MANAGED CARE IS NOT ONLY
ABOUT CONTAINING COSTS
GERALDINE BARTLETT
Medical
Scheme
FINANCIALS
Medical
Scheme
Financials
Health of
member
Financials
Health
Where does Managed CARE
come in?
What is Managed Care?
hospital utilisation
management
pre-authorisations
drug utilisation review
(DUR)
risk sharing and risk
transfer arrangements
fee arrangements
with providers
baskets of care
disease management
programmes
co-payments
case management
preferred providers & DSPs
formularies
capitation
provider
profiling
predictive modelling
gate-keeping
second opinions
Managed Care
• Broad and varied strategies and tools
• Involves interventions by the MCO
Managed
care
interventions
Costs
Care
What should be happening in
Managed Care?
What do we do?
What should we also
be doing?
Cost savings
Care management
Financial information
Clinical information
Provider interventions
Involve patient (DM)
Report on activities and
costs
Report on member health
• What is your MCO doing to manage the health
of your members?
• What is your MCO measuring re the health of
your members?
• What do you know about the health of your
members?
• What types of reports should you be asking
for?
The Health Continuum
Wellness
Illness
Do you know ?
•
•
•
•
•
How many members have chronic illnesses?
What chronic illnesses?
How many are receiving quality care?
What is being done to improve care?
What are the outcomes?
Chronic condition prevalence
Are these members receiving
quality care?
Measuring Care
Donabedian Model
Structure
Process
Outcome
Diabetes - measuring care (process)
Necessary
monitoring
% of patients at first measure
HbA1c
Lipogram
Blood pressure
Renal function
21
54
65
53
Eye examination
Podiatrist
26
38
Case study : Diabetes Disease Management Programme
Diabetes - measuring care
Necessary
monitoring
% of patients
At first
measure
At current
measure
%
improvement
HbA1c
21
75
257
Lipogram
54
87
61
Blood pressure
65
85
31
Renal function
53
85
60
Eye examination
26
56
115
Podiatrist
38
60
58
Case study : Diabetes Disease Management
Programme
% of diabetic patients having HbA1c test
80
70
60
50
% of diabetic
40
beneficiaries
30
20
10
0
Jan-13
Apr-13
Jul-13
Oct-13
Jan-14
Jan 2013 - July 2014
Case study: Diabetes Disease Management Programme
Apr-14
Jul-14
But ….is their chronic condition
well controlled?
Benefits of Good Control
Measures
Benefit
Blood sugar
(including HbA1c)
Per 1% reduction in
HbA1c
 37% reduction in complications e.g.
amputations, blindness, kidney damage
 16% reduction in heart attacks
 21% reduction in diabetes-linked deaths
Blood Pressure
 51% reduction in major cardiovascular
events e.g. heart attacks and strokes.
 32% reduction in diabetes-linked deaths
Lipids (LDL)
 55% reduction in major cardiovascular
events e.g. heart attacks and strokes
 48% reduction in deaths
Ref: SEMDSA Guidelines on Management of Type 2 Diabetes 2012
South African Dyslipidaemia Guidelines Consensus statement 2012
South African Hypertension Guideline 2011
Measures
Targets
HbA1c
•Young, low risk, newly diagnosed <6.5%
•Majority of patients < 7%
•Elderly, frail, high risk, CVD < 7.5%
Lipids- LDL
•Low-med risk <3mmol/l
•High risk <2.5mmol/l
•Very high risk <1.8mmol/l
Blood pressure
•All stages < 140/90mmHg
•High risk <130/80mmHg
SEMDSA Guidelines on Management of Type 2 Diabetes 2012
Diabetes - measuring care
Measure
% of patients “controlled”
(within target)
At first
At current
measure
measure
%
improvement
HbA1c
41
79
93
Lipids
38
64
68
Blood pressure
67
89
33
Case study: Diabetes Disease Management Programme
HbA1c within acceptable levels
90
80
70
60
% of diabetic 50
beneficiaries 40
30
20
10
0
Jan-13
Jul-13
Jan-14
Jan 2013 - July 2014
Jul-14
Diabetes- Improving Outcomes
Hospital admissions
Pre- DM
programme
Current
% improvement
5.3%*
0.9%
83%
* Per annum
Asthma
Number of patients using medicines
correctly
At first measure
At current measure
59%
82%
GINA: Update 2014
Asthma – Health status
Asthma control
At first
measure
At current
measure
Controlled
52%
79%
Partially controlled
33%
15%
Uncontrolled
15%
6%
Ref: GINA Update 2014
Asthma- Improving Outcomes
Hospital admissions
Pre-DM
programme
Current
% Improvement
5.1%
0.2%
88%
Case study: Asthma Disease Management Programme
HIV – Health status
CD4 Ranges
% of HIV
patients
Stage 1
>500-600 cells/ml
42
Stage 2
350-500 cells/ml
38
Stage 3
200-350 cells/ml
12
Stage 4
< 200 cells/ml
8
Stage (CD4)
WHO Consolidated guidelines on use of antiretroviral drugs
for treating and preventing HIV infection. June 2013
? Are these patients having
• Viral load tests
• CD4 counts
HIV – Health status
Status
2nd Q 2014
Improved
43%
Stable
49%
Regressed / deteriorated
8%
Ref: HIV Disease Management Programme
What do you know about
hospital admissions?
How many hospital admissions
are preventable?
4.5%
4.0%
3.5%
3.0%
2.5%
% OF HOSPITAL
ADMISSIONS 2.0%
1.5%
2012
1.0%
2013
0.5%
0.0%
TYPES OF ADMISSIONS
Prevention and Screening
• Flu vaccines
• Pneumococcal vaccines
• Mammograms
• Cervical cytology
• HIV screening
• Cholesterol screening
• Glaucoma screening
• Colorectal cancer screening
• Managed Care is not only about cost savings
• Managed Care is also about CARE - members’ health
• MCO’s should be measuring costs and care
• MCO’s should be reporting on members’ health/care
Every Board of Trustees should have at least one
person who has a medical background.
THANK YOU