population health success at the north carolina...

Population Health Success at the North Carolina State Health Plan

April 15, 2015 Janet Cowell, Treasurer, State of North Carolina

Charles Saunders, M.D., Chief Executive Officer, Healthagen

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

Conflict of Interest Janet Cowell and Charles Saunders, MD have no real or apparent conflicts of interest to report

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Learning Objectives 1. Explain how the North Carolina State Health Plan designed a technology-enabled population health and care management strategy that became a national model for improving health and well-being across its membership.

2. Identify the advantages of a diverse outreach strategy leveraged by the North Carolina State Health Plan including its direct impact on care quality, member engagement and costs

3. Best practices for personalized and meaningful outreach efforts

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Benefits Realized for the Value of Health IT

Satisfaction Engaged members are surveyed to assess their satisfaction with population health programs and nurse coach interaction

Treatment and Clinical

Reduction in overall, lifestyle-related risk factors

Electronic Information and Data

Clinical analytics and data give us the ability to stratify and engage our population through high-touch, highly personalized population health efforts

Prevention and Patient Education

Education through various communication channels is key to meeting our clinical and financial goals

Savings The NCSHP has recorded lower than expected net claims payments and net administrative costs

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Who We Are • We serve teachers and local school

personnel, state employees, retirees, current and former lawmakers, state university and community college faculty and staff and their dependents

• We empower members to make healthier lifestyle choices and to become partners in addressing their health care needs

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NC State Health Plan Demographics Total Membership

• 680,000 Medicare/MA, Active, COBRA and Pre-65 Retiree members • 80% are Active, COBRA and Pre-65 Retiree members

Average age is 46 11% use tobacco* 32% are obese*

Members reside in all 100 counties across the state

*Source: NC Behavioral Risk Factors Surveillance Survey 2012

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Areas of focus for today • NCSHP’s Strategic Plan • Member Health and Population Health IT • Financial Status

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48% 51%

1%

More than half of our members have a chronic illness including 1% with a catastrophic illness

Chronic Illness

Healthy/Acute

Catastrophically Ill

% of Total Population

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Source: Segal Report CRG 2013

12%

76%

12%

Chronically ill members account for 76% of annual costs

Chronic Illness

Healthy/Acute

Catastrophically Ill % of Total Claim Cost

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Source: Segal Report CRG 2013

Guiding principles for our strategic plan Mission Improve the health and health care of North Carolina teachers, state employees, retirees and their dependents in a financially sustainable manner, thereby serving as a model to the people of North Carolina for improving their health and well-being.

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Guiding Principles • Improve Affordability

• Improve Members’ Health

• Ensure Access to Quality Care

• Incent Member Engagement

• Promote Health Literacy

• Provide Member Choice

• Maintain Financial Stability

Priority Description Goal Description

Improve members’ health

PCMH Utilization Increase % of members receiving care from a NCQA recognized PCMH

Quality of Care Increase % of members with targeted high prevalence conditions receiving care according to national clinical standards

Worksite Wellness

Increase number of worksites offering worksite wellness

These goals and future targets will lead to: • Healthier and more engaged members • Better managed chronic disease • Members receiving high quality, coordinated care


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Population health programs to meet the population’s diverse needs: • Disease and case management

• Active lifestyle coaching

• 24 hour nurse-line

• Clinical decision support and health opportunity identification

• Patient Centered Medical Home practice support

• Tobacco cessation programs


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Complex Chronic

Major Chronic

Minor Chronic

At Risk

Healthy

High Impact Intensive Outpatient Care Management

Moderate Impact Care Coordination

Lower Impact Wellness & Lifestyle Enhancement

Decision Support


Catastrophic

Population health shifts from a disease focus to a care focus

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Find the right people with the right data Improve members’ health

Data Aggregation

Clinical Alerts Analytics Care Coordination Patient Engagement

Analysis and Intelligence Provider Workflow

Data Integration

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Analyze data against clinical rules and evidence-based medicine

10,000+ Clinical analytic rules

Based on standards from American Heart Association, National Institute of Health, CDC, BMJ, American Academy of Pediatrics, American Diabetes Association, and more

1,453 Care considerations (CCs)

250+ Unique conditions

100+ Care management assessments

200+ Quality measures*

Evidence-based Medicine Claims evaluation based on EBM rules**

Health opportunity identification

Health opportunity communication to patients and providers

Clinically Validated Rules

*ActiveHealth, NQF, PQRS, Meaningful Use, HEDIS, Medicare Stars and 21 measures endorsed by NQF **Rules are reviewed and endorsed by Harvard


