Care Facilitation Quality Improvement Report

Transcription

1 Disease Management Program Clinical Outcomes for Reporting Period: 2006 Diabetes 100.0% 90.0% % of participants with diabetes 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% % participants with at least one A1c % participants with two or more A1c % participants with an LDL-C cholesterol screen % participants with a dilated retinal exam % participants monitored for nephropathy Diabetes Numerator Denominator Group Baseline Group Year 1 (2006) (Baseline to 2006) Premera AK (2006) (Group to Premera AK) % participants with at least one A1c % 79.7% 0.2% 77.6% 2.7% % participants with two or more A1c % 47.0% 2.0% 47.2% -0.4% % participants with an LDL-C cholesterol screen % 68.8% -5.8% 70.8% -2.8% % participants with a dilated retinal exam % 28.9% -3.6% 34.2% -15.4% % participants monitored for nephropathy % 37.6% 2.9% 44.2% -14.9% Norm = Premera Insured Book of Business in Alaska 1

2 Disease Management Program Clinical Outcomes for Reporting Period: 2006 Heart Failure 100.0% 90.0% % of participants with HF 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% % participants with an ACE/ARB or hydralazine/nitrate % of participants taking a beta blocker % of participants readmitted for primary Heart Failure within 30 days % of participants readmitted for primary Heart Failure within 90 days Heart Failure (HF) Numerator Year 1 Denominator Group Baseline Group Year 1 (2006) (Baseline to 2006) Premera AK (2006) % Diff (Group to Premera AK) % participants with an ACE/ARB or hydralazine/nitrate % 62.5% 1.6% 70.3% -11.1% % of participants taking a beta blocker % 84.6% 18.5% 65.5% 29.2% % of participants readmitted for primary Heart Failure within 30 days % 0.0% % 12.5% % % of participants readmitted for primary Heart Failure within 90 days % 0.0% % 12.5% % Norm = Premera Insured Book of Business in Alaska 2

3 Disease Management Program Clinical Outcomes for Reporting Period: 2006 Coronary Artery Disease 100.0% 90.0% 80.0% % participants with CAD 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% % of participants with an ACE or ARB post myocardial infarction % participants with a beta blocker post myocardial infarction % participants with an LDL-C cholesterol screen Coronary Artery Disease (CAD) Numerator Denominator Group Baseline Group Year 1 (2006) (Baseline to 2006) Premera AK (2006) % Diff (Group to Premera AK) % of participants with an ACE or ARB post myocardial infarction % 64.3% -11.6% 71.1% -9.6% % participants with a beta blocker post myocardial infarction % 72.7% -19.2% 76.5% -4.9% % participants with an LDL-C cholesterol screen % 71.4% -4.0% 70.1% 1.9% Norm = Premera Insured Book of Business in Alaska 3

4 Disease Management Program Utilization Outcomes for Reporting Period: 2006 Admissions ER Visits Admissions per 1000 DM Members Diabetes Heart Failure Coronary Artery Disease ER Visits per 1000 DM Members Diabetes Heart Failure Coronary Artery Disease Group No. of Events (Baseline) Group No. of Events (Yr 1) Group Baseline (Per 1000 Disease Management Members) Group (Per 1000 Disease Management Members) (Baseline to 2006) Premera AK 2006 (Per 1000 Disease Management Members) (Group to Premera AK) Admissions Diabetes % % Heart Failure % % Coronary Artery Disease % % Bed Days Diabetes % % Heart Failure % % Coronary Artery Disease % % Emergency Room Visits Diabetes % % Heart Failure % % Coronary Artery Disease % % Norm = Premera Insured Book of Business in Alaska 4

5 Disease Management Program Financial Outcomes for Reporting Period: 2006 Condition Base Period Member Months Member Months Adjusted Base Period PMPM PMPM Savings PMPM Diabetes 3,771 3,581 $1, $1, $64.38 Heart Failure $2, $1, $1, Coronary Artery Disease $1, $1, $ Total 4,886 4,635 $1, $1, $ Summary Total Member Months 4,635 Total Savings $850, Total Fees $134, ROI 6.34 Self-Funded Group Composite Results Condition Base Period Member Months Member Months Adjusted Base Period PMPM PMPM Savings PMPM Diabetes 35,677 35,710 $ $ $56.13 Heart Failure 1,610 1,502 $2, $1, $ Coronary Artery Disease 7,144 7,990 $1, $1, $ Total 44,431 45,202 $1, $ $92.97 Summary Total Member Months 45,202 Total Savings $4,202, Total Fees $1,257, ROI 3.34 Credibility Blended ROI* ROI Credibility Weighting Self-Funded Composite % U of Alaska (mbr count = 413) % Total % *Credibility for each group is calculated as (# of diseased members/600)*100%. The group's ROI is weighted according to the credibility rating. The self-funded composite ROI is weighted to make up the remaining % to 100%. For example, if the group credibility rating is 75%, the group ROI is weighted 75% and the self-funded composite ROI is weighted 25% in the total. JHU 5

