Data Ja Jam May 2017 Understanding Your Population with the - - PowerPoint PPT Presentation

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Data Ja Jam May 2017 Understanding Your Population with the

Medicaid Utilization: Services and Costs Report

Scott Wetzler, PhD Montefiore Medical Center Wednesday, May 31, 2017

CMS Change Package: Primary and Secondary Drivers

Patient and Family- Centered Care Design 1.1 Patient & family engagement 1.2 Team-based relationships 1.3 Population management 1.4 Practice as a community partner 1.5 Coordinated care delivery 1.6 Organized, evidence-based care 1.7 Enhanced access Continuous, Data- Driven Quality Improvement 2.1 Engaged and committed leadership 2.2 QI strategy supporting a culture of quality and safety 2.3 Transparent measurement and monitoring 2.4 Optimal use of HIT Sustainable Business Operations 3.1 Strategic use of practice revenue 3.2 Staff vitality and joy in work 3.3 Capability to analyze and document value 3.4 Efficiency of operation

President and CEO University Behavioral Associates

Scott Wetzler, PhD

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Data Jam Objectives

By the end of this session, participants will :

• 1. Understand how their utilization reports are generated
• 2. Know how to analyze a sample Services & Cost Report
• 3. Be able to evaluate reports generated from different patient

populations

• 4. Begin to integrate report elements into their transformation plan

for value based payment contracting

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Medicaid Data Warehouse (MDW)

• New York State Department of Health stores all claims submitted to

Medicaid in their Medicaid Data Warehouse (MDW)

• MMC has a Data Exchange Agreement for the Care Transitions Network to:
• Access Medicaid claims of members served by Network enrollees
• Aggregate all claims for an organization’s population
• Classify claims into service categories to create reports illustrating the service

utilization and cost patterns of an organization’s population

• Distribute reports to enrolled organizations to inform and support risk contracting
• Note:
• Organization or provider NPI may be used to identify your population
• Due to the time lag inherent in claims data, each year of data is generated with a 3-

month run-out to improve completeness and maximize comparability

• Completion factor needed to fully understand total costs

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Report Structure

I. Population Overview

• Number of members, months of service, health plan information

II. Service Categories, Subcategories, and Associated Cost Totals

• III. Cost Analysis in PMPM (“per member per month”)
• In organization vs. out of organization (excluding pharmacy & case management)
• Medical vs. behavioral (excluding pharmacy & case management)
• By aid category (HARP vs. SSI vs. TANF/SN populations)

*Each section includes a two year look-back

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Outpatient

• Medical (PCP)
• Medical (specialty)
• Mental health
• Alcohol & opiate dependence
• Hospital-based outpatient

services

Hospitalizations

• Medical
• Mental health
• Drug & alcohol

Pharmacy ER Visits

• Medical
• Behavioral health

Additional Services

• Home health
• Case management
• HCBS
• Nursing facility
• Transportation
• Test, labs, x-rays
• Durable medical equipment
• Miscellaneous

Medicaid Utilization: Services & Cost

Care Transitions Network

Montefiore Psychiatry Clinics: Glebe, Moses, Wakefield Population 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14 Adult Members with Utilization1 5177 4976 4746 Member Months Total 61421 59498 56854 Dual Eligible Members with Medicare 724 711 713 HARP 2061 2039 2007 SSI 1624 1584 1557 TANF/SN 1492 1353 1182 Health Plan Population2 8/1/15 - 7/31/16 HealthFirst 1535 (29%) Fee For Service3 1257 (24%) Affinity 655 (12%) Fidelis 545 (10%) MetroPlus 393 (7%) Other Health Plans 906 (17%) Member Outpatient Behavioral Health Visit Count 8/1/15 - 7/31/16 1-2 Visits 517 (12%) 3-5 Visits 899 (20%) 6-10 Visits 1357 (30%) 11 or More Visits 1679 (38%)

