An Intensive Medical Home for Patients with Chronic Disease - - PowerPoint PPT Presentation

An Intensive Medical Home for Patients with Chronic Disease

Presented to the National Academy of Medicine’s Value Incentives and Systems Innovation Collaborative meeting December 18th, 2017 Lawrence R. Kosinski, MD, MBA, AGAF, FACG

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Why Crohn’s Disease?

A “High Beta” Illness with a Significant Opportunity to Bend the Cost Curve Payer provided us with claims

• Medical and pharmacy claims on 21,000 patients with Crohn’s disease during 2010-2011
• Average cost of Crohn’s disease: $24,000 per patient per year

Expense Breakdown

• > 50% of all expenses incurred were for hospital inpatient services
• 17% Hospitalization Rate due to high complication rate
• Biologics account for a growing % of total expenditures
• Physician payments represent < 4% of overall costs

Patient Engagement

• Over 2/3 of patients hospitalized for a serious complication did not have any physician interaction in

the 30 days prior to inpatient admission

• Deterioration in symptomatology often unrecognized by patients
• A Sonar System is needed to engage patients between face to face visits

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Project Sonar Pilot - 2013

Physicians

• CDS Tools
• Guidelines
• Risk

Assessments Patients

• Portal-based

Tools

• Nurse Care

Manager Data Data

• Assessments
• Order Sets
• Alerts
• Guidelines
• Reports
• Algorithms

50 Crohn’s patients

• Not randomly selected
• No particular phenotype

CDS Tools Deployed

• Based on AGA CDCP
• Risk Assessments Performed

End Points

• Hospitalization Rate
• ER Visits

Results

• Hospitalization Rate cut by >50%
• ER Visits cut by > 50%

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Project Sonar Timeline

2012 2013 2014 2015

Jan 2012

Began meeting with BCBSIL to obtain cost data on Crohn’s

May 2012

Received large database from BCBSIL with cost data on 21,000 patients

July 2012

Began developing CDS tools and patient engagement tools

Jan 2013

Deployed Project Sonar on 50 LK patients

Mar 2013

Presented concept

• f Project Sonar to

BCBSIL

Data Analysis Jan 2014

Early Data showing decrease in hospitalization

Oct 2013

Meeting at BCBSIL to discuss structure and data

Feb 2014

LOI signed between BCBSIL and IGG

Apr 2014

Final Agreement signed with BCBS

Mar 2014

Meeting with Takeda to discuss data

Sep 2014

Final patient attribution list provided Patient Enrollment

Dec 2014

Go live on financial shared savings period

Dec 2014

Financial Data available

• n patients

AGA Crohn’s Disease Care Pathway Aug 2014

AGA Crohn’s Dis Care Pathway published

Project Sonar Testing Live June 2015

Agreement signed with Takeda and Xcenda to validate platform

June 2015

SonarMD Web APP/Platform Deployed

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Practice and SonarMD receive Attribution List

Practice receives Payment

Practice receives PMPM Payment

SonarMD receives monthly claims data and provides Data Analytics to Practices

Attribution Enrollment Hovering Data Analytics

Patient Attribution

The payer attributes the patient with the chronic disease The practice engages the patient

• Explains the program
• Schedules Supervisit with Nurse

Care Manager

• May schedule concurrent provider

visit if indicated

• BCBS Provides Claims Data on each

patient quarterly

Patient Enrollment

The patient undergoes an enrollment visit which includes:

• Identification of Goals, Barriers
• Depression Screen
• Nutritional Assessment
• Action Plan
• Consent Forms
• Signoff by all

Enrollment in SonarMD Platform

• Initial Manual Ping
• Initial Sonar Score
• Risk Assessment

Patient Hovering

Patient receives text message with secure hyperlink Patient completes disease specific questionnaire Sonar Score is calculated by platform Immediate feedback is provided to the patient Sonar Score is sent to NCM NCM interprets score based upon algorithm NCM communicates with provider if necessary

Data Analysis

Payer provides quarterly claims data to SonarMD SonarMD provides performance reports to practice

• Sonar Ping response rate
• Average Sonar Score by practice,

provider and NCM

• Average Sonar Slope by practice,

provider and NCM

• Cost Analysis

The SonarMD Process

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Risk Assessment

0.5 1 1.5 2 2.5 3 Inf Burden Risk ESR Comorbidity Risk Perianal Abcess Inf Burden Risk Localized Tenderness Dis Burden Risk Perianal Disease Dis Burden Risk Ulcers Inf Burden Risk Cutaneous Signs Inf Burden Risk Fever Inf Burden GI Bleeding Comorbidity Risk Abcess Inf Burden Risk Anemia Dis Burden Risk Stricturing Comorbidity Risk Prior Surgery Comorbidity Risk Advanced Medical Therapy

Risk Factors

Cost Factor

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Web-based Patient Engagement Tools

Crohn’s Disease Activity Index (CDAI) CDAI = Sum(2S+5P+7G+20ΣC+30D)* Algorithm for automated responses drives behavior

What patients tell you (subjective) is different from what really happens (objective) reporting Portal response rate 27% and application response rate 80%

*S = number of liquid or soft stools each day for 7 days; P = abdominal pain (graded from 0–3 on severity) each day for 7 days; G = general well being, subjectively assessed from 0 (well) to 4 (terrible) each day for 7 days; C = presence of complications, 1 point each for each set of complications; D = taking Lomotil or opiates for diarrhea.

