CareScientific PBMI


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Launch of CareScientific at PBMI 2009 with discussion around plausibility of DM programs to give an ROI

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CareScientific PBMI

  1. 1. The Disease Management Imperative: Collaborating To Improve Outcomes 2009 PBMI Drug Benefit Conference Brenda Motheral, PhD President, CareScientific 1
  2. 2. A Tipping Point for Disease Management Failures of Disease Management Potential for New Models of Collaboration A Critical Element to Future Success
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  4. 4. Up to now, the CMS, like other payers, has accepted clinical rationales and the promise of cost savings to undertake DM demonstrations. Given the lack of broad success, it raises questions about the impacts and reports of cost savings with DM in other settings. CMS (Bott et al.), Health Affairs, 2009 4
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  6. 6. “Some Quality Measures in MHS Improved, Yet Outcomes Didn’t. So what happened? Simply this: the hypothesized pathway between quality improvement and quality outcomes ain’t necessarily so. “ Medicare Health Support: 8 Takeaways on Building Better Bridges by Thomas Wilson, PhD, DrPH and Vince Kuraitis January 7, 2009 6
  7. 7. Formula-driven ROI is not really ROI Compared to what? COST MEAN Lowest Highest cost cost group group 7
  8. 8. Are Savings Plausible? $ Per Asthmatic % of Total Per Year Expenditure Total Spend $2,000 ER/IH Spend-All Reasons $1,000 50% ER/IH Spent-Asthma Related $500 25% Program Fee $100 5% Asthma-related ER/IH To get a must decrease 40% 2:1 ROI If 25% reached, must decrease 160% among reached members Source: Lewis and Linden. 8
  9. 9. Plausibility Calculator available at 9
  10. 10. Clinically Appropriate Cost Effective Cost Saving 10
  11. 11. Preventing chronic disease: An important investment, but don’t count on cost savings. Careful choice about frequency, groups to target and component costs can increase the likelihood that interventions will be highly cost-effective or even cost-saving. Russell. Health Affairs. 2009 11
  12. 12. Focus on cost-saving behaviors More cost- Smoking cessation effective Aspirin – Cardiovascular Disease BMI < 30 Blood pressure control – Diabetes Statins – Coronary Artery Disease Blood Pressure – Hypertension Cost-saving BB and ACE – Heart Failure BB – post – Myocardial Infarction Cost-effective Warfarin – Atrial Fibrillation Steroid – Asthma Clinically appropriate Kidney FX – Diabetes Retinal exam – Diabetes Foot Exam – Diabetes Kahn, Diabetes Care, 2008 Less cost- A1C test – Diabetes Brantes, American Journal of Managed Care, 2008 effective Lipid Profile - Diabetes 12
  13. 13. Know  Learn from history…or be destined to repeat it What  Collaboration necessary but not sufficient Saves  Cost-effectiveness integral to real savings 13