Section (I) Population Overview

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Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14 OUTPATIENT SERVICES Medical - PCP4 Visits Per 1000 Members 11472 9148 11185 Total Cost5 $5,833,388 (7%) $4,514,226 (6%) $5,594,729 (7%) Medical - Specialty Visits Per 1000 Members 4255 4960 4562 Total Cost5 $3,508,147 (4%) $3,571,521 (5%) $2,759,128 (4%) Mental Health Visits Per 1000 Members 4547 7112 5558 Total Cost5 $3,243,109 (4%) $4,886,265 (6%) $3,823,376 (5%) Alcohol & Opiates Dependence Treatment Visits Per 1000 Members 7068 11337 10551 Total Cost5 $1,935,252 (2%) $2,985,966 (4%) $2,318,054 (3%) Hospital based Outpatient Services Total Cost

(Injection Therapy, Diagnostics, Other Imaging)

$1,024,062 (1%) $698,521 (1%) $593,904 (1%) PMPM6 (%) $253 (20%) $280 (22%) $265 (23%) OUTPATIENT TOTAL $15,543,958 $16,656,499 $15,089,189

OUTPATIENT

Section (II) Service Categories

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11%

Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14 HOSPITALIZATION Medical Average LOS 5 5 5 Days Per 1000 Members 958 945 903 Discharge Per 1000 Members 190 172 172 Total Cost5 $7,465,477 $6,826,430 $5,973,079 Mental Health Average LOS 15 15 17 Days Per 1000 Members 1216 1193 1298 Discharge Per 1000 Members 81 81 77 Total Cost5 $4,261,143 $4,508,504 $4,727,604 Drug and Alcohol (D&A) Average LOS 7 6 7 Days Per 1000 Members 178 260 304 Discharge Per 1000 Members 27 42 43 Total Cost5 $464,457 $562,160 $641,010 PMPM6 (%) $198 (16%) $200 (16%) $199 (17%) HOSPITALIZATION TOTAL $12,191,077 $11,897,094 $11,341,693

Section (II) Service Categories

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HOSPITALIZATIONS

Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14 ER VISITS ER Visits ER Visits Per 1000 Members 779 409 495 Medical Percentage7 85% 80% 82% Behavioral Health Percentage 15% 20% 18% PMPM6 (%) $16 (1%) $7 (1%) $8 (1%) ER TOTAL $998,062 $400,544 $438,143 Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14 PHARMACY Pharmacy Prescriptions Per 1000 Members 50739 49710 48773 PMPM6 (%) $325 (25%) $349 (28%) $303 (26%) PHARMACY TOTAL $19,949,566 $20,784,747 $17,227,201

Section (II) Service Categories

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PHARMACY ER VISITS

Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14 ADDITIONAL SERVICES Home Health8 PMPM (%) $224 (18%) $188 (15%) $143 (12%) Total Cost5 $13,746,368 $11,162,455 $8,130,854 Case Management (Health Home) PMPM (%) $69 (5%) $61 (5%) $47 (4%) Total Cost5 $4,224,770 $3,641,158 $2,696,710 Mental Health Rehabilitation Services - HCBS PMPM (%) $26 (2%) $24 (2%) $24 (2%) Total Cost5 $1,624,038 $1,416,672 $1,381,895 Nursing Facility (SNF) PMPM (%) $9 (1%) $5 (0%) $6 (1%) Total Cost5 $533,660 $267,749 $340,931 Transportation PMPM (%) $36 (3%) $29 (2%) $24 (2%) Total Cost5 $2,218,361 $1,753,998 $1,389,435 Test, Labs, X-Rays PMPM (%) $30 (2%) $20 (2%) $20 (2%) Total Cost5 $1,815,669 $1,166,719 $1,134,368 Durable Medical Equipment (DME) PMPM (%) $10 (1%) $9 (1%) $10 (1%) Total Cost5 $625,437 $563,505 $592,209 Miscellaneous PMPM (%) $82 (6%) $87 (7%) $97 (8%) Total Cost5 $5,010,179 $5,202,975 $5,489,414 ADDITIONAL SERVICES TOTAL $29,798,482 $25,175,230 $21,155,818

