CHACC
Steve Wegner, MD, JD
Chairman
North Carolina Community Care Network
13 Sep 2012
Shared Savings
vs
Commercial HMO
2
Background
 CCNC
 Primary Care Case Management
 IMPACT
 5% cost 54% : Who are these children and
what can be saved?
 Transitions
3
Readmissions - Medicare
 Causes of readmissions vary across and within states
 Readmission rates are influenced by the local pattern
of hospital utilization
 Four types of readmission (relationship to initial
hospitalization)
 related and unplanned
 related and planned
 unrelated and planned
 unrelated and unplanned
4
Readmissions – Medicare
(cont.)
Factors that lead to readmissions, and potentially
preventable readmissions, for Medicare beneficiaries*
 inadequate relay of information to caregivers
 poor compliance
 inadequate follow-up
 variation in hospital bed supply, and
 medical errors
* Stone J, Hoffman GJ. Medicare Hospital Readmissions: Issues, Policy Options and PPACA,Congressional Research
Service 2010.
5
Care Transitions Intervention
The Four Pillars
Medication
SelfManagement
Dynamic
PatientCentered
Record
Follow-Up
Red Flags
Doctor to Doctor Care Plan
6
Referral
7
Doctor to Doctor Care Plan
8
Other Strategies to Reduce
Readmissions
 Improved discharge planning process
 Patient/family activation
 Telemedicine
 Evidenced based practice/guidelines
 Care Coordination
 Post discharge follow-up visits by a Nurse
Practitioner
9
CCNC
3M™ Health Information System’s Clinical Risk Groups (CRG)
CRG assignment occurs in four phases
Phase 1
Phase 2
Phase 3
Phase 4
• Builds a
profile of a
member’s
past medical
history
based on
claims data
(IP, OP,
physician,
pharmacy)
• Identifies
and ranks
the
member’s
most
significant
chronic
disease(s)
• Assigns the
member to a
risk group
(CRG) with a
severity level
• Includes the
member in
an
aggregated
risk group
(Total of 269
categories)
(uses 9 core
health status
groups such as
catastrophic,
single/moderate
chronic, and
significant
acute)
10
Data
Data
Risk Factors
Model
Team with
Embedded
Case
Managers
Impactable
Interventions
11
Medicaid Claims Data
Limitations:
 Data for services can lag care up to 6 months
 Single hospitalizations can occur over multiple sites
creating data headaches
 Codes (e.g., Hospital & Practice Identifiers) change over
time
 Codes are “gamed” to maximize payments
 Intricacies of data make “simple” changes in analyses
not-so-simple to do
12
Analysis Overview
 Includes children over < 17 years old
 Calendar years 2009 – 2011
 Medicaid claims for ≥ 3 hospitalizations in any 365day period1
 Most frequent Dx group based on all ICD9 codes in all
claims records over 3 years
 Primary Dx = 1st ICD9 on 1st claim
 Special priority assigned for any mention of :
NICU > Cystic fib > Cancer > Sickle cell > Diabetes
1Berry,
JG, Hall, DE, Kuo, DZ et al, Hospital Utilization and Characteristics of Patients Experiencing Recurrent
Readmissions Within Children’s Hopsitals, JAMA. 2011;305(7):682-690.
13
Months from First Admission
NC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
8000
A
d
m
i
s
s
i
o
n
s
7000
6000
No. of admits
in same mo.
5000
6th
5th
4000
4th
3rd
/ 3000
2nd
C 2000
o
u
n 1000
t
0
0
1
2
3
4
5
6
7
8
9
10
11 12
13
14 15
16 17
18 19
20 21
22 23
24
Number of months from first admission (where 0 = month of admission)
14
Most Frequent by Primary Group
NC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Primary
Group
Admits Hosp
No. of No. of
Per
Cost/
Patients Admits Patient Admit
Total
Hospital
Cost
AMC
Costs
Tertiary
Costs
Total Costs
NICU
1226
5323
4.3
13,212
68,597,336
52,643,205
8,322,202
719,768,329
Infection
719
2742
