UNIVERSITY OF MICHIGAN

MEDICAL MANAGEMENT CENTER

August, 2006
 Presentation Goals
 Explain the role of the UMHS Medical
Management Center (MMC)
 Demonstrate MMC attempts to
implement the Chronic Care Model
within provider setting
 Present outcomes
 Describe P4P programs supporting MMC
efforts
CMS Physician Group Practice Demonstration Project
BCBSM Physician Group Incentive Project
 Discussion
 UMHS Medical Management Center (MMC)
Created in 1996 to advance population-based

medical and chronic disease mgt.
Focus on:


Proactive case finding & outreach

Complex care management
Clinician-directed disease management
Evidence-based guidelines & provider feedback
Pharmacy management
Transitional care between inpatient/outpatient
Patient centered care based on the Chronic
Care Model
System integration
Align efforts with external funding opportunities

 UMHS Medical Management Center (MMC)
2004 BCBS Physician Group
Incentive Program
2004 CMS Physician Group Practice
Demonstration Project

2003 JCAHO Disease-Specific

Care Certification 2004 Kids
─ 7 UMHS programs certified ─ Connection

2002 MMC adds Washtenaw

2001 Activecare (GM) joins MMC Health Plan

2001 MMC adds MCARE HMO &

Medicaid (~80,000 lives)

1998 Partnership Health (Ford Motor) &

1997 BMC2
Medical Management Center

1996 GUIDES: Guideline development,

measurement & feedback
 Chronic Care Model
CC

Health System
Community
Resources and Policies Health Care Organization

Self- Delivery Decision Clinical

Management System Support Information
Support Design Systems

Informed, Prepared,
Activated Productive Proactive
Patient Practice Team
Interactions

Improved Outcomes
 CC

Health System
Community
Resources and Policies Health Care Organization

Self- Delivery Decision Clinical

Management System Support Information
Support Design Systems

Informed, Prepared,
Activated Proactive
Patient Practice Team

Productive Interactions
Healthy Stable chronic Unstable
disease chronic disease Hospitalized Post
or at risk or high risk discharge
Acutely ill

Improved Outcomes
 Application of the Chronic Care Model
CC

Health System
Community
Resources and Policies Health Care Organization

Self- Delivery Decision Clinical

Management System Support Information
Support Design Systems

GENERAL CAUSE VARIATION

Healthy Stable chronic Unstable

disease chronic disease Hospitalized Post
or at risk or high risk discharge
Acutely ill

TEAM APPROACH
(Physicians, Nurse Practitioners, Social Work...)
 Application of the Chronic Care Model
GENERAL CAUSE VARIATION

Healthy Stable chronic Unstable

disease chronic disease Hospitalized Post
or at risk or high risk discharge
Acutely ill

•All-payer disease registries

- claims data (BCBSM; MCARE HMO, CMS; internal billings)
- EMR + data warehouse (lab, text searches, etc.)
- pharmacy data (UMHS employees)
- sample reviews for validation of assignment algorithm
- diabetes (9,537), CHF (3,943), CAD(4,382), depression (3,768), asthma (?)

TEAM APPROACH
(Physicians, Nurse Practitioners, Social Work...)
 Application of the Chronic Care Model
GENERAL CAUSE VARIATION

Healthy Stable chronic Unstable

disease chronic disease Hospitalized Post
or at risk or high risk discharge
Acutely ill

• All-payer disease registries

• Measure evidence-based outcomes

- 25 clinical guidelines reviewed &
approved by UMHS physicians
(http://www.med.umich.edu/i/oca/practiceguides/)

TEAM APPROACH
(Physicians, Nurse Practitioners, Social Work...)
 Application of the Chronic Care Model

GENERAL CAUSE VARIATION

Healthy Stable chronic Unstable

disease chronic disease Hospitalized Post
or at risk or high risk discharge
Acutely ill

• All-payer disease registries

• Measure evidence-based outcomes
• Feedback to providers (by site & clinician)

TEAM APPROACH
(Physicians, Nurse Practitioners, Social Work...)
UMHS All Payor Diabetes Performance;
By Health Center, Care Provider
 Application of the Chronic Care Model

