Safety Net Success: Evaluation of the Illinois Medicaid Medical Home Program Fourth National Medical Home Summit, February 27 29, 2012
History of Illinois Health Connect Implemented in 2006; driven by desire to control costs, improve access and quality, and expand eligibility. Primary Care Case Management Model: Hybrid model of healthcare delivery that combines emphasis on primary care and management through a medical home with fee for service payment Medical Home model preceded NCQA or other accreditation standards Blended payment model: PMPM, enhanced fee schedule and P4P In 2006, 1.2 million eligible pts, now 2.0 million eligible pts Parallels MCOs: 200,000 pts in Vol MCOs, 40,000 in mandatory MCOs Parallel DM program, Your Healthcare Plus, for 2006 2011. 2
Provider Story Currently the IHC has a network of 5,700 participating Medical Homes including family doctors, pediatricians, internists, rural health clinics and FQHCs with capacity for 5.4 million clients. Must meet certain quality standards such as 24/7 coverage. Provider Service Representatives and QA nurses make approximately 350 visits to provider offices per week to assist with billing/coding; IHC administration; Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) standards; and clinical quality improvement. Four advisory subcommittees meet quarterly and create opportunity for stakeholder input. Information provided via quarterly newsletters, blast fax, IHC website, and weekly webinars. Nearly 90% of providers are satisfied with the administration of the program and 93% think that IHC is beneficial to patients. 3
IHC Quality Tools Claims History: Compilation of claims data available on every current Medicaid client Provider Profiles: semi annual report card on HEDIS measures Panel Rosters: registry of patients and preventive services, available online in Excel format. Bonus Payment Program: P4P on certain measures (e.g. immunizations, mammography) 4
Client Story Approximately 75% of all clients make an active choice for best fit medical home. Others are auto assigned. Clients must see their PCP/medical home for primary care. Specialists and other providers, who do not participate with IHC as a PCP, do not require a referral for care from the PCP. Call center assists with access to subspecialty care, making well child appointments, educates clients on the medical home concept. Sends reminder letters for both child and adult preventive care. For past 3 years, over 90% of all clients surveyed are satisfied or extremely satisfied with both PCP and IHC program. 5
Research Aims The Robert Graham Center conducted a rapid, external evaluation of IHC with the aim of answering the following question: How effective is Illinois Health Connect (IHC) in reducing costs, reducing inappropriate utilization, creating patient provider continuity, and improving outcomes and delivery of appropriate preventive care between 2004 and 2011? 6
Data Illinois Medicaid claims Detailed information for all services indicating dates of service, category of services, the rendering provider, type of provider, charges and payments. Patient and provider enrollment file Information on beneficiaries demographic characteristics as well as which type of programs the beneficiary was eligible for or enrolled in for each day. Covers both pre (2004, 2005) and post IHC implementation (2006 2010) period 7
