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A Roadmap to Integrated CarePrimary Care and Behavioral Health
The Business Case for Integrated Medical-Behavioral Healthcare
An Actuary’s Perspective
Steve Melek, FSA, MAAADoug Norris, FSA, MAAA, PhDJune 3, 2015
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Integrating Behavioral and Medical Healthcare
Source: Kathol and Gatteau – Healing Mind and Body, 2007
June 3, 2015
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48.3%
12.7%
34.9%
5.3%
June 3, 2015
4
The Quality of Treatment
In spite of effective treatments and evidence-based guidelines, only 1 in 5 individuals with depression who seek treatment are treated according to minimum standards (JAMA, 2003).
5 June 3, 2015
Condition Identification
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Prevalence of Co-morbidities
Unützer, Jürgen. Integrated Behavioral Health Care. Powerpoint Presentation. Seattle , Washington. May 2, 2011.
7 June 3, 2015
Cost Impact and Savings Opportunities
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Findings from an Analysis of Comorbid Chronic Medical & Behavioral Conditions in Insured Populations
Basis for analysis was detailed claim and membership files for Commercial, Medicare and Medicaid populations
Commercial and Medicare populations were divided into 4 cohorts:1. No MH/SUD
2. Non-SPMI MH
3. SPMI
4. SUD
Total spending and per member per month (PMPM) costs were separated between Medical, Medical Rx, Behavioral, and Behavioral Rx
June 3, 2015
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Findings from an Analysis of Comorbid Chronic Medical & Behavioral Conditions in Insured Populations
June 3, 2015
PopulationBehavioral Health
DiagnosisMember Months Medical Behavioral Medical Rx Behavioral Rx Total
Commercial No MH/SA 2,048,000,000 $280 $3 $53 $4 $340Non-SPMI MH 278,000,000 $661 $23 $145 $74 $903SPMI 47,000,000 $759 $128 $135 $175 $1,197SA 22,000,000 $830 $73 $102 $67 $1,072Total 2,386,000,000 $335 $8 $66 $16 $425
Medicare No MH/SA 508,000,000 $579 $3 N/A* N/A* $582Non-SPMI MH 23,000,000 $1,369 $40 N/A* N/A* $1,409SPMI 21,000,000 $1,222 $215 N/A* N/A* $1,437SA 6,000,000 $1,291 $213 N/A* N/A* $1,504Total 556,000,000 $640 $13 N/A* N/A* $653
Medicaid No MH/SA 437,000,000 $309 $4 $63 $5 $381MH/SA 109,000,000 $757 $286 $172 $86 $1,301Total 546,000,000 $398 $61 $85 $21 $565
Total No MH/SA 2,993,000,000 $335 $3 $55 $4 $397MH/SA 494,000,000 $751 $100 $148 $86 $1,085Total 3,487,000,000 $394 $17 $69 $17 $497
Per Member Per Month (PMPM) Healthcare Costs by Market
Total Spending for Full Population(PMPM, 2012 Allowed Dollars)
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Findings from an Analysis of Comorbid Chronic Medical & Behavioral Conditions in Insured Populations
June 3, 2015
PopulationBehavioral Health
DiagnosisMedical Behavioral Medical Rx Behavioral Rx Total
Commercial No MH/SA $573,171 $5,628 $109,464 $8,833 $697,096Non-SPMI MH $184,147 $6,502 $40,361 $20,507 $251,517SPMI $35,408 $5,954 $6,312 $8,167 $55,841SA $18,227 $1,596 $2,236 $1,473 $23,532Total $800,317 $18,336 $157,038 $37,695 $1,013,386
Medicare No MH/SA $294,241 $1,619 N/A N/A $295,860Non-SPMI MH $31,167 $914 N/A N/A $32,081SPMI $26,142 $4,596 N/A N/A $30,738SA $8,346 $1,379 N/A N/A $9,725Total $355,559 $7,234 N/A N/A $362,793