GENERAL CAUSE VARIATION

Healthy Stable chronic Unstable

disease chronic disease Hospitalized Post
or at risk or high risk discharge
Acutely ill

• All-payer disease registries

• Measure evidence-based outcomes
• Feedback to providers (by site & clinician)

• Patient education & self-management

TEAM APPROACH
(Physicians, Nurse Practitioners, Social Work...)
 Self Management Goals

 Develop patient friendly self-management form

 Pilot form and reminder postcard or phone call
 Report self management goals on Health
Center leadership reports
 Educate providers and staff regarding
documentation of self management in Problem
Summary List
Over the past 6 months, when receiving medical care for my chronic illness, I was:
Almost Generally Most of Almost
Never Not Sometimes the Time Always
1. Asked for my ideas when we made
a treatment plan. 1 2 3 4 5
2. Given choices about treatment to
think about. 1 2 3 4 5
3. Asked to talk about my goals in
caring for my illness. 1 2 3 4 5
4. Helped to set specific goals to
improve my eating or exercise. 1 2 3 4 5
5. Given a copy of my treatment plan. 1 2 3 4 5
6. Encouraged to go to a specific
group or class to help me cope with
my chronic illness. 1 2 3 4 5
7. Sure that my doctor or nurse
thought about my values and my
traditions when they recommended
treatments to me. 1 2 3 4 5
8. Helped to make a treatment plan
that I could do in my daily life. 1 2 3 4 5
9. Helped to plan ahead so I could take
care of my illness even in hard
times. 1 2 3 4 5
10. Helped to set a goal with my doctor
or health team member. 1 2 3 4 5
11. Given a form or book in which to
help me record the progress I am
making on my goals. 1 2 3 4 5
 Enter Self Management Goal or
Health Maintenance Data in PSL

Click ‘Self
management
goal’’

Enter
‘Additional
information’,
the ‘date’, and
click ‘Save’
*If the exact date is not
known enter the month
and year.
 Application of the Chronic Care Model
GENERAL CAUSE VARIATION

Healthy Stable chronic Unstable

disease chronic disease Hospitalized Post
or at risk or high risk discharge
Acutely ill

• All-payer disease registries

• Measure evidence-based outcomes
• Feedback to providers (by site & clinician)
• Patient education & self-management

• Resources : Patients = Few : Many

• Emphasis: Improve quality for all

TEAM APPROACH
(Physicians, Nurse Practitioners, Social Work...)
 UMHS All Payor Diabetes Quality
Indicators by provider type
Through 12/31/2005; compared to HEDIS 90th percentile as well as to previous time-point (June 30, 2004)

100% 100%

90% 90%

80% 80%

70% 70%

60% 60%

50% 50%

40% 40%

30% 30%

20% 20%

10% 10%

0% 0%
Proteinuria
A1C A1C A1C LDL-C LDLC < LDLC < Monitor for Foot Eye BP <
On Statin and on
Test < 9% < 7% Test 130mg/dL 100mg/dL Nephropathy Exam Exam 135/80
ACE/ARB

PC Only (N=5,582) 91% 81% 50% 93% 81% 61% 66% 71% 80% 57% 66% 48%
Jointly Managed (N=1,640) 97% 83% 46% 95% 84% 65% 64% 92% 80% 81% 73% 54%
E&M Only (N=1,340) 95% 85% 47% 79% 70% 52% 52% 86% 71% 75% 39% 54%
HEDIS 90th (CY 2003) 92% 79% 95% 73% 50% 65% 66%
Total 6/30/2004 92% 79% 42% 88% 74% 52% 51% 68% 70% 53% 49%
Total 12/31/2005 (N=8,562) 93% 82% 49% 91% 80% 60% 64% 77% 79% 64% 63% 50%
 CAD Outcomes

 79% of pts. With LDL<100 in past 12

mos. (goal > 80%)
 88% on anti-hyperlipidemic
medication (goal >90%)
 88% on platelet aggregation
medication (goal > 90%)
Driving 1/3rd of Health Care Costs: The 80%:20% Rule
1%
Severe &
Unique Average Annual
Conditions Costs

9% 1/3rd Total $71,600

Chronic Cost
Conditions

1/3rd Total
cost $6,600
90% High
frequency
common
conditions
1/3rd Total $1,200
cost

