Understanding and Using the CMMI and Actuarial Cost & - - PowerPoint PPT Presentation

Understanding and Using the CMMI and Actuarial Cost & Utilization Reports

Katie Matthews, ASA, MAAA Steve Melek, FSA, MAAA

March 7, 2019

Objectives

• 1. Gain understanding of and learn how to monitor the CMMI cost and utilization metrics.
• 2. Gain understanding of and learn how to monitor actuarial cost and utilization metrics.
• 3. Learn how to identify what is “Going Well” or “Not so Much” financially.

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Reports Overview

Why are these reports important?

• What is going on outside the practice?
• How do costs and use of services change over time?

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What detail is included?

Each report contains information split by the following level of detail:

• Practice compared to SIM aggregate cohorts (Family, Pediatric, or Adult)
• Baseline Year in total and by quarter
• Program Years-to-date and by quarter
• By Line of Business (Commercial, Medicaid, Medicare) and in total
• Risk Adjustment Scores Included

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Which patients are represented for each practice?

• CIVHC performs attribution
• Patients are assigned to a single primary care provider where they had the

most visits in recent years

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Attribution

CMMI Cost & Utilization Reports

What detail is included?

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CMMI Cost & Utilization Reports

Overview of CMMI Reports: Nine Metrics

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Out-of-pocket Expenditures for Consumers Total Cost of Care PMPM Admissions Emergency Dept. Rate Readmissions Follow-up after Hospitalization for Mental Illness

Physical Behavioral

Emergency Dept. Rate Admissions Readmissions

Actuarial Cost & Utilization Reports

Table 1a - Baseline Total Allowed Cost PMPM by Service Category

Sample SIM Practice Site 2015 Average Risk Scores:

See "Risk Adjustment" page for more information

Commercial 1.732 1.079 Medicaid 2.545 1.323 Medicare 2.012 1.678 Sample SIM Practice Site Comparison - SIM Family PCP Practices Combined Baseline (2015) Baseline (2015) Service Categories Q1 Q2 Q3 Q4 Total Q1 Q2 Q3 Q4 Total All Other Services $22.68 $21.83 $24.71 $22.83 $23.01 $53.25 $54.27 $54.56 $52.88 $53.74 Ambulance $31.02 $24.05 $24.83 $18.38 $24.55 $5.68 $5.43 $5.77 $5.27 $5.54 Diagnostic Imaging/X-ray $15.61 $18.69 $13.42 $10.18 $14.47 $8.99 $9.07 $8.99 $8.76 $8.95 Dialysis Procedures $0.11 $0.41 $0.09 $0.09 $0.17 $0.71 $0.67 $0.68 $0.67 $0.68 Durable Medical Equipment/Prosthetics $29.86 $32.31 $32.91 $27.35 $30.60 $16.78 $16.69 $16.51 $16.70 $16.67 Emergency Services $24.50 $23.05 $27.39 $23.78 $24.68 $26.73 $26.18 $27.76 $26.30 $26.74 Home Health Care $1.18 $0.55 $0.91 $0.71 $0.84 $8.39 $8.65 $9.09 $9.07 $8.80 Hospice $4.73 $5.23 $6.22 $7.39 $5.89 $3.21 $4.06 $4.38 $4.73 $4.10 Inpatient Hospital – Behavioral $0.21 $5.60 $13.95 $0.68 $5.10 $1.62 $2.24 $1.89 $1.43 $1.80 Inpatient Hospital – Physical $310.38 $294.90 $287.73 $276.13 $292.25 $101.15 $89.57 $96.92 $89.85 $94.34 Laboratory Services $8.84 $11.77 $8.15 $9.21 $9.50 $7.82 $8.10 $8.23 $7.88 $8.01 Long Term Care $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Outpatient Hospital – Behavioral $0.54 $0.24 $0.08 $0.08 $0.24 $0.55 $0.64 $0.57 $0.91 $0.67 Outpatient Hospital – Physical $503.79 $432.45 $442.00 $394.48 $443.03 $201.32 $203.27 $201.50 $198.45 $201.12

What detail is included?

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Actuarial Cost & Utilization Reports

Overview of Actuarial Reports: Three Metrics

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Allowed Cost PMPM Utilization per 1,000 Unit Cost

Overview of Actuarial Reports: Service Categories

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Service Categories All Other Services Ambulance Diagnostic Imaging / X-Ray Dialysis Procedures Durable Medical Equipment / Prosthetics Emergency Services Home Health Care Hospice Inpatient Hospital – Behavioral Inpatient Hospital – Physical Service Categories (Cont.) Laboratory Services Long Term Care Outpatient Hospital – Behavioral Outpatient Hospital – Physical Prescription Drugs – Behavioral Prescription Drugs – Physical Professional Primary Care – Physical Professional Specialty Care – Behavioral Professional Specialty Care – Physical Skilled Nursing Facility

How to Use Actuarial Reports

• Track performance over time
• Review which types of services show

increasing/decreasing costs

• Compare individual practice results to SIM

family / pediatric / adult practice results

• Risk scores shown by line of business
• Aggregate SIM report is also produced
• Inform cost projections, cost savings, ROI

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SIM PCP Practices Combined Model Test Year 1 (2016) Service Categories Q1 Q2 Total All Other Services $54.15 $53.93 $54.05 Ambulance $2.35 $2.06 $2.21 Diagnostic Imaging/X-ray $3.82 $3.74 $3.78 Dialysis Procedures $0.07 $0.09 $0.08 Durable Medical Equipment/Prosthetics $9.50 $10.06 $9.78 Emergency Services $6.51 $5.84 $6.18 Home Health Care $10.31 $10.57 $10.44 Hospice $0.25 $0.21 $0.23 Inpatient Hospital – Behavioral $0.68 $0.67 $0.68 Inpatient Hospital – Physical $45.85 $36.35 $41.14 Laboratory Services $4.06 $3.79 $3.93 Long Term Care $0.00 $0.00 $0.00 Outpatient Hospital – Behavioral $0.57 $0.52 $0.54 Outpatient Hospital – Physical $109.24 $104.43 $106.86 Prescription Drugs – Behavioral $16.52 $16.76 $16.64 Prescription Drugs – Physical $55.30 $54.99 $55.14 Professional Primary Care – Physical $25.32 $22.35 $23.85 Professional Specialty Care – Behavioral $6.49 $6.46 $6.47 Professional Specialty Care – Physical $13.63 $12.79 $13.21 Skilled Nursing Facility $0.12 $0.20 $0.16 Total $364.73 $345.82 $355.36 Total Member Months 685,467 673,027 1,358,494 Total Allowed Costs $250,013,261 $232,743,020 $482,756,281

Proposed Cost Savings & ROI

Proposed ROI through 3-Year SIM Program

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Cost Savings Investment ROI $126,587,853 $65,000,000 1.95 Cost Savings Investment ROI $126,587,853 $86,928,656 1.46

Assumed Grant Amount: Actual Grant Amount:

Cost Savings Assumptions

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Utilization & Cost Reductions Utilization & Cost Increases – Inpatient Physical – Inpatient Behavioral – Emergency Services – Ambulance – Skilled Nursing Facility – Professional Physical – Professional Behavioral – Diagnostic Testing – Imaging / Labs – Prescription Drugs

• Projected Savings: $17.3M (yr. 1), $42.2M (yr. 2), $67.1M (yr. 3)
• Savings translates to about $1.90 PMPM

Thank you

Katie Matthews, ASA, MAAA Katie.Matthews@milliman.com Steve Melek, FSA, MAAA Steve.Melek@milliman.com