Medicaid No MH/SA $134,920 $1,963 $27,710 $2,176 $166,769MH/SA $82,655 $31,264 $18,759 $9,389 $142,067Total $217,575 $33,227 $46,468 $11,566 $308,836
Total No MH/SA $1,002,332 $9,210 $137,173 $11,009 $1,159,724MH/SA $371,119 $49,587 $66,333 $38,252 $525,291Total $1,373,451 $58,797 $203,507 $49,261 $1,685,016
(Millions, 2012 Allowed Dollars)
Total Spending for Full PopulationTotal Healthcare Costs by Market
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Findings from an Analysis of Comorbid Chronic Medical & Behavioral Conditions in Insured Populations
June 3, 2015
Condition No MH/SA SPMI Non-SPMI SAArthritis $814 $2,065 $1,586 $1,827Asthma $569 $1,851 $1,389 $1,774Cancer $1,360 $2,525 $2,338 $2,668Chronic Kidney Disease $4,650 $5,664 $6,232 $6,901Congestive Heart Failure $1,274 $2,649 $1,955 $2,827Chronic Obstructive Pulmonary Disease $992 $2,719 $2,088 $2,028Chronic Pain $1,259 $2,355 $1,780 $2,387Back Pain $1,624 $3,109 $2,395 $2,705Headache $1,659 $3,311 $2,221 $3,354Diabetes (with complications) $1,821 $3,366 $2,681 $3,678Diabetes (without complications) $811 $1,775 $1,353 $1,848Hypercholesterolemia (with complications) $1,369 $2,769 $2,061 $2,349Hypercholesterolemia (without complications) $649 $1,498 $1,065 $1,411Hypertension (with complications) $1,447 $3,056 $2,220 $2,621Hypertension (without complications) $688 $1,641 $1,157 $1,494Ischemic Heart Disease $1,443 $3,006 $2,319 $2,335Osteoporosis $874 $2,312 $1,592 $1,720Stroke $1,673 $3,556 $2,590 $2,554None $221 $762 $528 $615Any Condition $695 $1,690 $1,271 $1,577Total $340 $1,197 $903 $1,071
2012 Allowed PMPMsImpact of Co-mobidities (Commercial Population)
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Findings from an Analysis of Comorbid Chronic Medical & Behavioral Conditions in Insured Populations
June 3, 2015
Condition No MH/SA SPMI Non-SPMI SAArthritis $1,237 $2,109 $1,852 $2,010Asthma $1,381 $2,227 $2,051 $2,325Cancer $1,230 $2,117 $1,826 $2,083Chronic Kidney Disease $2,677 $3,986 $3,772 $4,581Congestive Heart Failure $2,230 $3,478 $2,882 $3,713Chronic Obstructive Pulmonary Disease $1,598 $2,546 $2,335 $2,171Diabetes (with complications) $1,740 $2,964 $2,755 $3,085Diabetes (without complications) $811 $1,486 $1,379 $1,719Hypercholesterolemia (with complications) $1,292 $2,465 $2,119 $2,302Hypercholesterolemia (without complications) $676 $1,186 $1,043 $1,267Hypertension (with complications) $1,608 $2,917 $2,438 $2,936Hypertension (without complications) $822 $1,528 $1,326 $1,642Ischemic Heart Disease $1,392 $2,659 $2,261 $2,634Osteoporosis $1,052 $1,882 $1,627 $1,988Stroke $1,567 $2,809 $2,400 $2,409None $185 $665 $673 $821Any Condition $971 $1,701 $1,561 $1,744Total $582 $1,436 $1,410 $1,504
2012 Allowed PMPMsImpact of Co-mobidities (Medicare Population)
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Findings from an Analysis of Comorbid Chronic Medical & Behavioral Conditions in Insured Populations
June 3, 2015
Condition No MH/SA MHSABenign/In Situ/Uncertain Neoplasm $686 $1,580Cardio-Respiratory Arrest $4,798 $5,134Cerebro-Vascular $2,052 $3,299Cognitive Disorders $2,319 $3,552Diabetes $1,066 $2,368Ears, Nose, and Throat $488 $1,455Eyes $587 $1,625Gastrointestinal $843 $1,932Genital System $662 $1,538Heart $1,023 $2,134Hematological $1,419 $3,003Liver $1,328 $2,564Lung $737 $1,912Malignant Neoplasm $1,913 $3,185Musculoskeletal and Connective Tissue $693 $1,624Neurological $1,476 $2,365Nutritional and Metabolic $815 $1,923Pregnancy-Related $1,147 $1,669Skin and Subcutaneous $598 $1,771Urinary System $1,079 $2,395Vascular $1,808 $3,375Total $382 $1,301