From: Franklin Health, Chase H&O

 5%
of population

60% of claims

45% of
population 37%
of claims

50% of population

3%
of claims
3%
of claims

(Todd,W., Nash,D., Disease Management: A Systems Approach to Improving Patient Outcomes, 1997)
 Application of the Chronic Care Model
SPECIAL CAUSE
VARIATION
GENERAL CAUSE VARIATION

Healthy Stable chronic Unstable

disease chronic disease Hospitalized Post
or at risk or high risk discharge
Acutely ill
•7 JCAHO certified disease management programs;
• All-payer disease registries
• Measure evidence-based outcomes
specialty physician + nurse team:
• Feedback to providers Asthma
• Patient education & self-mgt.
• Resources : Patients = Few:Many
Diabetes
• Emphasis = Improve quality for all Depression
Heart Failure
Coronary Artery Disease
Stroke
Spine Pain
TEAM APPROACH
(Physicians, Nurse Practitioners, Social Work...)
 Application of the Chronic Care Model
SPECIAL CAUSE
VARIATION
GENERAL CAUSE VARIATION

Healthy Stable chronic Unstable

disease chronic disease Hospitalized Post
or at risk or high risk discharge
Acutely ill
•7 JCAHO certified disease management programs
• Health Navigator
• All-payer disease registries
• Measure evidence-based outcomes  RNs & Social Workers
• Feedback to providers
• Patient education & self-mgt.
• Resources : Patients = Few:Many
 #1 complaint: “feeling lost in a
• Emphasis = Improve quality for all
complicated system”
 Same-day MMC notification of
discharge or ED visit
 High-cost + High risk reports
 Transitional care
 January/February 2001 – Volume 20, Number 1

HEALTH
AFFAIRS
Interview:
By Fitzhugh Mullan, p137-141
A Founder of Quality Assessment
Encounters A Troubled System Firsthand
“At the University of Michigan, the outpatient and inpatient teams
are entirely separate…There are areas where no one takes
responsibility, where planning is weak, where I am left on my own
…The system is the problem…Things won’t improve until
something is done about the design of the system…The system is
the responsibility of the doctors and the hospital leadership.

…….tell the committee that Donabedian said they have a problem.”

 Clinical Initiatives:
Transitional Care Problems

Problem Example Consequence

Timely appointment not made Health deteriorates

Appointments
Patient unaware of appointment Missed appointment

Contact
Discharge destination unknown Unable to contact patient
Information

Discharge Patient confused about medications Does not take medications

counseling Patient confused about tests Does not go to tests

Lacks transportation Misses appointment

Social
Cannot afford medications Does not take medications

Home care Visiting nurse not available Health deteriorates

 Transaction Costs: The ‘Health Navigator’
“I want to express my appreciation and thanks to the
Medical Management Center, especially Ms. Sue Smart
(Health Navigator) who has been following my case. Ms.
Smart has spent considerable time advising me of different
options and providing valuable information, which she has
attained from numerous independent sources. She has
been an invaluable part of my treatment plan. Her advice
will minimize extra medical appointments and missed
work, which could save tens of thousands of dollars for my
employer. Ms. Smart is the most informed, proactive and
knowledgeable person I have experienced during my 15
years plus of dealing with ‘insurance companies’. She is
absolutely fantastic and a gem!”
 Application of the Chronic Care Model
SPECIAL CAUSE
VARIATION
GENERAL CAUSE VARIATION

Healthy Stable chronic Unstable

disease chronic disease Hospitalized Post
or at risk or high risk discharge
Acutely ill
•7 JCAHO certified disease management programs
• Health Navigator
• All-payer disease registries
• Measure evidence-based
outcomes
• Patient self-monitoring trial for CHF
• Feedback to providers

- Daily input by patient

• Patient education & self-mgt.
• Resources : Patients =
Few:Many
• Emphasis = Improve quality for
all
- Manage ‘by exception’
- Evidence to date is uncertain
 Application of the Chronic Care Model
SPECIAL CAUSE
VARIATION
GENERAL CAUSE VARIATION

Healthy Stable chronic Unstable

disease chronic disease Hospitalized Post
or at risk or high risk discharge
Acutely ill
• 7 JCAHO certified disease management programs
• Health Navigator
• Patient self-monitoring trial for CHF