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Project Sonar: Process Overview

Develop the Algorithm Develop Predictive Analytics Assess the Risks Manage the Care Analyze the Payer Data

Project Sonar

Engage the Patient

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Change in Crohn’s-related Normalized Payments From Baseline (Digestive Disease Week, May 2016)

• 9.87%
• 57.14%
• 53.28%

8.97%

• 24.50%
• 70%
• 60%
• 50%
• 40%
• 30%
• 20%
• 10%

0% 10% 20%

Percentage Change From Baseline

Total Inpatient Emergency Department Infusable Biologics Injectable Biologics

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Enhanced Patient Engagement = Cost Savings

“To date, we see medical savings trending at $6,000 for each “pinger”—patients using the technology—compared with other patients. This rate has resulted in almost $500,000 in savings for the 81 pingers in the initial program.” HFMA Journal February 2017: Care Not Just for Primary Care Practices See more at: http://www.hfma.org/Leadership/Share_Your_Story_Blog/2017/February/Value-B ased Care Not Just for Primary Care Practices

All Services Total Control Study Pingers Nonpingers Savings against Control Savings % Patients 1049 864 185 111 74 Inpatient Cost 1,476,937.77 $ 1,261,079.67 $ 215,858.10 $ 77,949.06 $ 137,909.04 $ Inpatient Cost/PT 1,407.95 $ 1,459.58 $ 1,166.80 $ 702.24 $ 1,863.64 $ (757.34) $

• 52%

Total Outpatient Cost 6,096,846.84 $ 5,073,329.16 $ 881,270.68 $ 517,382.29 $ 500,344.39 $ OPT Cost per patient 5,812.06 $ 5,871.91 $ 4,763.63 $ 4,661.10 $ 6,761.41 $ (1,210.81) $

• 21%

Total Savings 7,331.49 $ (1,968.15) $

• 27%

Comparison against a Control Group

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Ping Response Rate Drives Cost Savings

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Performance Update: HCSC Data Results: Comparison against Matched Controls Medicare Normalized Data

Study Matched Control Savings

Metrics

2016 2016

Patients Count 185 864 % of Male 47.6% 45.0% Patient Age 46 46 Concurrent Risk Score, First Quarter 2016 2.868 2.703 Concurrent Risk Score, Whole Year 2016 2.635 2.925 Crohn's Related Services Inpatient Cost $94,122 $887,381 Inpatient Cost/PT $509 $1,027 ($518.29) Total Outpatient Cost $358,813 $2,209,751 Outpatient Cost/PT $1,940 $2,558 ($618.05)

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Patient Experience (TS)

43 year old female with Crohn’s Ileocolitis 2011: Stable on medical therapy but desired pregnancy

• 6MP Discontinued at recommendation of OB
• Successful pregnancy in 2012

2013: Placed on Pilot of Project Sonar August 2014: Disease Flare – Detected by Rising Sonar Scores

• Patient seen in office
• Flexible Sigmoidoscopy Performed – Active Colitis

Diagnosed

• Medications adjusted – Medication change – Clinical

Improvement

April 2015:Rising Sonar Score/Persistent symptoms

• Fe Def Anemia/Iron Infusions added
• Biologic initiated – Humira

June 2015: Poor response to Humira

• Dose increased to weekly
• Skin Rash on hands – side effect of Humira

Sept 2015 Persistently high Sonar Scores

• Humira discontinued
• Entyvio started

Stabilized Sonar Scores

• Flex Sig April 2016 – endoscopic improvement

No hospitalization or ER Visit

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PTAC Update

Announcement: The Physician-Focused Payment Model Technical Advisory Committee (PTAC) has completed its two-day public meeting to deliberate and vote on three proposals for physician-focused payment models. The full Committee voted to make the following recommendations to the Secretary of the Department of Health and Human Services (HHS):

• Project Sonar submitted by the Illinois Gastroenterology Group and SonarMD, LLC: recommend

for limited-scale testing

• The COPD and Asthma Monitoring Project (CAMP) submitted by Pulmonary Medicine, Infectious

Disease and Critical Care Consultants Medical Group Inc. (PMA): do not recommend

• The ACS-Brandeis Advanced APM submitted by the American College of Surgeons: recommend

for limited scale testing The next step is for PTAC to draft its report to the Secretary transmitting its recommendations and rationales for those recommendations. The Secretary will post his response to PTAC’s recommendations

• n the CMS website.

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Aligning the Incentives

Project Sonar

Patient

Payer

Provider

Improved Symptoms Less loss work/school Fewer complications Improved overall wellbeing Enters the Value Space Generates more revenue Improves Patient Care Becomes part of the solution Controls Cost/Risk Partners with Providers Bonds with Patients Differentiates from the competition

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Lawrence R. Kosinski, MD, MBA lkosinski@sonarmd.com (847) 370-8878