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Risk stratification – population level

Healthy At Risk Minor Chronic

Major Chronic

Catastrophic and End of

Life

Preventative care

Isolated lifestyle issues

At risk for diabetes

At risk for CAD

At risk for stroke

At risk for cancer

Pre-hypertension

Overweight

Smoking

Asthma

Hypertension

Obesity

Diabetes

Heart disease

COPD

Cancer

Chronic kidney disease

Late-stage diseases

Long term care

Hospice care

Patients at risk and opportunities to close gaps in care are identified, so resources can be tailored to the unique needs of sub-populations

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Poorly-controlled congestive heart failure

Poly-chronic conditions Frequent/High utilizers Advanced illness

Diabetic - Blind (retinopathy) - End-stage kidney

(nephropathy) Regimen well-titrated

- HbA1c well-controlled (<7.0)

Hypertension - Single medication, marginal

BP control Borderline hyperlipidemia Pre-diabetes

- Metabolic syndrome pattern

Risk stratification – individual level To focus resources, individuals are prioritized by risk and the ability to impact


*Expanded Outreach: High Cost Claimants High ED Utilization High Hospital Utilization

Frequent Ambulance Rider High Number of Prescriptions Cystic Fibrosis

CHF Diabetes Asthma

IVIG

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Platform Technology

Segment • Groups members by

common needs, desires and behaviors

Stratify • Represents the

opportunity to impact clinical outcomes

Wherever the member is on the spectrum of health, the Clinical Rules Engine monitors his or her health condition

Engagement Personalization Insights

Recommend and Communicate

• Tailors program recommendations by taking into account member profile and opportunity score

• Messages opportunities to the member and physician via various channels based on segment

Collect and Synchronize • Sorts and organizes

large volumes of data

Identify • Assesses member’s

risk for disease and validates presence of conditions


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Platform Technology Collect and Synchronize

Large volumes of data are ingested from a variety of sources: Medical, Rx, and

behavioral claims Member

self-report Physician and inpatient EMR

Labs and biometrics

Care team via ActiveAdvice

Physician feedback

Engage • Individualized • Prioritized

• Clinically robust • Motivational

• Health literate • “Snackable”

Engagement modes vary by opportunity:

And use consistent content across all services:

high-tech digital

high-touch one-on-one

to

Segment and communicate

Members are grouped by needs, behaviors and preferences

Communications are tailored and modes of engagement are promoted

Stratify Individuals are assessed for impactability:

Acute or complex

Moderate to high risk Low risk Healthy,

no risks

Recommend Individuals are referred to available programs:

Decision support

Lifestyle coaching

Condition management

Maternity support

Transitions of care

Compassionate care

Case management

General wellness

Identify Clinical Rules Engine identifies opportunities for health improvement using:

Evidence-based algorithms

Predictive analytics


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Asthma Step 2 Therapy

“Your patient has evidence for asthma and for multiple refills of short-acting beta agonists…”

Doctor version

Ask about Inhaled Steroids

“Our data shows that you have asthma that may not be well controlled. Ask your doctor…”

Patient version

Alert patients and providers of opportunities to improve care through preferred communication channel


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Engage and recruit practices

Evaluate $ Build Support Coordinate

Develop payment model along value-

based spectrum

Maximize Patient Centered Medical Home effectiveness • Patient centered care coordination model designed to support physicians and

practices and increase member engagement • Use provider facing care management application to integrate various sources

of clinical and member derived data including real time ADT data • Exploring HIE partnerships and provider EMR workflow access/integration

Evaluate effectiveness

using independent third party consultant

Improve coordination by using a combination of

embedded care managers and

telephonic support


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Improvement in 23 of 28 measured clinical outcomes since inception

2.4% 2.9% 2.7% 3.0% 2.7% 3.3%

0%1%2%3%4%

Diabetes:Nephropathy

Asthma:Appropriate Meds

Breast CancerScreening

Cervical CancerScreening

CHF: ACE/ARB CHF: LVEF Eval

8.8% 7.4% 7.9%

16.4% 17.1%

0%2%4%6%8%

10%12%14%16%18%

Asthma: β-agonist overuse reduction

Diabetes: HbA1c Diabetes: LDL Colon CancerScreening

CHF ReadmissionReduction

*Clinical measures 2010-2013


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Notify members of program eligibility through targeted communications

Diversify outreach: Leverage multiple communication channels, including print, digital and telephonic

High volumes: 3.9 million touches through portals, webinars, mailers, calls and alerts – average of 7.3 touches per member