• Pharmacy management program under MMC

- University purchased contract for PBM services
- Provider-specific utilization feedback
- Pharm D. participates to advise and assist with intervention
- Cost savings of ~$500,000
- Funding additional Pharm D. & server space in 2006
 Lipids: New anti-hyperlipidemic prescriptions by year

Increasing use of preferred drugs over time

1000
Preferred
Non-Preferred 69% 70%
750

62%

500
60%

250

0
1998 1999 2000 2001
 Application of the Chronic Care Model
SPECIAL CAUSE
VARIATION
GENERAL CAUSE VARIATION

Healthy Stable chronic Unstable

disease chronic disease Hospitalized Post
or at risk or high risk discharge
Acutely ill
• 7 JCAHO certified disease management programs
• Health Navigator
• Patient self-monitoring trial for CHF
• Pharmacy management program under MMC

• Resources:Patients = Few:Few
•Emphasis = Intensive Case Management
 DISEASE MANAGEMENT
Volume 9, Number 1, 2006
© Mary Ann Liebert, Inc.

Population-Based Medical and Disease Management: An

Evaluation of Cost and Quality
CHRISTOPHER G. WISE, Ph.D., M.H.A.,1 VINITA BAHL, D.M.D., M.P.P.,2
RITA MITCHELL,2 BRADY T. WEST, M.A.,3 and THOMAS CARLI, M.D.1
ABSTRACT
Reports by the Institute of Medicine and the Health Care Financing Administration have emphasized that the integration of
medical care delivery, evidence-based medicine, and chronic care disease management may play a significant role in improving the
quality of care and reducing medical care costs. The specific aim of this project is to assess the impact of an integrated set of care
coordination tools and chronic disease management interventions on utilization, cost, and quality of care for a population of
beneficiaries who have complementary health coverage through a plan designed to apply proactive medical and disease
management processes. The utilization of health care services by the study population was compared to another population from
the same geographic service area and covered by a traditional feefor-service indemnity insurance plan that provided few medical or
disease management services. Evaluation of the difference in utilization was based on the difference in the cost permember-per-
month (PMPM) in a 1-year measurement period, after adjusting for differences in fee schedules, case-mix and healthcare benefit
design. After adjustments for both case-mix and benefit differences, the study group is $63 PMPM less costly than the comparison
population for all members. Cost differences are largest in the 55-64 and 65 and above age groups. The study group is $115 PMPM
lower than the comparison population for the age category of 65 years and older, after adjustments for case-mix and benefits.
Health Plan Employer and Data Information Set (HEDIS)–based quality outcomes are near the 90th percentile for most indications.
The cost outcomes of a population served by proactive, population-based disease management and complex care management,
compared to an unmanaged population, demonstrates the potential of coordinated medical and disease management programs.
Further studies utilizing appropriate methodologies would be beneficial. (Disease Management 2006;9:44–55)
 Cost Comparisons (PMPM)
Figure 4. Comparison of Per-Member-Per-Month (PMPM) Costs by Age Category
Control Population
$700 MMC Population; adjusted for case-mix & benefits $ 626
$600 MMC Population; adjusted for case-mix only $ 562
$ 511
$ 472
$500 $ 436 MMC Population; unadjusted $ 430
$ 410 $ 409
$ 373 $ 372
$400
PMPM

$ 289
$300 $ 247
$ 214
$ 188 $ 195
$200 $ 165
$ 95 $ 77 $ 85 $ 88
$100
$0
All Members Age<18 Age 18-54 Age 55-64 Age 65+

(Wise CG, et.al., Disease Management 2006;9:44–55)

 PROGRAMS SUPPORTING MMC EFFORTS

1. CMS “Physician Group Practice”

Demonstration Project

2. Blue Cross / Blue Shield of

Michigan “Physician Group
Incentive Program”
 CMS Physician Group Practice
Demonstration Participants

 Geisinger Clinic (PA)  Park Nicollet Health Services (MN)

