3,178,822 1.3
264 Coronary Disease w /o AMI w /Cardiac Cath $10,862,902 1.2 477 Malignant Neoplasm Rectum/Anus w /Surgery $2,985,750 1.2
153 Malignant Neoplasm of CNS w /Surgery $10,366,887 1.2 262 Coronary Disease w /o AMI w /Angioplasty $2,352,321 1.0
282 Cardiac Congenital Disorder w /Surgery $10,178,199 1.1 452 Inflam of Intestines/Abdomen w /o Surgery $2,293,327 1.0
76 Non-Neoplastic Blood Disease, Minor $9,999,538 1.1 282 Cardiac Congenital Disorder w /Surgery $2,103,403 0.9
162 Major Brain Trauma w /o Surgery $9,938,655 1.1 153 Malignant Neoplasm of CNS w /Surgery $2,011,666 0.8
Total For Top 20 ETGs $400,351,606 45.0 Total For Top 20 ETGs $132,843,254 55.0
Grand Total = $893,294,617 Grand Total = $241,542,404
GROUP B: >=$50K in 2005 and 2006 GROUP A: >=$50K in 2005
Commercial LOB: TOP 20 ETGs
Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report: Cost Drivers
23
ETGCode ETG Description Allowed
%TotalAllw
ETGCode ETG Description Allowed
%TotalAllw
722 Joint Degeneration, Local, w /o Surgery $2,592,627 3.3 553 Chronic Renal Failure, w ith ESRD $20,649,142 23.2
73 Neoplastic Disorder Blood & Ly mph, Ex Leuk $2,297,356 2.9 75 Non-Neoplastic Blood Disease, Major $5,249,796 5.9
656 Malignant Neoplasm of Breast w /o Surgery $1,887,226 2.4 76 Non-Neoplastic Blood Disease, Minor $4,212,880 4.7
721 Joint Degeneration, Local, w / Surgery $1,873,126 2.4 656 Malignant Neoplasm of Breast w /o Surgery $4,192,427 4.7
401 Malignant Pulmonary Neoplasm, w /o Surgery $1,736,043 2.2 73 Neoplastic Disorder Blood & Ly mph, Ex Leuk $3,544,421 4.0
265 Ischemic Heart Disese, Ex , CHF w /o AMI $1,718,398 2.2 991 Orphan Drug Record $3,063,321 3.4
553 Chronic Renal Failure, w ith ESRD $1,589,758 2.0 72 Leukemia w /o splenectomy $2,571,613 2.9
655 Malignant Neoplasm Breast, w / Surgery not BMT$1,465,064 1.9 51 Other Metabolic Disorder $1,810,990 2.0
262 Coronary Disease w /o AMI w / Angioplasty $1,409,685 1.8 478 Malignant Neoplasm Rectum/Anus w /o Surgery$1,748,250 1.9
29 Non-Insulin Dependent Diabetes w / Comorbidity $1,352,197 1.7 454 Malignant Neoplasm Intest/Abdom w /o Surgery$1,380,751 1.5
786 Other Major Neonatal D/O Perinatal Origin $1,194,070 1.5 373 Bacterial Lung Infection w ith Comorbidity $1,350,668 1.5
999 Orphan Record $1,145,019 1.5 401 Malignant Pulmonary Neoplasm $1,174,693 1.3
991 Orphan Drug Record $1,090,253 1.4 394 Emphy sema w ith Chronic Bronchitis $1,053,345 1.2
433 Inflammation of Esophagus w /o Surgery $1,018,298 1.3 262 Coronary Disease w /o AMI w /Angioplasty $985,902 1.1
160 Cereb Vasc Accident w /o Surgery $981,220 1.3 810 Late Effects and Late Complications $861,726 1.0
51 Other Metabolic Disorder $908,220 1.2 27 Insulin Dependent Diabetes w /Comorbidity $846,994 1.0
75 Non-Neoplastic Blood Disease Major $888,965 1.1 452 Inflam of Intestines/Abdomen w /o Surgery $754,833 0.9
47 Hy perlipidemia $887,798 1.1 280 Benign Hy pertension w /Comorbidity $723,403 0.8
72 Leukemia w /o Splenectomy $856,636 1.1 167 Hered/Degen Dis CNS w /o Surgery $708,984 0.8
253 Coronary Disease w /o AMI w / Angioplasty $792,093 1.0 266 Pulmonary Hear Disease w /o AMI $698,100 0.7