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Improve members’ experience

Customer Satisfaction

Maintain/improve overall customer satisfaction score

Annual Enrollment Service Level Agreements

Improve customer service SLAs

Member Engagement

Increase in # of active members registered on TPA site, usage of provider search and transparency tools, and attendance at educational roadshows

These goals and future targets will lead to: • Increased member engagement • Higher level of trust • More informed members empowered in their decision making


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• Increased awareness of member health status by engaging members in 2014

– Incent members through premium reduction to for complete Health Assessment

– Member portal provides each member with immediate feedback on personalized Health Assessment report with a detailed plan to take action

– Health Assessment completions increased from 10,919 in January 2013 to 233,368 in November 2014

– Generated 40+% increase in identified health opportunities across the population

Incent members to complete Health Assessment to be more aware


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Improve the members’ experience

85% engaged from

those contacted

14% total population

engaged

93% member

satisfaction

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Ensure a financially stable state health plan

Net Income/Loss Actual at or above budget for plan year

PMPM Claims Expenditures

At or below budget for plan year

Member Cost-Sharing

% of total claims cost paid by members through copays, deductibles and coinsurance at or below benchmark

These goals and future targets will lead to: • Reduced costs for members and the Plan • Reduced fraud, waste, abuse and overuse • Delivery of appropriate care in the appropriate setting • Payment for quality and value rather than quantity

Ensure financial stability

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Savings from Population Health Improvement

*Validated by independent 3rd party actuarial consultants


Actual vs. Expected Trend

Period Total Savings PMPM Savings

2010-2011 $149,676,520* $22.69 2011-2012 $142,701,928* $21.86 2012-2013 $148,817,452 $23.08

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ROI analysis showed the following annual changes: 2011-2012 2012-2013

Medical IP admissions 1.8% -0.6%

Surgical IP admissions -9.4% -6.7%

Ambulatory surgery services -6.5% -2.9%

Brand name medication utilization -18.9% -13.3%

ED visits -2.4%

Every 1% decrease in chronic disease = $90 million saved annually


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Utilization Annual Changes


0

10

20

30

40

50

Nov '10 - Oct '11 Nov '11 - Oct '12 Nov '12 - Oct '13 Mar '13-Feb '14

Total MIH/1000

Total Non-MIH/1000

Utilization Outcomes

0

10

20

30

40

50

60

70

2010 2011 2012 2013 Q2 2014

ED Use per K mbrs withasthma/yrHospital Use per Kmbrs with asthma /yr

0

50

100

150

200

250

300

2010 2011 2012 2013 Q2 2014

Hospitalizations per Kmbrs with CHF/yrReadmission Rates(denom is admissions)

Most Impactable Hospitalizations

Asthma

Heart Failure

MIH

E

D/H

ospi

tal U

se

Hos

pita

l/Rea

dmits

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The North Carolina State Health Plan saved the state $23 million by foregoing premium increases for the 2015 benefit year based on savings generated


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Recent Historical Financial Results Revenues and Expenses

$2.273

$2.676

$2.490

$2.798 $2.852

$2.960 $3.020

$2.290

$2.625

$2.559 $2.650 $2.620

$2.679

$2.845

$2.0

$2.2

$2.4

$2.6

$2.8

$3.0

$3.2

FY 2008 FY 2009* FY 2010 FY 2011 FY 2012 FY 2013 FY 2014

$ Billions

Revenues Expenses

*FY 2009 revenues include a $250 million general fund appropriation from the State.

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Recent Historical Financial Results Net Income/(Loss) & Ending Cash Balance

($17)

$51

($69)

$148 $232 $281

$175 $140 $190

$122

$270

$502

$784

$959

-$200

$0

$200

$400

$600

$800

$1,000

$1,200

FY 2008 FY 2009* FY 2010 FY 2011 FY 2012 FY 2013 FY 2014

$ Millions

Plan Income/(Loss)

Ending Cash Balance

*The Plan received a $250 million general fund appropriation from the State in FY 2009.

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Recent Historical Financial Results Expenditures (Claims + Administrative) PMPM

$298.84

$330.91 $321.93 $332.85

$328.60 $334.90

$352.30

$290.00

$333.48

$317.36

$347.49

$361.56 $358.70

$374.75

$280

$300

$320

$340

$360

$380

$400

FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014

PMPM Expenditures

Actual Expenses

Budgeted Expenses

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Questions?

Charles Saunders, MD [email protected]

Janet Cowell [email protected]

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mailto:[email protected]

mailto:[email protected]

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