2012 Allowed PMPMsImpact of Co-mobidities (Medicaid Population)
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Findings from an Analysis of Comorbid Chronic Medical & Behavioral Conditions in Insured Populations
June 3, 2015
Medical Condition SPMI Non-SPMI SA TotalArthritis $7,931 $26,567 $3,013 $36,372Asthma $6,298 $22,770 $2,633 $30,801Cancer $2,236 $13,100 $1,149 $16,201Chronic Kidney Disease $267 $2,082 $192 $2,485Congestive Heart Failure $2,981 $10,166 $1,308 $13,953Chronic Obstructive Pulmonary Disease $2,369 $7,829 $1,590 $11,428Chronic Pain $1,007 $3,686 $455 $5,002Back Pain $1,688 $4,598 $841 $6,894Headache $231 $398 $119 $683Diabetes (with complications) $1,745 $6,246 $586 $8,381Diabetes (without complications) $2,850 $9,982 $798 $13,334Hypercholesterolemia (with complications) $1,707 $6,106 $720 $8,285Hypercholesterolemia (without complications) $5,151 $17,842 $1,596 $24,000Hypertension (with complications) $2,399 $7,905 $1,090 $11,031Hypertension (without complications) $5,645 $20,161 $2,505 $27,241Ischemic Heart Disease $1,380 $5,321 $732 $7,208Osteoporosis $518 $1,602 $90 $2,209Stroke $632 $1,689 $262 $2,465None $13,373 $42,270 $4,547 $56,991Any Condition $21,781 $81,029 $9,188 $105,376Total $35,154 $123,299 $13,735 $162,366
Annual Value Opportunity (Commercial Population) - Total 2012 Dollars (millions)
Note: Results are not additive across conditions due to insureds with multiple conditions
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What IMBH Programs have worked?
Multifaceted Diabetes and Depression Program (MDDP) – medical savings of $39 PMPM observed over 18 months
Pathways program for diabetes & depression - $46 PMPM saved, or about 5% over 2 years
IMPACT program for depression among the elderly - $70 PMPM saved over 4-year period, or about 10%
Missouri CMHC health homes in 2012 – independent living increased by 33%, vocational activity increased by 44%, overall healthcare costs decreased by 8%
Observed savings of between 9% and 16% of value opportunity
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Findings from an Analysis of Comorbid Chronic Medical & Behavioral Conditions in Insured Populations
June 3, 2015
Payor Type Member Months Allowed Claims Value PotentialCost Impact of
IntegrationCommercial 2,386,000,000 $1,013,386 $162,366 $15,815-$31,629Medicare 556,000,000 $362,793 $30,803 $3,347-$6,693Medicaid 546,000,000 $308,836 $100,374 $7,103-$9,945Total 3,487,000,000 $1,685,016 $293,543 $26,265-$48,267
Average Annual Cost Savings Achievable through Effective IMBH (millions)
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More Economic Impact Analyses
A Focus on Children and Adolescents
Dependent Children and Adolescents
Age Groups 0-5. 6-12, 13-18, 19+
4 Cohort Analysis: Comorbid chronic medical-behavioral, SMI, non-SMI MH, SUD
Impact of behavioral conditions on the healthcare costs of parents
June 3, 2015
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PMPM Cost Comparison of Cohorts
June 3, 2015
Figure 2a: Children – Per Member Per Month (PMPM) Commercial Healthcare Costs by Age Group and Presence of Behavioral Conditions – 2015 Costs
Child’s Behavioral
Age Member
Medical Behavioral Med BHV Total