3.8
5,649
15,042,596
10,660,756
1,874,594
202,098,774
Respiratory
380
1661
4.4
5,495
8,885,614
5,929,410
960,270
325,941,082
Hema2
367
2432
6.6
4,617
10,914,435
7,128,787
2,453,326
469,689,617
Cancer
358
2863
8.0
9,873
26,282,035
23,141,230
2,615,672
277,227,177
Neuro
271
1335
4.9
8,689
11,034,530
8,933,634
1,092,355
313,222,627
GI
261
1243
4.8
6,993
8,391,098
6,291,441
1,156,601
166,043,874
Diabetes
211
1052
5.0
4,207
4,425,765
2,157,028
592,103
173,599,724
Kidney
96
528
5.5
6,559
3,049,938
2,728,385
115,762
63,267,472
Endocrine
73
401
5.5
7,163
2,643,083
1,977,415
355,472
90,409,594
Cystic Fibrosis
46
333
7.2
15,367
4,886,648
4,559,167
301,685
33,174,369
Cardiac
49
243
5.0
20,943
5,089,203
3,172,570
63,938
25,908,715
15
Most Frequent by Primary Diagnosis
NC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Primary Diagnosis
Admits Per
No. of Patients
Patient
Cost
Per
Admit
Total
Hospital
Cost
1,226
4.3
13,212
68,597,336
ESOPHAGEAL REFLUX
41
4.0
12,518
1,977,803
EPILEPSY NOS WO INTRACT
MALFUN NEURO DEVICE
GRAG
21
5.8
8,032
955,864
17
4.9
20,391
1,712,867
FOOD/VOMIT PNEUMONITIS
OBSTRUCTIV
HYDROCEPHALUS
17
6.6
15,411
1,710,650
15
3.9
20,931
1,213,969
ACUTE RESPIRATORY FAILURE
UNSPECIFIED ASTHMA, WITH
ACUTE EXACERBATION
ENCOUNTER FOR
ANTINEOPLASTIC
CHEMOTHERAPY
14
3.9
24,464
1,247,654
12
4.8
5,507
313,905
10
8.8
8,846
769,640
HYPOPLAS LEFT HEART SYND
7
5.3
42,277
1,564,255
NICU
Most Frequent by Primary Diagnosis
NC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Primary Diagnosis
Cancer
ENCOUNTER FOR
ANTINEOPLASTIC
CHEMOTHERAPY
ACUTE LYMPHOID LEUKEMIA
W/O MENTION OF ACHIEVED
REMISSION
NEUTROPENIA
Hematological
SICKLE CELL
IMMUNE
THROMBOCYTOPENIC
PURPURA
FACTOR DISEASE
Admits Per
No. of Patients
Patient
Cost
Per
Admit
Total
Hospital
Cost
358
8.0
9,873
26,282,035
184
9.9
8,848
15,041,147
29
5.8
12,792
2,097,943
30
7.8
7,837
1,833,821
367
6.6
4,617
10,914,435
272
7.2
4,298
8,144,444
4
3.5
5,724
80,136
4
7.3
18,652
540,907
Most Frequent by Primary Diagnosis
NC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Admits Per
Patient
Cost
Per
Admit
Total
Hospital
Cost
380
4.4
5,495
8,885,614
ASTHMA
UNSPECIFIED EPISODIC
DISORDER
153
4.3
2,102
1,370,633
8
3.1
7,053
169,283
FOOD/VOMIT PNEUMONITIS
BIPOLAR DISORDER
UNSPECIFIED
8
5.0
13,180
448,114
3
5.3
4,976
79,622
Neurological
271
4.9
8,689
11,034,530
Primary Diagnosis
Respiratory
No. of
Patients
EPILEPSY
MALFUN NEURO DEVICE
GRAG
90
5.0
6,286
2,816,251
16
5.9
15,087
1,357,837
INFANTILE SPASMS WO INTR
10
4.0
7,633
297,693
FOOD/VOMIT PNEUMONITIS
6
7.2
11,267
484,480
CEREBRAL CYSTS
UNSPECIFIED EPISODIC
DISORDER
5
3.4
7,985
135,752
4
3.8
4,729
61,471
Most Frequent by Primary Diagnosis
NC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Primary Diagnosis
Admits Per
No. of Patients
Patient
Cost
Per
Admit
Total
Hospital
Cost
GI
261
4.8
6,993
8,391,098
CONSTIPATION & IMPACTION
26
4.5
4,817
558,733
REG ENTERITIS
12
4.3
8,533
443,702
ESOPHAGEAL REFLUX
21
3.5
2,278
157,198
ACUTE PANCREATITIS
10
4.7
5,183
243,607
EPILEPSY NOS WO INTRACT
5
4.0
5,690
113,792
ESOPHAGEAL STRICTURE
4
5.5
12,237
269,204
PERSISTENT VOMITING
3
4.0
3,350
40,194
INTUSSUSCEPTION
3
3.7
21,520
236,723
HIRSCHSPRUNG'S DISEASE
3
3.7
9,081
99,893
BILIARY ATRESIA
3
8.7
15,300
397,802
Most Frequent by Primary Diagnosis
NC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Primary Diagnosis
Admits Per
No. of Patients
Patient
Cost
Per
Admit
Total
Hospital
Cost
Diabetes
211
5.0
4,207
4,425,766
DIABETES W KETOACIDOSIS &
MELLITUS
86
6.3
2,811
1,515,385
ASTHMA
9
6.1
2,339
128,651
DIABETES UNCOMPL JUVEN
UNSPECIFIED EPISODIC
DISORDER
5
3.0
3,148
