Breathing Easy: A Case Study on Asthma Prevention Bob Morrow, MD, MBA Market President, Houston & Southeast Texas Blue Cross and Blue Shield of Texas @DrBobMorrow A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
INTEGRITY RESPECT COMMITMENT CARING OUR PURPOSE To do everything in our power to stand with our members in sickness and in health @DrBobMorrow
What is the most clinically and financially effective way to manage an illness? To prevent it!! Community Partnerships @DrBobMorrow
Agenda - Community partnerships - Health care management - Provider reimbursement @DrBobMorrow 4
Partnership with American Lung Association
Reducing Unnecessary Treatment Hospitalizations All age categories < 18 > 18 Combined 56% 59% 52% Sample size 1856 846 1010 Emergency Department visits All age categories < 18 > 18 Combined 55% 54% 56% Sample size 1856 846 1010
Health Care Management @DrBobMorrow 7
Clinical and Business Case Prevalence Source: TX Claims Data 2015 Source: Texas BRFSS Maps, https://www.dshs.state.tx.us/chs/datalist.shtm 8
Clinical and Business Case Expenditure Source: TX Claims Data 2015 9
Proactive Identification of Members < < < Supported by Clinical Intelligence Rules > > > 1 2 Collect Claim History with Predictive Modeling Historical claims data is included in a scheduled predictive modeling run Identify Current Member Activity using real time referrals initiated by: Emergency room visits Preauthorization/notification Self referral Provider referrals Human Resources staff Pharmacy Data 24/7 Nurseline 3 Member Stratification Complex Catastrophic Care High-Risk Multiple Diseases Moderate-Risk Low-Risk Well Members
The Engagement Model Identifying, engaging and motivating members to be their healthiest with nurse outreach that supports real behavior change Multiple chronic conditions, significant med non-adherence, multiple gaps in care. >Calls every 1-2 months< Chronic condition w/ med nonadherence or w/ missing tests, asthma w/ no follow-up visit., multiple gaps in care. >Multi-channel support< No diagnosed chronic condition but with preventive service gaps. Complex High Acuity Moderate Acuity Low Acuity Risk Reduction Preventive Opportunities High-risk pregnancy, admission for diabetes w/ medication non-adherence, trauma, stroke, profound behavioral health issues. >Call every 1-2 weeks or as needed< CHD w/ recent heart attack, persistent w/ medication gap, recent ER visits for diabetes or CHD. >Calls every 3-4 months< No specific diagnosis, but risk factors for developing chronic conditions.
Blue Care Connection Medical Management Process Pre Authorization Claims Data/ Predictive Model FSU Self Referrals/Condition Support program 24/7 Nurseline Utilization Management Care coordination and early invention Case Management Condition Management Wellness Coordinator Follows case through entire IP stay, potential for CM/DM referral If necessary Special Beginnings Maternity Program Pre Admit and/or post discharge outreach according to readmission risk Neonatal intensive care Management Discharge planning and post discharge outreach by CM nurse Low Acuity Mailers High/Med. Acuity Telephonic Focus on: Diabetes Asthma Cardiac Clusters CHF COPD Smoking cessation, weight mgmt. and metabolic syndrome based on members Readiness to Change
Member Outreach Identify Members Verify Program Eligibility Outreach to Member Transfer Interested Members to Clinician Non-clinical staff can educate members about our Medical Management programs. Clinical staff are focused on members interested in one of our Medical Management programs. 13
Condition Management Well Members Low- Risk Moderate- Risk High-Risk Complex / Catastrophic Wellness and Preventive Care Lifestyle Management Programs Utilization Management Pre-certification Care Coordination / Early Intervention Condition Management Enhanced Case Management Blue Care Advisors > > > > > > Gap Closure/Physician Collaboration Model of Care Emphasizes opportunities for improvement in gaps in care for the core chronic conditions Engaged members receive condition specific education; access to resources and a customized plan of care. Outreach to network physicians for members who we are unable to reach by telephone or email Targeted core conditions: Diabetes Asthma Congestive Heart Failure (CHF) Cardiovascular Condition Clusters Chronic Pulmonary Obstructive Disease (COPD)
@DrBobMorrow Provider Reimbursement 15
Redefining Value in Health Care QUALITY VALUE Achieve better outcomes Increase safety Improve satisfaction COST Reduce avoidable medical spending Decrease total cost of care @DrBobMorrow 16
Bridges to Excellence
Available Programs Texas physicians can participate in any of the 13 programs: BCBSTX pays incentives on the asthma, cardiac, diabetes and IBD programs.
Our Current Model After achieving recognition, physician is automatically included in the BCBSTX program Recognized provider list comes from Altarum. BCBSTX identifies its members with diabetes, cardiac, asthma and IBD who see BTE recognized physicians. BCBSTX sends patient list to physicians. Physician collects biometric information and returns to BCBSTX for review and claim approval. Once approval is received, physician submits a claim. BCBSTX pays the incentive. Incentives: A BTE Diabetes Care recognized physician can earn $150 per Blue Cross and Blue Shield of Texas selected patient, per year A BTE Asthma, Cardiac or IBD recognized physician can earn $100 per Blue Cross and Blue Shield of Texas selected patient, per year
Asthma Care Program Established in January 2013 with 1 physician As of December 2016, we have 216 recognized physicians Over 8,000 members are treated by these physicians Savings benefits members and employers Incentive payments for recognized physicians
Return on Investment BTE Program BTE ROI PMPY Asthma (17 & Under) $100.00 Asthma (18 & Over) $875.00 Cardiac $2,600.00 Diabetes $120.00 Time period: Jan 2014 Dec 2015 BCBSTX PPO/POS Members only
Bridges to Excellence growth 2500 BTE Physician Recognition 2000 1500 1000 Asthma Cardiac Diabetes 500 0 YE 2009 YE 2010 YE 2011 YE 2012 YE 2013 YE 2014 YE 2015 YE 2016
Web Site Access Learn more about BCBSTX s involvement in Bridges to Excellence online. BCBSTX website: bcbstx.com/provider/training/bridges_excellence.html Bridges to Excellence website: hci3.org/programs-efforts/bridges-toexcellence/recognition_programs
Thank You @DrBobMorrow 24