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 1
CMS Change Package: Primary and Secondary Drivers Patient and Family- 1.1 Patient & family engagement Centered Care 1.2 Team-based relationships Design 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- 2.1 Engaged and committed leadership Driven Quality 2.2 QI strategy supporting a culture of quality and safety Improvement 2.3 Transparent measurement and monitoring 2.4 Optimal use of HIT Sustainable 3.1 Strategic use of practice revenue Business 3.2 Staff vitality and joy in work Operations 3.3 Capability to analyze and document value 3.4 Efficiency of operation
Scott Wetzler, PhD President and CEO University Behavioral Associates 3
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 4
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 5
Report Structure I. Population Overview • Number of members, months of service, health plan information II. Service Categories, Subcategories, and Associated Cost Totals Outpatient Hospitalizations Pharmacy ER Visits Additional Services • Medical (PCP) • Medical • Medical • Home health • Medical (specialty) • Mental health • Behavioral health • Case management • Mental health • Drug & alcohol • HCBS • Alcohol & opiate dependence • Nursing facility • Hospital-based outpatient • Transportation services • Test, labs, x-rays • Durable medical equipment • Miscellaneous 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 6
Section (I) Population Overview Medicaid Utilization: Services & Cost Care Transitions Network Montefiore Psychiatry Clinics: Glebe, Moses, Wakefield 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14 Population 5177 4976 4746 Adult Members with Utilization 1 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 8/1/15 - 7/31/16 Health Plan Population 2 1535 (29%) HealthFirst 1257 (24%) Fee For Service 3 655 (12%) Affinity 545 (10%) Fidelis 393 (7%) MetroPlus 906 (17%) Other Health Plans 8/1/15 - 7/31/16 Member Outpatient Behavioral Health Visit Count 517 (12%) 1-2 Visits 899 (20%) 3-5 Visits 1357 (30%) 6-10 Visits 1679 (38%) 11 or More Visits 7
Section (II) Service Categories OUTPATIENT Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14 OUTPATIENT SERVICES Visits Per 1000 Members 11472 9148 11185 Medical - PCP 4 $4,514,226 (6%) Total Cost 5 $5,833,388 (7%) $5,594,729 (7%) 11% Visits Per 1000 Members 4255 4960 4562 Medical - Specialty $3,571,521 (5%) Total Cost 5 $3,508,147 (4%) $2,759,128 (4%) Visits Per 1000 Members 4547 7112 5558 Mental Health $4,886,265 (6%) Total Cost 5 $3,243,109 (4%) $3,823,376 (5%) Visits Per 1000 Members 7068 11337 10551 Alcohol & Opiates Dependence Treatment $2,985,966 (4%) Total Cost 5 $1,935,252 (2%) $2,318,054 (3%) Hospital based Outpatient Services Total Cost $1,024,062 (1%) $698,521 (1%) $593,904 (1%) (Injection Therapy, Diagnostics, Other Imaging) PMPM 6 (%) $253 (20%) $280 (22%) $265 (23%) OUTPATIENT TOTAL $15,543,958 $16,656,499 $15,089,189 8
Section (II) Service Categories HOSPITALIZATIONS Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14 HOSPITALIZATION 5 Average LOS 5 5 Days Per 1000 Members 958 945 903 Medical Discharge Per 1000 Members 190 172 172 $6,826,430 Total Cost 5 $7,465,477 $5,973,079 15 Average LOS 15 17 Days Per 1000 Members 1216 1193 1298 Mental Health Discharge Per 1000 Members 81 81 77 $4,508,504 Total Cost 5 $4,261,143 $4,727,604 6 Average LOS 7 7 Days Per 1000 Members 178 260 304 Drug and Alcohol (D&A) Discharge Per 1000 Members 27 42 43 $562,160 Total Cost 5 $464,457 $641,010 PMPM 6 (%) $198 (16%) $200 (16%) $199 (17%) HOSPITALIZATION TOTAL $12,191,077 $11,897,094 $11,341,693 9
Section (II) Service Categories PHARMACY 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 PMPM 6 (%) $325 (25%) $349 (28%) $303 (26%) PHARMACY TOTAL $19,949,566 $20,784,747 $17,227,201 ER VISITS 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 Per 1000 Members 779 409 495 ER Visits Medical Percentage 7 85% 80% 82% Behavioral Health Percentage 15% 20% 18% PMPM 6 (%) $16 (1%) $7 (1%) $8 (1%) ER TOTAL $998,062 $400,544 $438,143 10
Section (II) Service Categories ADDITIONAL SERVICES 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 Health 8 PMPM (%) $224 (18%) $188 (15%) $143 (12%) Total Cost 5 $13,746,368 $11,162,455 $8,130,854 Case Management (Health Home) PMPM (%) $69 (5%) $61 (5%) $47 (4%) Total Cost 5 $4,224,770 $3,641,158 $2,696,710 Mental Health Rehabilitation Services - HCBS PMPM (%) $26 (2%) $24 (2%) $24 (2%) Total Cost 5 $1,624,038 $1,416,672 $1,381,895 Nursing Facility (SNF) PMPM (%) $9 (1%) $5 (0%) $6 (1%) Total Cost 5 $533,660 $267,749 $340,931 Transportation PMPM (%) $36 (3%) $29 (2%) $24 (2%) Total Cost 5 $2,218,361 $1,753,998 $1,389,435 Test, Labs, X-Rays PMPM (%) $30 (2%) $20 (2%) $20 (2%) Total Cost 5 $1,815,669 $1,166,719 $1,134,368 Durable Medical Equipment (DME) PMPM (%) $10 (1%) $9 (1%) $10 (1%) Total Cost 5 $625,437 $563,505 $592,209 Miscellaneous PMPM (%) $82 (6%) $87 (7%) $97 (8%) Total Cost 5 $5,010,179 $5,202,975 $5,489,414 ADDITIONAL SERVICES TOTAL $29,798,482 $25,175,230 $21,155,818 11
Section (II) Service Categories TOTAL COST 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 TOTAL 6 $1,278 $1,259 $1,148 Section (III) Cost Analysis Medicaid Utilization: Services & Cost 8/1/15 - 7/31/16 8/1/14 - 7/31/15 8/1/13 - 7/31/14 TOTAL PMPM 6 (%) Total PMPM $1,278 $1,259 $1,148 NON PHARMACY PMPM 6 (%) 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 PMPM 9 $1,568 $1,625 $1,506 SSI PMPM 9 $1,220 $1,189 $1,038 9 TANF/SN PMPM $929 $783 $679 12
Cost Trends using Look-Back Periods * Increasing costs may $1,600 due to population selection (we selected $1,400 $1278 $1259 people in care during target year, and they $1148 $1,200 may not have been in treatment in prior $423 $485 $1,000 years) $372 Column1 $7 $800 $16 $8 Additional Services $349 ER Visits $303 $325 $600 Pharmacy $400 $200 Hospitalization $199 $198 Outpatient $200 $280 $265 $253 $- 2 Year Look-back 1 Year Look-back Target Year 13
Health Care Cost Comparisons OMH Clinics Total PMPM $1278 Medical Services 24% Additional Services 38% Mental & Behavioral Health Services Pharmacy 13% 25% 14
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) 15
Comparing Reports Between Populations Mental Health Clinics Substance Abuse Clinics 16
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