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 Slide 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 DMAAs Best Disease Management Program Award
and FACCTs Innovator Award for Health Financing Slide 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 Slide 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 Slide 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 Slide 6
102903KeenanDMSummit:swh-6 Population-based Case Management Frail
Member Program Slide 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 Slide 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 1997 1998 1999 2001 2002 2003
Disease Management Continuum Slide 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 Slide 10 102903KeenanDMSummit:swh-10
Institutional Cost by Diagnoses 2001 Top 5% of Commercial members
PC DM Programs Non-DMOther Slide 11 102903KeenanDMSummit:swh-11
Institutional Cost by Diagnoses 2001 Top 5% of M+C members
Non-DMOtherPC DM Programs Slide 12 102903KeenanDMSummit:swh-12
Institutional Costs* for Top 5% Members *Costs for Mbrs who
received Institutional Svcs **Excludes OB/Neonatal Slide 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 Slide 14 102903KeenanDMSummit:swh-14 PHS
Cardiovascular Disease Management Congestive Heart Failure -- M+C
(ACEI Rx) Coronary Artery Disease (BB Rx) Slide 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 Slide 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% Slide 17
102903KeenanDMSummit:swh-17 2003 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 Slide 18
102903KeenanDMSummit:swh-18 DM Savings e.g., large group 11% of
members account for 81% of costs Slide 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 Slide 20
102903KeenanDMSummit:swh-20 Innovation InformationIntegration
Quality