ADDITIONAL SERVICES

Section (II) Service Categories

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Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14 TOTAL PMPM6 (%) Total PMPM $1,278 $1,259 $1,148 NON PHARMACY PMPM6 (%) Montefiore PMPM $300 (34%) $254 (30%) $210 (26%) Outside of Montefiore PMPM $584 (66%) $595 (70%) $587 (74%) PMPM Total $884 $849 $797 Medical PMPM Total $611 (69%) $544 (64%) $492 (62%) Behavioral Health PMPM Total $273 (31%) $304 (36%) $306 (38%) HARP PMPM9 $1,568 $1,625 $1,506 SSI PMPM9 $1,220 $1,189 $1,038 TANF/SN PMPM

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$929 $783 $679 Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14 UTILIZATION TOTAL COST UTILIZATION TOTAL $78,481,144 $74,914,114 $65,252,044 PMPM TOTAL6 $1,278 $1,259 $1,148

TOTAL COST

Section (II) Service Categories

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Section (III) Cost Analysis

Cost Trends using Look-Back Periods

13 $265 $280 $253 $199 $200 $198 $303 $349 $325 $8 $7 $16 $372 $423 $485

$1148 $1259 $1278

$- $200 $400 $600 $800 $1,000 $1,200 $1,400 $1,600 2 Year Look-back 1 Year Look-back Target Year Column1 Additional Services ER Visits Pharmacy Hospitalization Outpatient

* Increasing costs may due to population selection (we selected people in care during target year, and they may not have been in treatment in prior years)

Health Care Cost Comparisons

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Medical Services 24% Mental & Behavioral Health Services 13% Pharmacy 25% Additional Services 38%

OMH Clinics

Total PMPM $1278

Conclusions from Sample Report

• Majority of costs are medical and pharmacy, even though these patients

were identified through attendance at a mental health clinic

• Costs are stable over time
• A high proportion of spending is pharmacy
• Overall expenditures relative to rates (HARP, SSI, etc.)

Elaborations on the MDW report:

• Calculate completion factors for category and total costs (in progress)
• Identify high and frequent users
• Post hoc analyses of population by diagnosis
• Considerations for value contracting (*medical services)

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Comparing Reports Between Populations

Mental Health Clinics Substance Abuse Clinics

Clinic Comparisons

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Article 31: Department of Psychiatry

• Three mental health clinics

licensed by OMH

• Focus on treatment and recovery
• f persons with a mental illness
• Services include:
• outpatient psychiatric evaluation and

treatment

• medical care *primary care offered at
• ne location

Article 32: Division of Substance Abuse

• Three substance abuse clinics

licensed by OASAS

• Focus on treatment and recovery
• f persons with a substance use

disorder

• Services include:
• substance abuse treatment
• medication-assisted opioid treatment
• medical care *primary care on-site
• Hep C & HIV prevalence

*Value labels removed for values <$70 PMPM

$151 $122 $152 $152 $611 $1,022 $325 $258 $485 OASAS OMH 18

Health Care Cost Comparisons (PMPM)

Total PMPM $1278 Total PMPM $2285

Health Care Cost Comparisons

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Medical Services 14% Mental & Behavioral Health Services 30% Pharmacy 45% Additional Services 11%

OASAS Clinics

Total PMPM $2285

Medical Services 24% Mental & Behavioral Health Services 13% Pharmacy 25% Additional Services 38%

OMH Clinics

Total PMPM $1278

Conclusions from Report Comparisons

• Total dollars spent PMPM
• Relative areas of higher spending
• Pharmacy
• Outpatient services for Drug & Alcohol
• Different populations have different patterns of utilization and

different total costs

• Substance use patients have much more total cost
• Increased cost is not driven solely by substance abuse treatment costs

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Key Considerations for Contracting

• High cost areas for greatest impact
• Improving loyalty for medical care as well as behavioral care
• Intervening around medical care as well as behavioral care (Hep C)
• High cost areas differ by population
• Reducing hospitalizations by increasing outpatient engagement

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Questions?

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Thank you!

www.CareTransitionsNetwork.org CareTransitions@TheNationalCouncil.org

The project described was supported by Funding Opportunity Number CMS- 1L1-15-003 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. Disclaimer: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.