Method: eligibility Using enrollment data, we developed the IHC enrollment trends based on beneficiaries eligibility periods. Member months and year equivalent measures are derived using the beneficiaries eligible day counts during the corresponding calendar year. For pre program period 2004 and 2005, we use the hypothetical eligibility measure constructed by HFS applying the same IHC business criteria for 2006 to 2010. 8
Method : cost and utilization We studied costs and utilization trends by developing permember per month (PMPM) costs through the entire study period. Service utilization was further examined in both inpatient and outpatient settings to examine sources of cost saving. In the cost analysis, 2006 figures are treated as baseline year. Expected costs are developed using 2006 costs as baseline year and historical Medicaid costs increasing rate 3%. 9
Medicaid enrollee distribution 2006 FTE enrollees 2010 FTE enrollees age group Medicaid IHC YHP Other Medicaid IHC YHP Other 00to5 480,265 343,568 59,404 77,292 585,256 444,373 72,618 68,264 06 to 10 322,170 221,223 31,493 69,455 437,875 311,516 63,598 62,760 11to18 426,197 274,032 31,604 120,561 595,578 420,767 56,063 118,748 19 40 454,817 266,279 75,416 113,122 556,925 336,581 98,221 122,123 40 64 268,227 61,800 77,285 129,142 345,747 97,743 95,942 152,061 65andabove 156,609 9,244 1,342 146,023 183,912 11,670 2,325 169,917 total 2,108,286 1,176,146 276,543 655,596 2,705,291 1,622,650 388,767 693,873 10
Medicaid program distribution trend Medicaid IHC YHP Other 2006 100% 55.79% 13.12% 31.10% 2007 100% 58.06% 13.15% 28.79% 2008 100% 58.90% 13.98% 27.12% 2009 100% 59.84% 14.25% 25.91% 2010 100% 59.98% 14.37% 25.65% 11
IHC and YHP program costs Actual PMPM Costs Predicted PMPM Costs Cost savings IHC YHP IHC YHP IHC YHP 2004 $124.10 $640.14 $117.55 $613.63 $6.56 $26.51 2005 $122.54 $666.39 $121.07 $651.00 $1.47 $15.39 2006 $124.71 $670.53 $124.71 $670.53 $0.00 $0.00 2007 $125.53 $624.96 $128.45 $690.65 ($2.92) ($65.69) 2008 $125.45 $615.89 $132.30 $711.37 ($6.85) ($95.48) 2009 $129.87 $639.87 $136.27 $732.71 ($6.40) ($92.84) 2010 $127.47 $647.12 $140.36 $754.69 ($12.89) ($107.57) 12
IHC PMPM cost savings PMPM costs 115 120 125 130 135 140 Actual and predicted costs for IHC 2004 2005 2006 2007 2008 2009 2010 Year ihc ihc_predicted PMPM: per member pre month 13
YHP PMPM cost savings Actual and predicted costs for YHP PMPM costs 600 650 700 750 2004 2005 2006 2007 2008 2009 2010 Year yhp yhp_predicted PMPM: per member pre month 14
IHC and YHP program cost savings Cost savings pmpm # of member months Program cost savings IHC YHP IHC YHP IHC YHP 2004 $6.56 $8.10 12,625,745 3,283,268 82,795,581 26,584,954 2005 $1.47 $15.39 14,098,865 3,448,614 20,672,623 53,078,918 2006 $0.00 $0.00 14,113,757 3,318,520 0 0 2007 ($2.92) ($65.69) 15,816,956 3,583,092 (46,142,708) (235,376,340) 2008 ($6.85) ($95.48) 16,999,345 4,036,241 (116,479,596) (385,389,495) 2009 ($6.40) ($92.84) 18,413,922 4,384,537 (117,880,646) (407,073,704) 2010 ($12.89) ($107.57) 19,471,805 4,665,207 (250,945,300) (501,814,627) (531,448,250) (1,529,654,166) 15
IHC cost savings 2004 2010 IHC cost savings -30,000-20,000-10,000 0 10,000 IHC annual cost savings 2004-2010 2004 2005 2006 2007 2008 2009 2010 unit: 10,000 dollars 16
YHP cost savings 2004 2010 YHP cost savings -60,000-40,000-20,000 0 20,000 YHP annual cost savings 2004-2010 2004 2005 2006 2007 2008 2009 2010 unit: 10,000 dollars 17
Cost savings by category of services 2010 Costs Actual Predicted IHC YHP IHC YHP CLINIC $10.17 $17.50 $7.71 $14.48 INP $25.56 $164.34 $37.18 $226.98 LAB/XRAY $1.53 $3.24 $1.47 $3.33 OTP $12.33 $54.20 $13.22 $52.03 PHYS $21.28 $64.32 $23.24 $68.63 RX $21.94 $147.57 $23.05 $155.56 18