Diagnosis Group Months
Rx Rx
No MH/SUD
Child 0-5 157,739,550 $190.17 $0.41 $16.67 $0.44 $207.69
Child 6-12 196,614,885 $109.59 $1.66 $19.25 $3.59 $134.10
Child 13-18 167,624,597 $160.07 $5.53 $34.19 $4.86 $204.65
Child 19+ 122,836,661 $168.77 $5.31 $29.78 $4.84 $208.70 Total No MH/SUD
644,815,692 $153.70 $3.06 $24.51 $3.39 $184.65
Non-SPMI MH
Child 0-5 2,971,671 $989.18 $12.10 $57.74 $22.10 $1,081.13
Child 6-12 13,647,733 $291.72 $39.71 $52.13 $85.72 $469.27
Child 13-18 17,922,960 $344.04 $78.10 $68.70 $76.40 $567.24
Child 19+ 16,171,774 $415.78 $72.79 $65.04 $61.89 $615.50 Total Non-SPMI MH
50,714,137 $390.64 $62.21 $62.43 $71.10 $586.38
SPMI
Child 0-5 466,498 $1,339.10 $75.20 $37.02 $16.47 $1,467.78
Child 6-12 1,735,388 $658.87 $82.87 $77.33 $132.64 $951.71
Child 13-18 2,197,781 $536.41 $240.27 $80.21 $198.11 $1,055.00
Child 19+ 1,998,917 $657.13 $280.65 $64.31 $185.20 $1,187.29
Total SPMI 6,398,584 $665.86 $198.16 $71.31 $163.08 $1,098.41
SUD
Child 0-5 17,237 $6,066.54 $1.73 $152.92 $40.52 $6,261.72
Child 6-12 20,034 $444.46 $50.92 $82.47 $76.55 $654.41
Child 13-18 922,384 $457.50 $208.95 $42.13 $54.48 $763.06
Child 19+ 3,824,943 $594.32 $218.39 $56.34 $38.32 $907.37
Total SUD 4,784,597 $587.03 $215.09 $54.06 $41.60 $897.78
Total
704,465,793 $176.35 $9.37 $27.72 $9.73 $223.17
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PMPM Cost Comparison of Parents
June 3, 2015
Figure 2b: Parents – Per Member Per Month (PMPM) Commercial Healthcare Costs by Child’s Diagnosis Category – 2015 Costs Dependent’s Member
Medical Behavioral Med BHV
Total Diagnosis Months Rx Rx
Co-Morbid 18,775,451 $574.45 $17.43 $134.10 $41.57 $767.56
BH/SUD 78,974,834 $479.84 $14.85 $104.32 $32.64 $631.65
Medical 88,762,288 $416.77 $6.12 $89.47 $16.14 $528.49
No Condition 435,372,898 $371.79 $5.58 $72.30 $13.16 $462.83
Total 621,885,472 $398.05 $7.19 $80.68 $16.92 $502.84
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Total Costs for Children & Adolescents
June 3, 2015
Figure 3a: Children – Total Commercial Healthcare Costs by Age Group and Presence of Behavioral Conditions – 2015 Costs (millions)
Child’s Behavioral
Age Member
Medical Behavioral Med BHV Total
Diagnosis Group Months
Rx Rx
No MH/SUD
Child 0-5 157,739,550 $29,997 $65 $2,629 $69 $32,760
Child 6-12 196,614,885 $21,547 $327 $3,786 $706 $26,366
Child 13-18 167,624,597 $26,832 $928 $5,732 $814 $34,305
Child 19+ 122,836,661 $20,731 $652 $3,658 $595 $25,636 Total No MH/SUD
644,815,692 $99,107 $1,971 $15,804 $2,184 $119,067
Non-SPMI MH
Child 0-5 2,971,671 $2,940 $36 $172 $66 $3,213
Child 6-12 13,647,733 $3,981 $542 $711 $1,170 $6,404
Child 13-18 17,922,960 $6,166 $1,400 $1,231 $1,369 $10,167
Child 19+ 16,171,774 $6,724 $1,177 $1,052 $1,001 $9,954 Total Non-SPMI MH
50,714,137 $19,811 $3,155 $3,166 $3,606 $29,738
SPMI
Child 0-5 466,498 $625 $35 $17 $8 $685
Child 6-12 1,735,388 $1,143 $144 $134 $230 $1,652
Child 13-18 2,197,781 $1,179 $528 $176 $435 $2,319
Child 19+ 1,998,917 $1,314 $561 $129 $370 $2,373
Total SPMI 6,398,584 $4,261 $1,268 $456 $1,043 $7,028
SUD
Child 0-5 17,237 $105 $0 $3 $1 $108
Child 6-12 20,034 $9 $1 $2 $2 $13
Child 13-18 922,384 $422 $193 $39 $50 $704
Child 19+ 3,824,943 $2,273 $835 $215 $147 $3,471
Total SUD 4,784,597 $2,809 $1,029 $259 $199 $4,296
Total
704,465,793 $124,229 $6,604 $19,529 $6,856 $157,218
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Total Costs of Parents
