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. 2
Reports Overview
Why are these reports important? What is going on outside the practice? How do costs and use of services change over time? 4
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 5
Which patients are represented for each practice? Attribution CIVHC performs attribution Patients are assigned to a single primary care provider where they had the most visits in recent years 6
CMMI Cost & Utilization Reports
What detail is included? CMMI Cost & Utilization Reports 8
Overview of CMMI Reports: Nine Metrics Behavioral Physical Follow-up after Hospitalization for Mental Illness Total Cost of Care PMPM Emergency Dept. Rate Emergency Dept. Rate Out-of-pocket Expenditures for Admissions Admissions Consumers Readmissions Readmissions 9
Actuarial Cost & Utilization Reports
What detail is included? Actuarial Cost & Utilization Reports Table 1a - Baseline Total Allowed Cost PMPM by Service Category Sample SIM Practice Site Commercial 1.732 1.079 2015 Average Risk Scores: See "Risk Adjustment" page for more Medicaid 2.545 1.323 information 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 11
Overview of Actuarial Reports: Three Metrics Allowed Cost PMPM Utilization per 1,000 Unit Cost 12
Overview of Actuarial Reports: Service Categories Service Categories Service Categories (Cont.) All Other Services Laboratory Services Ambulance Long Term Care Diagnostic Imaging / X-Ray Outpatient Hospital – Behavioral Dialysis Procedures Outpatient Hospital – Physical Durable Medical Equipment / Prosthetics Prescription Drugs – Behavioral Emergency Services Prescription Drugs – Physical Home Health Care Professional Primary Care – Physical Hospice Professional Specialty Care – Behavioral Inpatient Hospital – Behavioral Professional Specialty Care – Physical Inpatient Hospital – Physical Skilled Nursing Facility 13
How to Use Actuarial Reports SIM PCP Practices Combined Model Test Year 1 (2016) Service Categories Q1 Q2 Total Track performance over time 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 Review which types of services show Dialysis Procedures $0.07 $0.09 $0.08 increasing/decreasing costs 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 Compare individual practice results to SIM Hospice $0.25 $0.21 $0.23 family / pediatric / adult practice results 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 Risk scores shown by line of business Long Term Care $0.00 $0.00 $0.00 Outpatient Hospital – Behavioral $0.57 $0.52 $0.54 Aggregate SIM report is also produced Outpatient Hospital – Physical $109.24 $104.43 $106.86 Prescription Drugs – Behavioral $16.52 $16.76 $16.64 Inform cost projections, cost savings, ROI 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 14
Proposed Cost Savings & ROI
Proposed ROI through 3-Year SIM Program Assumed Grant Amount: Cost Savings Investment ROI $126,587,853 $86,928,656 1.46 Actual Grant Amount: Cost Savings Investment ROI $126,587,853 $65,000,000 1.95 16
Cost Savings Assumptions Projected Savings: $17.3M (yr. 1), $42.2M (yr. 2), $67.1M (yr. 3) Savings translates to about $1.90 PMPM Utilization & Cost Reductions Utilization & Cost Increases – Inpatient Physical – Professional Physical – Inpatient Behavioral – Professional Behavioral – Emergency Services – Diagnostic Testing – Ambulance – Imaging / Labs – Skilled Nursing Facility – Prescription Drugs 17
Thank you Katie Matthews, ASA, MAAA Katie.Matthews@milliman.com Steve Melek, FSA, MAAA Steve.Melek@milliman.com
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