Complex Chronic Children

Population AnalyticsJacqueline Kueser

Vice President, Analytics

Matt Hall, PhDPrincipal Biostatistician

Today - Differentiate Patient Populations

• Define sick children to better understand longitudinal resource utilization patterns for potential prospective payment methodologies.

Next - Define Pediatric Accountable Network Models

• Identify optimal resources and payment models

Objectives: 2012 R&D Network Models

U.S. Health Care $2.7 TrillionMedicaid Chronic Kids Relatively Small

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$900 billionMedicare & Medicaid

$366 billionMedicaid: Adults & Children

Medicaid: $79 billion; 31 million children

Medicaid: $32 billion;7 million chronic, complex

& critical children

Pediatric Segmentation Definitions (Revised post June 2012 ED presentation)

U.S. Child Enrollees (extrapolated, 2 data sets)

BaselineBaseline ChronicChronicComplex Complex

& Chronic & Chronic CriticalCriticalHealthy Non-Healthy Non-

UsersUsers

MedicaidMedicaid 2020MillionMillion

5.45.4millionmillion 1.5 Million1.5 Million 124,000124,000 4.3 million4.3 million

CommercialCommercial 26 million26 million 2.2 million2.2 million 864,000864,000 54,00054,000 7.2 million7.2 million

US Medicaid Enrollees based on Kaiser Family Foundation estimates of average monthly users: 31 million Medicaid and CHIP, 8 million uninsured, and calculated commercial of 36 million (75 million US children – 39 million Medicaid/CHIP/uninsured) pediatric enrollees . Medicaid extrapolated across groups from one state data set; Commercial extrapolation from one multi-state data set.

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“Some” In Blind & Disabled CategoryFederal Benefit Payments by Eligibility Category (Outlays in Billions of Dollars)Federal Benefit Payments by Eligibility Category (Outlays in Billions of Dollars)

Children’s Hospital Association May 2012 CFO Meeting, JP MorganSource: Congressional Budget Office; “Medicaid Spending and Enrollment Detail for CBO’s March 2012 Baseline.”

Medicaid Population # & Resource Utilization, one state sample, 2009

Medicaid Medicaid BaselineBaseline ChronicChronic Complex Complex & Chronic& Chronic

CriticalCritical Healthy Healthy Non-UsersNon-Users

% Kids% Kids 63%63% 17%17% 5%5% 0.4%0.4% 14%14%

% Spend% Spend 31%31% 23%23% 32%32% 13%13% 00

Medicaid Medicaid claims costs claims costs per patient per patient monthmonth

$61$61 $163$163 $814$814 $3,876$3,876 00

Mean IP DaysMean IP Days 0.20.2 0.30.3 2.02.0 15.615.6 00

Commercial Population # & Resource Utilization, multi-state sample, 2009

CommercialBaselineBaseline ChronicChronic

Complex Complex & Chronic & Chronic CriticalCritical

Healthy Non-Healthy Non-UsersUsers

% Kids% Kids 67%67% 9%9% 4%4% <1%<1% 20%20%

% Spend% Spend 46%46% 23%23% 24%24% 8%8% 00

Commercial Commercial claims costs claims costs per patient per patient per monthper month

$133$133 $379$379 $1,238$1,238 $5,400$5,400 00

Pediatric Population Hierarchy

9Low Resource Utilization

Typical Utilization PatternTypical Utilization Pattern% of PHIS % of PHIS

PtsPts% of PHIS % of PHIS

DaysDays Efficiency Focus Efficiency Focus

Critical(CRG: 7-9)

5 30 Coordination of Care

Complex(CRG: 5b-6)

25 40 Reduction of Utilization

Chronic(CRG: 3-5a)

25 15 Outpatient Management

Baseline(CRG: 1-2)

45 15 Standardization of Care

High Resource Utilization2010 PHIS Data

Pediatric Population Hierarchy

10Low Resource Utilization

Typical Utilization PatternTypical Utilization Pattern% of PHIS % of PHIS

PtsPts% of PHIS % of PHIS

DaysDays Efficiency Focus Efficiency Focus

Critical(CRG: 7-9)

5 30 Coordination of Care

Complex(CRG: 5b-6)

25 40 Reduction of Utilization

Chronic(CRG: 3-5a)

25 15 Outpatient Management

Baseline(CRG: 1-2)

45 15 Standardization of Care

High Resource Utilization2010 PHIS Data

Children with a Medically

Complex (CMC)

Children’s hospitals are increasingly being viewed as a haven for children with special healthcare needs due to pediatric specialty care providers with equipped facilities and resources.

Children’s hospitals are <1% of hospitals in the US, but …

National Market Share for Children with a Medical Complexity (CMC)

Market share is substantial at children’s hospitals…Market share is substantial at children’s hospitals… ...and growing at a rate of around 1% per year...and growing at a rate of around 1% per year

2009 H-CUP KID Data

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Children with a Medical Complexity (CMC) in PerspectiveThe proportion of resources consumed by the CMC population at children’s hospitals is two times that of non-children’s hospitals

2009 H-CUP KID Data

Children’s Hospitals are Highly

Dependent on the CMC Population

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Growth in Resources Consumed by Children with a Medical ComplexityThe growth rate of the CMC population at children’s hospitals is two times greater than at non-children’s hospitals.