June 3, 2015
Figure 3b: Parents – Total Commercial Healthcare Costs by Child’s Diagnosis Category– 2015 Costs (millions) Dependent’s Member Medical Behavioral Med BHV Total
Diagnosis Months
Rx Rx
Co-Morbid 18,775,451 $10,786 $327 $2,518 $781 $14,411
BH/SUD 78,974,834 $37,895 $1,173 $8,238 $2,577 $49,884 Medical 88,762,288 $36,993 $543 $7,941 $1,433 $46,910
No Condition 435,372,898 $161,867 $2,431 $31,477 $5,730 $201,505
Total 621,885,472 $247,541 $4,474 $50,175 $10,521 $312,710
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PMPM Costs by Medical Condition - Children
June 3, 2015
Figure 5a - Children and Adolescents - Impact of Behavioral Comorbidities, Commercial Population – 2015 Total PMPM Costs
Child’s Medical Condition No MH/SUD SPMI Non-SPMI
MH SUD
Arthritis $461 $1,907 $1,155 $1,508
Asthma $354 $1,466 $1,044 $1,282
Cancer $1,686 $3,461 $3,704 $3,589
Chronic Kidney Disease $4,727 $11,005 $9,024 $8,967
Congestive Heart Failure $2,228 $3,869 $3,787 $4,615
Chronic Obstructive Pulmonary Disease $465 $2,412 $2,614 $2,106
Chronic Pain $1,923 $4,918 $3,049 $2,559
Back Pain $1,610 $3,697 $3,510 $3,409
Headache $1,502 $5,554 $4,457 $2,766
Diabetes (with complications) $1,377 $6,392 $3,533 $7,234
Diabetes (without complications) $996 $2,272 $1,744 $2,843
Hypercholesterolemia (with complications) $4,637 $5,931 $4,071 $1,564
Hypercholesterolemia (without complications) $464 $1,761 $1,422 $1,789
Hypertension (with complications) $6,026 $6,701 $9,086 $13,905
Hypertension (without complications) $1,093 $3,138 $2,399 $2,221
Ischemic Heart Disease $3,721 $12,433 $6,891 $3,568
Osteoporosis $3,125 $8,621 $8,484 $3,667
Stroke $3,972 $3,202 $4,758 $3,422
No Medical Condition $156 $974 $460 $765
Any Medical Condition $440 $1,646 $1,193 $1,486
Total $185 $1,098 $586 $898
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Prevalence Rates of Conditions - Children
June 3, 2015
Figure 6a - Children and Adolescents - Condition Prevalence, Commercial Population – 2015
Child’s Medical Condition No MH/SUD SPMI Non-SPMI
MH SUD
Arthritis 2.55% 5.28% 5.34% 7.34%
Asthma 6.45% 10.42% 9.83% 7.61%
Cancer 0.28% 0.64% 0.73% 0.64%
Chronic Kidney Disease 0.02% 0.06% 0.06% 0.06%
Congestive Heart Failure 0.10% 0.30% 0.37% 0.31%
Chronic Obstructive Pulmonary Disease 0.58% 1.02% 0.85% 1.89%
Chronic Pain 0.01% 0.05% 0.06% 0.10%
Back Pain 0.00% 0.10% 0.08% 0.25%
Headache 0.00% 0.02% 0.01% 0.03%
Diabetes (with complications) 0.01% 0.06% 0.06% 0.06%
Diabetes (without complications) 0.35% 1.46% 0.92% 1.00%
Hypercholesterolemia (with complications) 0.00% 0.02% 0.01% 0.02%
Hypercholesterolemia (without complications) 0.10% 0.80% 0.38% 0.50%
Hypertension (with complications) 0.00% 0.04% 0.03% 0.05%
Hypertension (without complications) 0.14% 0.83% 0.53% 1.15%
Ischemic Heart Disease 0.00% 0.02% 0.02% 0.08%
Osteoporosis 0.00% 0.03% 0.02% 0.01%
Stroke 0.02% 0.13% 0.07% 0.16%
No Medical Condition 90.03% 81.43% 82.77% 81.62%
Any Medical Condition 9.97% 18.57% 17.23% 18.38%
Total 100.00% 100.00% 100.00% 100.00%
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The Annual Value Opportunity - Children
June 3, 2015
Figure 6b – Children and Adolescents – Annual Value Opportunity - Commercial Population – Total 2015 Dollars (millions) Child’s Medical Condition SPMI Non-SPMI SUD Total
Arthritis $489 $1,881 $368 $2,738
Asthma $741 $3,439 $338 $4,518
Cancer $72 $749 $58 $879