 Marshfield Clinic (WI)  Integrated Resources for Middlesex (CN)
 The Everett Clinic (WA)
 Forsyth Medical Group (NC)
 St John’s Health System (MO)
 Deaconess Billings Clinic (MT)
 The University of Michigan (MI)
 Dartmouth-Hitchcock Clinic (NH)
 Pay-for-Performance:
Calculating the return
 If UM holds Medicare per-patient case-mix
adjusted cost to 2% less than the growth in
our regional comparison group, UM can “earn
back” up to 80% of the savings over 2%
 Amount of savings returned to UM is based on a
combination of cost savings and quality
 Year 1 = 70% cost savings / 30% quality

 Year 2 = 60% cost savings / 40% quality

 Year 3 = 50% cost savings / 50% quality

 25% of earn-back withheld by CMS until end of

project
 PGP Clinical Quality Indicators:
Weighting by difficulty of data collection
Coronary Artery
Diabetes Mellitus Congestive Heart Failure Preventive Care
Disease
Left Ventricular (LV) Blood Pressure
1 HbA1c Test 4 1 Antiplatelet Therapy 1 1
Assessment Measured
LV Ejection Antihyperlipidemic Blood Pressure
2 HbA1c < 9% 1 4 1 1
Fraction Testing Therapy < 140/90
Blood Pressure Beta-Blocker Therapy: Care Plan if
3 1 Weight Measured 1 1 1
< 140/90 Prior MI elevated BP
Blood Pressure Breast Cancer
4 LDL Test 4 Blood Pressure Measured 1 1 4
Measured Screening
Colorectal Cancer
5 LDL < 130 1 Patient Education 1 Lipid Profile 4 1
Screening

6 Urine Protein Testing 4 Beta-Blocker Therapy 1 LDL < 130 1

ACE-I if diabetes or LV
7 Eye Exam 4 ACE-I (inhibitor) Therapy 1 1
systolic dysfunction

8 Foot Exam 1 Warfarin - atrial fibrillation 1

9 Influenza Vaccination 1 Influenza Vaccination 1

10 Pneumonia Vaccine 1 Pneumonia Vaccination 1

TOTAL Points 22 13 10 8
 Clinical Initiatives:
Complex care coordination solutions

# of
Problem Provider Focus patients

Coordination Nurse navigator Multiple comorbidities, clinically complex 50/month

Social worker Psychosocial problems, frail elderly 70/month
Health navigator Other 2000/mo.

Identification Data analysts High risk and/or high cost patients by:
& monitoring Care managers  real-time review admissions & discharges

 real time review emergency room visits

 establishing automated flags for

 high use – high cost

 high risk – major diseases

Reporting Data Analysts Produce financial & clinical reports

Produce outcome reports
 Turner Emergency
Hospitalist
Dept. Program Clinical
Geriatrics
Care
Coordinators

MCIT
Palliative
Care
CMS Demo
Michigan Core Functions BCBS
Visiting • Health Navigation PGIP
Nurses
• Disease Management
• Transitional Care
• Pharmacy Management Nursing
Homes
• Evidence-based
Office of
Clinical
Affairs
Nurse
Educators

CQIP Discharge Delirium

Planning Project
 BCBSM PGIP
 Payments based on provider’s proportion of ambulatory
activity (E & M codes)
 Quarterly payments to provider groups for:
‘All payer’ chronic disease registries
Innovative implementation strategies
Measured outcomes
Credit for working with other provider groups
Advancing Wagner’s ‘Chronic Care Model’
 Payments to MMC for advancing structure & processes;
no risk arrangement
 Opportunity to collaborate with payer-based programs
 CC

Health System
Community
Resources and Policies Health Care Organization

Self- Delivery Decision Clinical

Management System Support Information
Support Design Systems

GENERAL CAUSE VARIATION SPECIAL CAUSE VARIATION

Healthy Stable chronic Unstable

disease Hospitalized Post
chronic disease
or at risk discharge
Acutely ill or high risk

• All-payer registries • 7 JCAHO cert. DM programs

• Measure evidence-based outcomes
• Feedback to providers
• Patient ed. & self-mgt.
• Resources : Patients = Few : Many
• Emphasis = Improve quality for all
• Health Navigator
• Patient self-monitoring trial for CHF
• Pharmacy Management
• Resources : Patients = Few : Few
• Emphasis = Intensive case management
THE END