Application of Predictive Modeling to
Identify, Stratify, and Triage Members in
Care Management Programs:
A Health Plan Case Study
Soyal Momin, MS, MBA
Sylvia Sherrill, RN, MS
Lelis Welch, RNC, CCM
Judy Slagle, RN, MPA
Terence Shea, PharmD
Steven Coulter, MD
Outline
• Historical View: Case Management at
BCBST
• Concept: Next Generation Care
Management (NGCM)
• Implementation and Evaluation of NGCM
• Enhancements/Improving Process
Efficiency
History
• Identifying Members for Case 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
• Case managers workload
– 103/CM/Month
• DCG implementation validation revealed
missed opportunities for case management
Base Year and Year-2 Risk Profile of Members Referred to Case Management
Commercial Line of Business
7,000
6,170
6,000
Current methodology of identifying members for case
management (Trigger List) seems to be working
5,000
4,543
4,244
4,117
4,124
4,000
3,000
2,683
2,120
2,000
1,000
2,087
1,926
840
0
Risk Level 1 ($0-1K)
Risk Level 2 ($1K-$5K)
Risk Level 3 ($5K-$10K)
Base Year (04/01-03/02)
Risk Level 4 ($10K-$25K)
Year-2 (04/02-03/03)
Risk Level 5 (>25K)
Year-2 Detailed Risk Profile of Members NOT Referred to Case Management
Commercial Line of Business
1000
872
907
900
800
700
600
500
Light Touch
400
303
300
200
88
100
27
24
$60,000-$70,000
$70,000-$9,999,999
0
$25,000-$30,000
$30,000-$40,000
$40,000-$50,000
$50,000-$60,000
Year-2 (04/02-03/03)
Year-2 Case Mix Index of Members NOT Referred to Case Management
Commercial Line of Business
24
22
20
17.04
18
16
14
12
10
6.87
8
6
3.23
4
1.13
2
0.24
0
Risk Level 1 ($0-1K)
Risk Level 2 ($1K-$5K)
Risk Level 3 ($5K-$10K)
Risk Level 4 ($10K-$25K)
Year-2 (04/02-03/03)
Risk Level 5 (>25K)
Next Generation Care Management:
One size does not fit all
Segmentation
% Members
% Cost
Healthy Group
40%
0%
Worried Well
52%
45%
Chronically Ill
7%
30%
Catastrophic
1%
25%
Next Generation Care Management:
Triage Guidelines
Segmentation
DxCG Risk
Level
Management Type
Healthy Group;
Worried Well
1–2
Lifestyle/Health
Counseling
Chronically Ill
3–4
Refer to Care
Coordination Unit
Catastrophic
5
Refer to Catastrophic
Case Management
Lifestyle/Health Counseling
for Healthy and Worried Well:
• Information on disease/condition
– Web resources
– Pamphlets
– Telephonic health library
• Encouragement to take more active
role/accountability
Care Coordination
for Chronically Ill
• Telephonic coordination with members
and their providers
• Ensures appropriate treatments and
pharmaceuticals
• Six different programs included in this
model
Care Coordination Programs
• Pharmacy Care Management
• Emergency Room (ER) Visits
Management
• Centers of Excellence (COE)
• Transition of Care
• Condition Specific Care Coordination
• Disease Management
Care Coordination Program # 1
• Pharmacy Care Management for Specialty
Populations
– Pharmacy Case Management Programs:
•
•
•
•
Hepatitis C
AMI-Beta Blocker
Migraine
Polypharmacy
Care Coordination Program # 2
• Emergency Room (ER) Visits Management
Program
– Monthly report identify ER “frequent flyers”
– Contacted by a nurse with psychiatric
training
– Clinical counseling and guidance
– Discuss options of care with goal to reduce
ER Visits
Care Coordination Program # 3
• Centers of Excellence (COE) Program
– Identify providers based on utilization and quality of
care indicators (CQI using ETGs) and input from
regional staff
•
•
•
•
•
Asthma
Diabetes
CHF
COPD
CAD
– Can be used to refer/steer members to providers
considered COE
Care Coordination Program # 4
• Transition of Care Program
– Formerly known as discharge planning, make
sure members are in appropriate setting for
treatment
– Assist facility, physician, and member with
transition
•
•
•
•
Lower ALOS for per diem admissions
Better outcome for DRG admissions
Reduce re-admissions
Smooth transition of care
Care Coordination Program # 5
• Condition Specific Care Coordination
– Assess and advise program with one time
follow-up
•
•
•
•
•
•
•
CAD
CHF
COPD
Asthma
Diabetes
Hypertension
GI disorders
Care Coordination Program # 6
• Disease Management programs
– Carved out to LifeMasters Supported
SelfCare, Inc.
• CAD
• CHF
• COPD
• Asthma
• Diabetes
Next Generation Care Management:
Catastrophic Case Management
• Directed to members with
–
–
–
–
–
Terminal illness
Major trauma
Cognitive/physical disability
High-risk condition
Complicated care needs
• Systematic process of assessing,
planning, coordinating, implementing,
and evaluation of care
Next Generation Care Management:
Implementation
• MCSource
• Predictive Modeling Using
– DCG
– ETG
• Rolling 12 Months DCG Explanation
Prospective Model
• ETG Cost to Supplement DCG Prediction
Better Understanding of Predictive
Modeling
• Do Predictive models work like a crystal
ball?
• Models do not predict a disease (ICD-9)
• Helps quantify a disease
• Provides early warning for certain
diseases with high future resource
requirements
Example of Predictive Modeling
• Clinical Profile of Member XYZ
• Diagnosed with CHF (Date: 10/01/2002)
• Diagnosed with Diabetes (Date: 10/30/2002)
• Our traditional methods might refer this member for
Case Management (CM) some time in 2003
• DCG/ETG approach will identify this member for CM
in 11/2002 or 12/2002
Next Generation Care Management:
Program Evaluation
• Medication cost avoidance and members’
compliance
– Hepatitis C ($1.5M/Year)
– Beta Blockers post AMI ($1.3M/Year)
– Migraine care management
• Member and provider satisfaction
• CM staff turnover
• Triaging efficiencies
Next Generation Care Management:
Program Evaluation
Total Number of
Members
(04/03 - 03/04)
• Lifestyle/Health Counseling - 1,555
• Care Coordination
- 7,229
• Catastrophic Case Mgmt.
- 13,622
• Number of Cases/CM/Month=76/CM/Month
Next Generation Care Management:
Program Enhancements
• Developed SQL database containing DCG
and ETG information
– Improved processes/workflow
– Easy and continuous access
– Better documentation
Next Generation Care Management:
Program Enhancements
Next Generation Care Management:
Program Enhancements
Conclusions
•
•
•
•
More scientific/standardized approach
Able to touch more lives efficiently
Well accepted by our case managers
NGCM has helped
– streamline our processes
– better manage case managers case load
• Provide “Peace of Mind” to our
members and clients