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Evaluating Disease Management Return on Investment “Lessons Learned”

Evaluating Disease Management Return on Investment “Lessons Learned”. Sally J. Duran Disease Management Summit May 11, 2003. Lessons Learned. MAMSI Health Plans Health Plan Advantage Disease Management Programs Lessons Learned Evaluating DM ROI . MAMSI Health Plans . MDIPA OCI

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Evaluating Disease Management Return on Investment “Lessons Learned”

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  1. Evaluating Disease Management Return on Investment“Lessons Learned” Sally J. Duran Disease Management Summit May 11, 2003 MAMSI Health Plans 2003 (c)

  2. Lessons Learned • MAMSI Health Plans • Health Plan Advantage • Disease Management Programs • Lessons Learned • Evaluating DM ROI MAMSI Health Plans 2003 (c)

  3. MAMSI Health Plans • MDIPA • OCI • MLH • Alliance PPO • HomeCall, HomeCall Infusion and Hospice MAMSI Health Plans 2003 (c)

  4. Health Plan Advantage • Integrated Structure versus Carve-Outs • Build DM Programs • Risk Stratification using Medical, Pharmacy and Lab values • Teachable Moments • Home Health Services including Infusion and Hospice Services • Primary Care Physician (PCP) MAMSI Health Plans 2003 (c)

  5. Health Plan Advantage • Team Approach • Use of “best” sub-acute facilities • Reduced readmits to acute care from 47% to 19% • Neurological Event Project • Rehabilitation Project • Depression screening for all patients with chronic illnesses in Case Management • New outpatient infusion center as alternative to home or inpatient care • Medication Compliance MAMSI Health Plans 2003 (c)

  6. Disease Management (DM) Programs • Interventions stratified by severity • Post hospitalization to Case Managers (Level 3) • Repeat ER utilizers ( Level 2) • Telephonic support and education • Utilizing Readiness to Change Model • HomeCall • Entire population (Level 1) • Newsletters • Educational mailings • Glucometers and Peak Flow Meters • Reminders MAMSI Health Plans 2003 (c)

  7. DM Programs • Case Management • Telephonic Support • Computerized telephonic support for behavior change based on Readiness to Change Model • Diet • Exercise • Smoking • Cholesterol • Hypertension • Worksite Wellness • Home Health MAMSI Health Plans 2003 (c)

  8. Asthma Admits/1000 Asthmatics MAMSI Health Plans 2003 (c)

  9. ER/1000 Asthmatics MAMSI Health Plans 2003 (c)

  10. Diabetes MAMSI Health Plans 2003 (c) Source: NCQA Quality Compass ® 2002

  11. Lessons Learned • Population Definition and Measurement • Data Collection • Contracting Issues- Build or Buy • What Works? MAMSI Health Plans 2003 (c)

  12. Lessons Learned Population Definition and Measurement • Enroll the entire target population • Measure the entire population, the consecutive population and the continuous population • Define measurable population and program goals • Define enrollment of new members for quality purposes versus DM ROI purposes MAMSI Health Plans 2003 (c)

  13. Lessons Learned Data Collection • Measurement- utilization and cost • Data – quality, validity and timeliness • Predictive modeling • Interventions- member and provider • Data transfer to vendor • Overall program goals MAMSI Health Plans 2003 (c)

  14. Lessons Learned Contracting Issues • Build or Buy • Internal data capacity & resources • Partnering with a third party • Funding • Risk Sharing Per Member Per Month • Prospective or Retrospective payment • Outcomes • Cost Savings • Utilization Shifts MAMSI Health Plans 2003 (c)

  15. Lessons Learned What Works? • Health Plan • Defining the baseline costs and utilization • Population based Programs • Team Approach to Care Coordination • Teachable moments • Multiple contacts – newsletter, CM, Health Ed. • Worksite Wellness • Physicians • Members MAMSI Health Plans 2003 (c)

  16. Evaluating DM ROI • Population – Do they really have the disease (or just allergies) • Utilization shifts and Cost Shifts • Baseline Utilization – HMO versus PPO • Interventions – accurate phone numbers • completed calls not attempts • Timeframe required to measure ROI MAMSI Health Plans 2003 (c)

  17. Evaluating ROI Bottom Line: • Who did the work? • Health Plan • DM Program • Physician • Member • What worked? • Pharmacy Compliance • Case Management • Physician Treatment • Behavior Change MAMSI Health Plans 2003 (c)

  18. Evaluating ROI Bottom Line: • Can You Measure it? • Data integrity • Chart Review • Can You Sustain the Program Over Time? • Costs: Per Health Plan Member Per Month • Fees: Per DM Program Participant Per Month • Reconciliation: Cost Savings and Performance MAMSI Health Plans 2003 (c)

  19. Evaluating ROI Results • Asthma • 42% decrease in hospitalizations • 49% decrease in ER visits • Diabetes • >10% increase in sugar & cholesterol testing • >10% increase in diabetic control • Secondary Prevention of Cardiovascular Disease • >10% increase in medication after heart attack • >30% increase in cholesterol control • New Prenatal and Neonatal Programs • >30% decrease in NICU bed days between 2000 and 2002* *(Source: MAMSI SPA Department, 2/03) MAMSI Health Plans 2003 (c)

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