Proportion of cost savings 2010 Costs Savings % Savings IHC YHP IHC YHP CLINIC $2.46 $3.02 32% 21% INP ($11.62) ($62.63) 31% 28% LAB/XRAY $0.06 ($0.09) 4% 3% OTP ($0.89) $2.17 7% 4% PHYS ($1.96) ($4.31) 8% 6% RX ($1.11) ($7.99) 5% 5% 19
IHC Hospitalization IHC hospitalizations Hospitalization 70 80 90 100 110 2004 2005 2006 2007 2008 2009 2010 Year units: 1000 full time (year) equivalent enrollee 20
YHP hospitalization YHP hospitalizations Hospitalization 320 340 360 380 400 2004 2005 2006 2007 2008 2009 2010 Year units: per 1000 full time (year) equivalent enrollee 21
IHC inpatient bed days IHC inpatient days per 1000 FTE IHC inpatient days 250 300 350 2004 2005 2006 2007 2008 2009 2010 year unit: per 1000 full time (year) equivalent enrollee 22
YHP inpatient bed days YHP inpatient days 1600 1700 1800 1900 2000 YHP inpatient days per 1000 FTE 2004 2005 2006 2007 2008 2009 2010 year unit: per 1000 full time (year) equivalent enrollee 23
IHC ER counts Emergency room visits 400 450 500 550 IHC ER visits and IHC non-flu ER visits 2004 2005 2006 2007 2008 2009 2010 YEAR ihc ihc_nonflu unit: 1000 full time (year) equivalent enrollee 24
YHP ER counts YHP ER visits and non-flu ER visits Emergency room visits 1300 1400 1500 1600 1700 1800 2004 2005 2006 2007 2008 2009 2010 YEAR yhp yhp_01 unit: 1000 full time (year) equivalent enrollee 25
Avoidable & ER resulted hospitalization IHC IHC ER resulted/avoidable hospitalization hospitalization 20 30 40 50 60 2004 2005 2006 2007 2008 2009 2010 year ERINP AVOIDINP unit: per 1000 full time equivalent enrollee 26
Avoidable & ER resulted hospitalization YHP YHP ER resulted/avoidable hospitalization hospitalization 0 50 100 150 2004 2005 2006 2007 2008 2009 2010 year ERINP AVOIDINP unit: per 1000 full time equivalent enrollee 27
Flu ER counts IHC Emergency room visits 80 100 120 140 IHC Flu ER visits per 1000 FTE 2004 2005 2006 2007 2008 2009 2010 YEAR FTE: full time (year) equivalent enrollee 28
Flu ER counts YHP Emergency room visits 150 200 250 300 2004 2005 2006 2007 2008 2009 2010 YEAR FTE: full time (year) equivalent enrollee YHP Flu ER visits per 1000 FTE 29
Takeaways We found significant reductions in cost for PCCM program: $531 million for IHC, $1.53 billion for YHP. The rate of annual savings since 2006 increased from about 2.5% per year in 2007 to nearly 10% in 2010. The largest savings in 2010, actual vs predicted (based on 2006), within IHC, come from reductions in inpatient services ( 31.3%), physician services ( 8.4%), and outpatient hospital services. IHC hospitalization rates fall by nearly 20% between 2006 and 2010. Over the same period, bed days also fell by 22.0% (21.5% for IHC, 19.2% for YHP). IHC beneficiary emergency department visits declined by 8% as of 2010. 30
Future Work Outpatient visits cost: PC vs Non PC visits cost Primary care provider engagement patterns in PCCM program: patient panel size and composition Practice pattern transformation among providers considering: continuity, comprehensiveness and coordinated care Variation of cost saving performance among different types of primary care providers 31
Presenters: Meiying Han, PhD The Robert Graham Center Center for Policy Studies in Family Medicine and Primary Care, Washington DC (MHan@aafp.org) Margaret Kirkegaard, MD, MPH Illinois Health Connect, Medical Director (mkirkegaard@automated health.com) 32