6 Premera Blue Cross Blue Shield of Alaska Disease Management Reporting Definitions Description of Why is this How does this Annual Measure measure important? show value? Diabetes % participants with at least one A1c % participants with two or more A1c % participants with an LDL-C cholesterol screen Description and Overview Clinical and Utilization Outcomes reporting provides a comprehensive picture of the impact our disease management programs have on the population. Clinical and Utilization Outcomes reporting should be considered two of the most important pieces of reporting as it provides evidence of the efficacy of the program interventions, nursing interactions, and program participant s overall compliance with selected standards of care. Clinical Outcomes Reporting Clinical Outcomes Reporting provides information on patient compliance with specific standards of care. There are a number of measures for each program that Healthways reports over. Unless indicated otherwise, to be eligible for measurement, participants must have been identified as: having the indicated condition, enrolled in the health plan as of the last day of the reporting period, enrolled in the program for at least 11 months, and between the ages of Exceptions include participants with medication contraindications. This hemoglobin A1c test is used to measure a person's average blood sugar level over the past 2-3 months. Blood glucose is the main sugar found in the blood and the body's main source of energy. Poor blood sugar control can lead to serious complications such as blindness and kidney damage. This test measures the amount of 'bad' cholesterol, which is important since diabetics have an increased risk of developing heart disease. % participants monitored for nephropathy Urinary protein/microalbumin screening: This test measures the amount of protein in urine, which is a sign of potential kidney problems. % participants with a dilated retinal exam This test helps to detect eye disease that results from damage to the small blood vessels in the retina. Without treatment, it may lead to loss of eyesight. For every 1% reduction in results of the A1c blood tests, the risk of developing eye, kidney and nerve disease is reduced by 40% (CDC, 2005). Improved control of cholesterol can reduce cardiovascular complications by 20-50% (CDC, 2005). Diabetes is the leading cause of kidney disease, accounting for 44% of new cases in 2002 (CDC, 2005). Detecting and treating diabetic eye disease with laser therapy can reduce the development of severe vision loss by an estimated 50-60% (CDC, 2005). 6

7 Premera Blue Cross Blue Shield of Alaska Disease Management Reporting Definitions Heart Failure (HF) % participants with an ACE/ARB or hydralazine/nitrate ACE Inhibitors and Angiotensin Receptor Blockers (ARBs) are widely The most common causes of heart failure are coronary artery used to treat high blood pressure, kidney disease and heart failure. disease, hypertension or high blood pressure, and diabetes. Studies among people with heart disease have shown that lowering About 7 of 10 people with heart failure had high blood pressure high blood cholesterol and high blood pressure can reduce the risk of before being diagnosed. The risk of death within 5 years of dying of heart disease, having a nonfatal heart attack, and needing being diagnosed with heart failure is more than 50 percent. heart bypass surgery or angioplasty. These vasodilators are Controlling high blood pressure can help to reduce the risk of medicines that act directly on muscles in blood vessel walls to make developing other complications of heart failure. There is no cure blood vessels widen (dilate). Dilating the blood vessels allows for a for heart failure at this time (CDC, 2005). decrease in blood pressure and delays general symptoms of CHF. % of participants taking a beta blocker Beta-blockers are used in the treatment of high blood pressure (hypertension). Some beta-blockers are also used to relieve angina (chest pain) and in heart attack patients to help prevent additional heart attacks. Beta-blockers decrease the heart's need for blood and oxygen by reducing its workload. They also help the heart to beat more regularly. Beta Blockers can also prevent HF from progressing. A point reduction in blood pressure can reduce the risk of heart attack by 21% (CDC, 2004). % of participants readmitted for primary Heart Failure within 30 days % of participants readmitted for primary Heart Failure within 90 days Hospital readmission is a costly event, and provides evidence of a poorly controlled condition. Preventing readmissions increases financial savings, and improves patient quality of life. Coronary Artery Disease (CAD) % of participants with a beta blocker post myocardial infarction Beta-blockers are used in the treatment of high blood pressure (hypertension). Some beta-blockers are also used to relieve angina (chest pain) and in heart attack patients to help prevent additional heart attacks. Beta-blockers decrease the heart's need for blood and oxygen by reducing its workload. They also help the heart to beat more regularly. Beta Blockers can also prevent HF from progressing. A point reduction in blood pressure can reduce the risk of heart attack by 21% (CDC, 2005). 7