Total For Top 20 ETGs $27,684,052 35.0 Total For Top 20 ETGs $57,582,239 71.0
GROUP C: >=$50K in 2005 and <$50K in 2006 GROUP D: >=$50K in 2004, 2005 and 2006
Grand Total = $78,098,373 Grand Total = $81,451,176
Commercial LOB: TOP 20 ETGs
Identify & Stratify Members for Care ManagementValue of Working High Cost Member Report: Cost Drivers
24
• 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 scoresFocus on members with the highest index scores
Identify & Stratify Members for Care ManagementDeveloping a Stratification Index (SI)
25
0%
20%
40%
60%
80%
100%
0 10 80-85 86-90 91-95 96-100
Chronic Impact Level
Perc
ent o
f Mem
bers
High Index ScoresModerate Index ScoresLow Index Scores
Validating SI ScoreChronic & Acute Impact: Break Down by SI Score
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-50 51-70 71-85 86-95 96-100
Acute Index Level
Perc
ent o
f Mem
bers
High Index ScoresModerate Index ScoresLow Index Scores
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 1 - 2 3 - 4 > = 5
Number of Chronic Gaps
Perc
ent o
f Mem
bers High Index Scores
Moderate Index ScoresLow Index Scores
Validating SI Score Chronic & Preventative Gaps: Break Down by SI Score
0%10%20%30%40%50%60%70%80%90%
100%
0 1 - 2 > = 3
Number of Preventative Gaps
Perc
ent o
f Mem
bers High Index Scores
Moderate Index ScoresLow Index Scores
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0%
20%
40%
60%
80%
100%
$0-999 $1000-4999 $5000-9999 $10000-24999
>$25000
Forecasted Cost Level
Perc
ent o
f Mem
bers
High Index ScoresModerate Index ScoresLow Index Scores
Validating SI Score Forecasted Cost Risk: Break Down by SI Score
28
• 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?
Validating SI Score Mover Identification
29
Current Risk Level
Forecasted Risk Level Frequency Mean Index
ScoreI II 430,312 4.52I III 11,370 9.87I IV 451 12.75I V 2 11.00II III 96,352 10.26II IV 7,737 13.03II V 51 13.04III IV 22,492 13.47III V 225 13.95IV V 2,142 14.85
Validating SI Score Index Scores for Movers
30
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Commercial LOB 10/2005
High Scores: >=11(10.2%)
Moderate Scores: 6-10(18.4%)
Low Scores: <=5(71.4%)
Validating SI Score Distribution of Index Scores
31
Segmentation Risk Level Management Type
Healthy Group; Worried Well
Low
Lifestyle/Health
Counseling
Chronically Ill Moderate Refer to Care Coordination Unit
Catastrophic
High
Refer to Catastrophic Case Management
Care Management Challenges: Triage & Intervene Members for Care Management NeedsCare Management Model
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• Information on disease/condition– Web resources– Pamphlets– Telephonic health library– 24/7 Nurse Line– HRA/PHR
• Encouragement to take more active role/accountability
Care Management ModelLifestyle/Health Counseling for Healthy and Worried Well
33
• Telephonic coordination with members and their providers
• Ensures appropriate treatments and pharmaceuticals
• Five different programs included in this model
Care Management ModelCare Coordination for Chronically Ill
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• Pharmacy Care Management
• Emergency Room (ER) Visits Mgmt.