44,066
4
4.0
4,374
69,986
ESOPHAGEAL REFLUX
3
3.3
1,913
19,130
Cardiac
49
5.0
20,943
5,089,203
CONGENITAL OTHER
14
5.2
24,927
1,819,662
CONGESTIVE HEART FAILURE
5
3.8
25,847
336,010
PAROX VENTRIC TACHYCARD
CARDIAC DYSRHYTHMIAS
NEC
2
4.5
48,781
439,029
2
5.5
6,344
69,783
AMC Admissions/Costs
NC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Primary
Condition
Total
Hospital
Cost
ECU
Admits
ECU
Costs
Duke
Admits
Duke
Costs
UNC
Admits
UNC
Costs
WFB
Admits WFB Costs
NICU
68,597,336
407
6,566,106
559
12,364,734
689
14,136,120
661
10,147,718
Infection
13,906,960
113
839,951
132
2,985,675
181
2,412,782
166
1,849,145
Respiratory
10,232,347
73
1,000,707
197
2,606,489
113
1,472,998
93
797,697
Hema2
10,925,191
222
925,749
211
1,901,895
111
1,536,395
328
1,305,327
Cancer
26,282,035
305
3,034,428
520
6,539,482
378
4,367,551
546
4,297,371
Neuro
12,944,543
88
846,396
284
2,992,139
213
2,638,879
228
2,136,756
GI
8,900,613
51
289,387
146
1,610,659
237
2,125,127
117
716,120
Diabetes
4,279,750
49
356,800
53
285,879
50
335,930
43
164,429
Kidney
3,420,272
36
191,194
54
355,368
117
1,026,640
82
573,528
Cardiac
7,458,008
22
396,142
109
2,617,977
48
1,125,066
79
1,913,426
Endocrine
2,475,159
10
63,648
20
124,401
93
1,095,216
48
403,600
Cystic Fibrosis
4,886,648
2
7,809
75
2,006,282
135
1,959,353
12
74,060
21
Tertiary Ref Centers - Cost
NC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
Primary
Condition
Total
Hospital
Cost
Wake
Med
Mission CMC NE
Presby
Moses
Cone
Cape Fear New Han
NICU
68,597,336
2,064,948
710,969
2,214,651
392,690
1,333,986
Infection
13,906,960
311,336
486,926
419,128
136,527
254,454
Respiratory
10,232,347
164,954
75,856
246,853
75,244
173,627
Hema2
10,925,191
256,823
86,932
1,059,800
419,930
199,939
Cancer
26,282,035
1,228,097
18,054
1,238,461
18,943
69,374
Neuro
12,944,543
301,456
160,145
433,898
176,864
239,264
GI
8,900,613
286,410
196,305
307,539
86,156
139,734
Diabetes
4,279,750
209,725
52,151
35,013
45,655
77,759
Kidney
3,420,272
14,191
13,370
52,672
6,586
7,294
Cardiac
7,458,008
81,796
35,482
24,034
12,330
11,170
Endocrine
2,475,159
189,692
11,488
7,841
13,455
14,244
Cystic Fibrosis
4,886,648
266,444
11,472
17,901
5,868
22
Repeat Admissions
NC Medicaid, < 17 yr, all General Hospitals, calendar years 2009-2011
30000
Repeat Admissions
25000
Count
20000
15000
10000
5000
0
2nd
3rd
1800
1600
Higher Frequency Repeat
Admissions
1400
1200
Count
(Y-axis has
changed to
show lower
counts)
1000
800
600
400
200
0
4th
5th
6th
7th
8th
9 - 10th
11 to 14th
Admission after initial hospitalization
15 to 16
17 to 19
20 to 39
23
Patients* with Infection as Most Frequent
Primary Diagnosis – continued next slide
Primary
Condition
All Pts
Pts* w
Infection
% with
Infection
Infection
700
534
76%
Cystic_Fibrosis
46
25
54%
NICU
1226
582
47%
Newborn
190
75
39%
Respiratory
406
132
33%
Skin
71
22
31%
Cardiac
92
24
26%
GI
280
72
26%
Injury
50
12
24%
Endocrine
66
14
21%
Neuro
330
69
21%
Kidney
108
20
19%
Musculo_Skel
38
7
18%
Pregnancy
249
34
14%
Hema2
368
45
12%
Diabetes
208
22
11%
Cancer
358
26
7%
MHDD
990
11
1%
24
Integrated Care for Physical
and Emotional Disorders
Patients with a mental health grouping with a
primary medical diagnosis
DISEASE CATEGORY
TOTAL UNIQUE
PATIENTS
HOSPITAL COST
PER ADMIT
AVERAGE NUMBER
OF ADMITS
TOTAL COSTS
CANCER
23
23,924
4.3
1,770,392
ENDOCRINE
42
15,612
6.1
3,980,997
GI
12
11,029
6.2
816,153
HEMATOLOGIC
1
3,138
4.0
12,553
HIV
2
9,038
3.5
63,263
KIDNEY
8
3,575
5.1
146,590
NEURO
45
8,363
4.9
1,856,677
RESP
48
18,564
5.9
5,272,219
SICKLE CELL
9
8,045
8.6
619,474
NICU/PREG
12
13,952
4.8
795,271
202
$13,703
5.5
$15,333,590
25