Chronic Kidney Disease $25 $129 $12 $166
Congestive Heart Failure $32 $289 $35 $356
Chronic Obstructive Pulmonary Disease $128 $922 $148 $1,198
Chronic Pain $10 $37 $3 $50
Back Pain $13 $73 $22 $107
Headache $5 $20 $2 $28
Diabetes (with complications) $19 $65 $17 $101
Diabetes (without complications) $119 $350 $88 $558
Hypercholesterolemia (with complications) $2 $0 $0 $0
Hypercholesterolemia (without complications) $66 $186 $32 $284
Hypertension (with complications) $2 $47 $19 $68
Hypertension (without complications) $109 $348 $62 $519
Ischemic Heart Disease $9 $34 $0 $42
Osteoporosis $11 $60 $0 $72
Stroke $0 $30 $0 $19
None $4,257 $12,747 $2,378 $19,382
Any Condition $1,434 $6,584 $920 $8,938
Total $5,691 $19,331 $3,298 $28,320
25
Annual Value Opportunity - Parents
June 3, 2015
Figure 6c – Parents – Annual Value Opportunity - Commercial Population – Total 2015 Dollars (millions) Parent’s Medical Condition Co-Morbid BH/SUD Total
Arthritis $967 $1,817 $2,784
Asthma $655 $1,036 $1,691
Cancer $260 $288 $548
Chronic Kidney Disease $34 $0 $18
Congestive Heart Failure $245 $358 $603
Chronic Obstructive Pulmonary Disease $171 $302 $473
Chronic Pain $98 $83 $181
Back Pain $139 $374 $514
Headache $27 $18 $45
Diabetes (with complications) $165 $204 $369
Diabetes (without complications) $362 $990 $1,352
Hypercholesterolemia (with complications) $122 $194 $315
Hypercholesterolemia (without complications) $586 $1,655 $2,242
Hypertension (with complications) $136 $289 $426
Hypertension (without complications) $647 $1,490 $2,136
Ischemic Heart Disease $90 $156 $246
Osteoporosis $31 $70 $101
Stroke $6 $61 $68
None $1,138 $4,240 $5,378
Any Condition $2,311 $5,266 $7,577
Total $3,450 $9,505 $12,955
26
Annual Potential Savings Projection
June 3, 2015
Figure 7: Average Annual Cost Savings and Impact Through Effective Integration – 2015 Totals (All Costs in Millions)
Payer Type Member Months Total Claims Value
Opportunity Cost Impact of
Integration
Child 0-5 161,191,635 $36,734 $3,288 $296 - $526
Child 6-12 212,009,339 $34,426 $6,004 $540 - $961
Child 13-18 188,129,569 $46,947 $8,883 $799 - $1,421
Child 19+ 143,135,251 $39,111 $11,207 $1,009 - $1,793
Child Total 704,465,793 $157,218 $28,320 $2,549 - $4,531
Parent 621,885,472 $312,710 $12,955 $1,166 - $2,073
Total 1,326,351,265 $469,929 $41,275 $3,715 - $6,604
27
The Colorado SIM Opportunity
$65 million award
4-year program, 1 ramp up year, 3 test years
Targeting 80% of Coloradans
CMS wants an ROI
CMS wants sustainability
CMS wants portability
CMMI investment of $1 billion annually is “cheap” compared to the costs of Medicare/Medicaid of $2 billion every day
Payment reform is a MUST
The Triple Aim and the 3-legged stool
June 3, 2015
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Payment Model Reform Ideas
Primary Care Capitation, including primary physical and behavioral healthcare services with care coordination and management
Cap rates must be population-specific and risk adjusted Options in Cap Rate for the addition of different levels of
behavioral service responsibilities Variations between urban, rural and frontier areas Risk Sharing or Gain Sharing of non-primary care services Requires setting risk adjusted targets PMPM for different
member populations (commercial, Medicaid, Medicare) for IP facility, OP facility, other physician specialists, Rx and all other services.