• Transition of Care
• Condition Specific Care Coordination
• Disease Management
Care Management ModelCare Coordination Programs
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• 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
Care Management ModelCatastrophic Case Management
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Triage & Intervene Members for Care Management Needs Implementation
• 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
38
39
40
41
42
43
44
Triage & Intervene Members for Care Management Needs Implementation: 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
45
• 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
Care Management Challenges: Evaluate Care Management Interventions
46
Predictive Modeling with Inflation FactorsYr1 Yr2
Net Savings 12,606$ 72,811$ ROI 1.43 3.72
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
47
Predictive Modeling w/Inflation Factors and AdjustmentsYr1 Yr2
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
48
Evaluate Care Management InterventionsTotal Cost Approach
Direct CostsDirect Costs by SI Score – 2007 Commercial Subscribers
Median 2007 Direct Costs by SI Score - Commercial Subscribers Enrolled in 2007
0
10,000
20,000
30,000
40,000
50,000
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score
Num
ber o
f Sub
scrib
ers
$0
$6,000
$12,000
$18,000
$24,000
$30,000
$36,000
Med
ian
Dire
ct C
osts
Number of Subscribers Median 2007 Direct $
Percent of Direct Costs & Commercial Subscribers by SI Score - Subscribers Enrolled in 2007
0%
2%
4%
6%
8%
10%
12%
14%
16%
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score
% of Total Subscribers % of Direct $ in 2007
80% of Members 20% of Members
49
Evaluate Care Management InterventionsTotal Cost Approach
Indirect CostsIndirect Costs by SI Score – 2007 Commercial Subscribers
Median 2007 Indirect Costs by SI Score - Commercial Subscribers Enrolled in 2007
0
10,000
20,000
30,000
40,000
50,000
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score
Num
ber o
f Sub
scrib
ers
$0
$4,000
$8,000
$12,000
$16,000
$20,000
Med
ian
Indi
rect
Cos
ts
Number of Subscribers Median 2007 Indirect $
Percent of Indirect Costs & Commercial Subscribers by SI Score Subscribers Enrolled in 2007
0%
2%
4%
6%
8%
10%
12%
14%
16%
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score
% of Total Subscribers % of Indirect $ in 2007
80% of Members 20% of Members
50
Evaluate Care Management InterventionsTotal Cost Approach
Total CostsTotal Costs by SI Score – 2007 Commercial Subscribers
Median 2007 Total Healthcare Costs by SI Score - Commercial Subscribers Enrolled in 2007
0
10,000
20,000
30,000
40,000
50,000
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score
Num
ber o
f Sub
scrib
ers
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
Med
ian
Tota
l Hea
lthca
re C
osts
Number of Subscribers Median 2007 THC $
Percent of Total Healthcare Costs & Commercial Subscribers by SI Score - Subscribers Enrolled in 2007
0%
2%
4%
6%
8%
10%
12%
14%
16%
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20SI Score
% of Total Subscribers % of THC $ in 2007
80% of Members 20% of Members
51
Evaluate Care Management InterventionsTotal Cost Approach
-$14,000
-$12,000
-$10,000
-$8,000
-$6,000
-$4,000
-$2,000
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10
EBI Score Change From December 2006 to 2007
Median Change in Indirect $ (06 vs. 07)Median Change in Direct $ (06 vs. 07)
Change in SI Score vs. Change in Median THC Change in SI Score vs. Change in Median THC for Commercial Subscribers in 2006 & 2007for Commercial Subscribers in 2006 & 2007
SI Score Reduced
SI Score Increased
Each 1 point reduction in Score = $775 in THC savings PMPY
Each 1 point increase in Score = $750 THC increase PMPY
Med
ian
Chan
ge in
Co
sts
SI Score Change From December 2006 to 2007
52
Conclusions
• More scientific/standardized approach• Able to touch more lives efficiently• Well accepted by our care managers• PM approach has helped
– Streamline our processes– Better manage case managers case load
• Provide “Peace of Mind” to our members and clients