8 Premera Blue Cross Blue Shield of Alaska Disease Management Reporting Definitions % participants with an LDL-C cholesterol screen Studies among people with heart disease have shown that lowering A 10% decrease in total blood cholesterol levels may reduce the high blood cholesterol and high blood pressure can reduce the risk of incidence of coronary heart disease by as much as 30% (CDC, dying of heart disease, having a nonfatal heart attack, and needing 2005). heart bypass surgery or angioplasty. Lipid Medications lower bad cholesterol (LDL), and increase good cholesterol (HDL). Sometimes called statins, they can reduce the progression of heart disease, decrease the risk of heart attack, and improve survival rates. % members post myocardial infarction with ACE Inhibitors or Angiotensin Receptor Blockers (ARBs) are widely Coronary Heart Disease is the number 1 killer of men and an ACE or ARB used to treat high blood pressure, kidney disease and heart failure. Studies among people with heart disease have shown that lowering women in the United States, and the leading cause of premature, permanent disability in the US. People who survive a high blood cholesterol and high blood pressure can reduce the risk of heart attack have times higher chance of illness and dying of heart disease, having a nonfatal heart attack, and needing heart bypass surgery or angioplasty. These vasodilators are medicines that act directly on muscles in blood vessel walls to make death than the rest of the population. Within 1 year of a recognized heart attack, 25% of men and 38% of women will die (Get with the Guidelines - CAD, CDC). blood vessels widen (dilate). Dilating the blood vessels allows for a decrease in blood pressure and delays general symptoms of CHF. Utilization Outcomes Reporting Utilization Reporting provides data on the percentage change in admissions, bed days and emergency room visits for program participants. Description of Measure Admissions Per 1000 Disease Management Members (by specific program) Bed Days Per 1000 Disease Management Members (by specific program) Why are these measures important? One goal of the disease management program is to educate members on the importance of regular doctor s visits, timely screening tests and medication usage. As a result, we hope to see fewer hospital admissions, and thus fewer bed days, as well as less frequent trips to the ER due to improved health and/or improved management of their condition. How do these measures show value? Tracking these measures is an important indicator of the efficacy of the program interventions in educating participants about how to better manage their condition. By better managing health, we anticipate that program participants will have a lower rate of utilizing high-cost resources. Emergency Room Visits per 1000 Disease Management Members (by specific program) 8

9 Financial Savings Methodology The following steps illustrate how Premera and Healthways calculate financial savings for the disease management programs. Note that: Program fees are not included as total health care costs, and a $120,000 stop-loss is applied. Participants assigned to a primary program using an established disease hierarchy. The hierarchy is for measurement and billing purposes, and eliminates the risk of double counting savings for participants with comorbidities. Base Period 1. An annual pre-program base period is defined. Membership and eligibility data from the base period are used to identify all members eligible for the program, had the program been in place during the base period. 2. Claims data are used to identify all members with each program disease in the base period. Member trigger dates are determined. The program hierarchy is applied to assign a primary disease program for each identified member. 3. Member months are calculated for non-diseased and diseased members. 4. For each member month, total healthcare costs are calculated for non-diseased and diseased members. Total healthcare costs include medical and pharmacy claims. Reporting Period 1. The measurement period is defined. The first reporting period is typically the first year of program operations. 2. On-going during the program year, participants are identified for the program in the same manner used to identify base period members.. 3. Member months are calculated for non-diseased and diseased members. 4. For each member month, total healthcare costs are calculated for non-diseased and diseased members. Total healthcare costs include medical and pharmacy claims. 5. The trend adjustment factor is determined. This captures all changes between the base period and the reporting period other than those due to the impact of the Healthways program. The total health care costs of all non-diseased members in the base period are calculated and divided by the corresponding member months for those members. The total health care costs of all non-diseased members in the reporting period are calculated and divided by the corresponding member months for those members. These are divided to determine the Trend Adjustment Factor. 6. Trended base period costs are calculated. The total health care costs of all diseased members in the base and reporting periods are calculated and divided by the corresponding member months for those members. The adjustment factor is applied to the diseased member base period costs, which are measured as per disease member per month, or PDMPM. This is the Trend Adjusted Base Period Cost for the diseased population. 7. The adjusted base period is compared to the reporting period. The difference is the Gross Savings PDMPM. 8. Healthways fees paid for the reporting period are subtracted from the Gross Savings. The difference is the Net Savings PDMPM. 9. Gross Savings is divided by Healthways program fees. The result is the Return on Investment (ROI).