2009 H-CUP KID Data & PHIS

And the fastest growing population within children’s hospitals.

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Additionally, growth might be due to increased retention of adult CMC patients within children’s hospitals.

Growth in Resources Consumed by Children with a Medical ComplexityGrowth due, in part, to the increase in transferring of patients from non-children’s hospitals.

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Medicaid in Children with a Medical Complexity (CMC)

2009 H-CUP KID Data

The percent of hospital days for CMC insured by Medicaid is higher at children’s hospitals, and growing at 1% per year

Growth within PHIS Hospitals

2010 PHIS Data

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Annual Hospital Utilization Predictability

Baseline patients are 30 times more predictable in their annual hospital utilization than critical patients.

Prop

ortio

n of

Pati

ents

Hospital DaysSource: PHIS, 2010 (CRG Grouper)

Baseline

Chronic

Complex

Critical

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The Story in Summary for Children with a Medical Complexity

CH Compared to CH Compared to Non-CHNon-CH

Trend at CHTrend at CH

Market share for CMC

Percent of days from CMC

Percent of CMC days from Medicaid

Lack of predictable in the CMC resource utilization

Future?

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Potential Models for Managing Children with a Medical Complexity• Medical Homes

• CMMI Grant

• Home Care

• Care Coordination – Inpatient and Outpatient

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Average Distance Travelled to Hospital

2010 PHIS Data

Patients Crossing State Lines for Care

Medicaid Other

11.6% 21.5%

10.9% 21.0%

9.8% 16.3%

8.2% 16.3%

Interstate Travel for Children with a Medical Complexity

22Source: PHIS, 2010 (CRG Grouper)

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Distance Travelled for Critical Patients

2010 PHIS Data

Structured Programs

Structured clinical programs aimed at coordinating the care for critical patients may be one way to extend a hospital’s referral base.

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How does this data help?

Identifies the need to effectively group patients by clinical complexity AND resource utilization across the continuum of care

Preliminarily identifies consistency in distribution of volumes and cost/utilization patterns for the different patient types across data sets

Defines differences between commercial and Medicaid patientsMedicaid includes higher proportion of chronic, complex chronic and critical patients Medicaid has higher PMPM enrollee costs

To be developed: a potential cautionary tale regarding variation within distributions

Drill Down: Bundle Payment Analysis

Model and understand how bundled payments might contribute to children’s hospitals taking on more accountability and incentives.

Pediatric Chronic Conditions:Diabetes (Type 1)

Cystic FibrosisEnd Stage Renal Disease (excludes transplants)

Member Participants:BostonCincinnatiConnecticutChicagoDallasIndianapolisKansas CityWashington, DCHema Bisarya, Madeleine McDowell, MD,

Jacqueline Kueser, Project Leads

UHC Partner Project

Create new products around the management of complex acute and chronic illness – targeted at payers (public and private) and consumer-oriented insurance exchanges.

Such products should reduce systemic costs while allowing providers to share in efficiency gains as a safe glide path to an eventually lower equilibrium.

Acute: Total Knee ReplacementsLongitudinal: Lung Cancer (Commercial); Chronic Heart Failure (Medicare)

Member Participants: Duke University Health System (NC) Penn Medicine (PA)Rush University (IL) Oregon University Hospitals Case Medical Center (OH)Froedtert Health (WI) Health Sciences University (OR)IU Health (Clarian) (IN)

Volume & Variation

Age Condition #patients/ select markets

Total # patients

Average per patient (2 yrs)*

% SOI 3 or 4

Range: least – most efficient markets*

<18 Diabetes 15,000 53,000 $11,000 10% $8K-$13K

<18 CF 7,400 7,400 $64,000 12% $56K-$71K

<25 ESRD 472 4,000 $103,000 2% $88K-$125K

Source: 2009-2010 Milliman Health Care Guidelines (HCG) Consolidated Database and Medstat data

ESRD – Medicare claims data – 5% sampleDiabetes/CF- commercial claims data*costs standardized across markets

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Opportunities to Manage for Better Quality and Cost Efficiency

Consistent reporting that non-billable support services including care management and care coordination, particularly for the SES and non-English speaking populations drive quality and cost-efficiency.

Clinical and executive leaders; 8 children’s hospitals

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Recommendation: Pilot Incremental Bundle for Longitudinal Care

Recommended age groupings: <1 yr>1-6yrs7-18 yrs 29

Granularity in resource utilization• Consumption of specialty & other resources by patient

segmentation• ESRD cost analysis

Medicaid analyses • State datasets

Assess network adequacy & efficiency management• Medical home management experience

Next Step: