Soyal Momin MS, MBA

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 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 populations interaction
with the health care system
9
Population Assessment Major 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 Assessment Major 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 Assessment Population Profile
12
Population Assessment Illness Burden by Major
Practice Category
13
Population Assessment Provider Efficiency by
Major Practice Category
14
Population Assessment PMPM Cost Index by Major
Practice Category
15
Understand Population Care Management Needs
Total 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 Workers 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
Indirect
Direct
Indirect
13,761,278
9,476,144
13,761,278
9,476,144
3,334 / FTE
2,296 / FTE
3,334 / FTE
2,296 / FTE
59.2
40.8
59.2
40.8
Inpatient
Pharmacy
Presenteeism
STD
Inpatient
Pharmacy
Presenteeism
STD
Turnover
Turnover
Professional/
Work
Professional/
Work
376
804
318
220
376
804
318
220
74
74
Outpatient
Comp
Outpatient
Comp
6.7
14.3
5.7
3.9
6.7
14.3
5.7
3.9
Sick Leave
Sick Leave
1.3
1.3
2,154
82
2,154
82
FMLA
LTD
FMLA
LTD
1,322
1,322
38.3
1.5
38.3
1.5
274
4
274
4
23.5
23.5
4.9
0.1
4.9
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 gt 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 gt 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 lt 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 gt 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 gt 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 lt 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 gt 50K N 7,404 (100) PMPM
8,910 PMPY 106,921 Average MM 10.94
Allowed gt 50K N 1,635 (22) PMPM
10,251 PMPY 123,006 Average MM 11.47
Allowed gt 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 Score Chronic Preventative Gaps
Break Down by SI Score
27
Validating SI Score Forecasted Cost Risk Break
Down by SI Score
28
Validating SI Score Mover 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 members 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 Score Index Scores for Movers
Current Risk Level Forecasted Risk Level Frequency Mean Index Score
I II 430,312 4.52
I III 11,370 9.87
I IV 451 12.75
I V 2 11.00
II III 96,352 10.26
II IV 7,737 13.03
II V 51 13.04
III IV 22,492 13.47
III V 225 13.95
IV V 2,142 14.85
30
Validating SI Score Distribution of Index Scores
Commercial LOB 10/2005
High Scores gt11 (10.2)
Moderate Scores 6-10 (18.4)
Low Scores lt5 (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
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
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
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
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

46
Evaluate Care Management InterventionsPredictive
Modeling
47
Evaluate Care Management InterventionsPredictive
Modeling w/Adjustments










48
Evaluate Care Management InterventionsTotal Cost
Approach
Direct Costs by SI Score 2007 Commercial
Subscribers
49
Evaluate Care Management InterventionsTotal Cost
Approach
Indirect Costs by SI Score 2007 Commercial
Subscribers
50
Evaluate Care Management InterventionsTotal Cost
Approach
Total Costs by SI Score 2007 Commercial
Subscribers
51
Evaluate Care Management InterventionsTotal Cost
Approach
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