Population Health: Prediction in Sensitivity through Cluster Analysis
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Keynote by Katherine J Sullivan, PhD, PT, FAHA, CEO & Founder, Health, Education, & Technology Institute at the Smart Health Conference 2018, held at Bally's Las Vegas on the 26-27th of April, 2018.
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Population Health: Prediction in Sensitivity through Cluster Analysis
- 1. 527 Molino Street, Suite 307 Los Angeles, CA 90013 Population Health: Prediction in Sensitivity through Cluster Analysis Katherine J Sullivan, PhD, PT, FAHA CEO & Founder Health, Education, & Technology Institute
- 2. 811 Traction Ave Los Angeles, CA 90013 360wellness_solutions.net ASK THE RIGHT QUESTION HOW DO WE ACHIEVE THE TRIPLE AIM OF HEALTHCARE REFORM?
- 3. 811 Traction Ave Los Angeles, CA 90013 360wellness_solutions.net BETTER HEALTH OF LOCAL COMMUNITY. BETTER HEALTHCARE BY MEDICARE COMPLIANT ACO PROVIDERS. AT REDUCED COST TO MEDICARE, MEDICARE HMOs, & any global City
- 4. 527 Molino Street, Suite 307 Los Angeles, CA 90013 healthedtech.org Technology Inflection Point: Best care, at the right time, by the most appropriate provider Molina Healthcare - Rehabilitation Services Proposal Technology Partners Reduced health cost: Bundled payment Clinical Outcomes Rehabilitation & Disability Services
- 5. 527 Molino Street, Suite 307 Los Angeles, CA 90013 LA City Population 3,976,322 Children 0-18 yrs 918,530 Healthy 861,581 Special Needs 56,949 Adults 19-64 yrs 2,649,278 Healthy 2,485,581 Special Needs 163,697 Seniors 65+ 417,514 Healthy 229,633 Impaired 187,881 POPULATION HEALTH = PUBLIC HEALTH Dual eligible Children Adults Seniors 408,527 eligible for Rehab Services
- 6. 527 Molino Street, Suite 307 Los Angeles, CA 90013 MICRO ECONOMIES: The Art District/DTLA area is transitioning to a LA version of SOHO. Within a 2-mile radius of the Arts District, lives a population of 165,000; 44% are female girls, women, and seniors (72,600 pop). CLUSTER ANALYSIS:
- 7. 527 Molino Street, Suite 307 Los Angeles, CA 90013 The majority of residents are between 25 – 44 yrs with a median income of $27,000 compared to national median of $56,000. There is a serious shortage of Women’s Health professionals in the target area and business’ owned by women are floundering POPULATION ANALYSIS
- 8. 527 Molino Street, Suite 307 Los Angeles, CA 90013 MediCal City of LA Managed Medicare HOMELESS POPULATION ANALYSIS: Mother’s & Children Mentally ill Physically disabled (need wheelchair) Senior with dementia CONSEQUENCE: High cost to City of LA High cost to Hospital Poor health of homeless Health insurance but no healthcare to child or adult
- 9. Covered California HMO Membership 5/3/2018 Copyright - Intellectual Property of Dr Katherine Sullivan & Health, Education, & Technology Institute 6.3M “Big Brand” Members Full Services Healthy Temporarily Disabled Disability Services Poverty Services Eligible for Medicaid Social Services ≤ 200% FPL Eligible for Medicare Services Functional Disability Senior Services Developmental Disability Services Severe Mental & Physical Disability Homeless with dementia Homeless with substance abuse
- 10. DEGREES OF FREEDOM: 1-year Post-Acute Care Recovery Program Recovery Phases Acute Hospital Admission Physiologic Recovery Strength & Conditioning Resiliency Building Community Re- integration Estimated Timeframe Critically ill Acute or chronic infection 65+ or disabled Post-Acute 1 dy – 90 days Months 4-5-6 Months 7-8-9 Months 10-11-12 Settings Trauma Center, Community Hospital, Critical- access Hospital, ER Skilled Nursing Facility (SNF) Long Term Care Home with Home Health Inpatient Rehab Outpatient Medical, dental, mental health, rehabilitation practice settings Outpatient Medical, dental, mental health, rehabilitation practice settings Outpatient Medical, dental, mental health, rehabilitation practice settings Medicare covered services Medicare Part A Hospital (inpatient) Medicare Part A IRF/ SNF/LTAC (inpatient) Medicare Part B Medical Medicare Part B Medical Medicare Part B Medical Medicare Part B Medical Medicare Part B non- physician professional services (Inpatient rehab) Medicare Part B non- physician professional services Medicare Part B non- physician professional services Medicare Part B non- physician professional services Patient experience Location & Services Complicated discharge plan (homeless, no family, severe) Transitional care (Inpatient SNF/ homeless mental health) Nursing & Rehab Services Assisted living at home with in-home support Rehab Services Team Occupational therapy Rehab Services Team Work re-entry Rehab Services Team
- 11. Technology Inflection Point: Do Well & Do Good Molina Healthcare - Rehabilitation Services Proposal
- 12. 527 Molino Street, Suite 307 Los Angeles, CA 90013 https://youtu.be/gQFpsIdRF6s How can block chain technology transform the healthcare space? What could this mean to increasing access to affordable, timely, effective healthcare for underserved populations?
- 13. 527 Molino Street, Suite 307 Los Angeles, CA 90013 Case Study: Child Poverty Collaborative of Cincinnati & Northern Kentucky
- 14. 527 Molino Street, Suite 307 Los Angeles, CA 90013
- 15. 527 Molino Street, Suite 307 Los Angeles, CA 90013 Technology Partner Health Services Parner Financial Partner
- 16. 527 Molino Street, Suite 307 Los Angeles, CA 90013 Bringing goodness together. https://innovation.cms.gov/initiatives Next-Generation-ACO-Model/
- 17. 527 Molino Street, Suite 307 Los Angeles, CA 90013 Better health of our families. Coordinated care between Medicare professionals. Savings for Medicare.
- 18. 811 Traction Ave Los Angeles, CA 90013 360wellness_solutions.net Los Angeles Population eligible for Medicare Part B Rehab & Recovery Health Home Services 57,000 CHILDREN 164,000 ADULTS 188,000 SENIORS 409,000 HEALTH HOME MEMBERS
- 19. 527 Molino Street, Suite 307 Los Angeles, CA 90013 healthedtech.org 3+ health conditions 2 or more ADL limitations (difficulty walking, talking, living alone, homeless) severe cognitive (dementia) or motor (paralysis) 85 or older Developmental Disabilities Chronic Health Conditions Mental Health Conditions with or without Addiction Long Term or End-of-Life Care Management HMO Payor plans control practice, payments, and hospitals: Technology can create savings through coordinated care Referral from: Disability Service Providers for Children & Adults with: Primary Care Doctor Hospital ER Or Community Clinic HMO Managed MediCal or Medicare health plan
- 20. 811 Traction Ave Los Angeles, CA 90013 360wellness_solutions.net Financial projections for LA based on NY State Medicaid Health Home mid-severity rate: 40,900 (10% capture of 409,000) $235 per member per month 9.6M per month (115M per yr)
- 21. 527 Molino Street, Suite 307 Los Angeles, CA 90013 The Touchstone Survey notes that “participants appear to be in a "wait and see" mode – rather than considering broader and more transformational changes, they continue to use traditional cost-shifting approaches to control health spend;” and that “57% of participants expect to continue to increase employee contributions in the next three years, while 38% (29% for Rx) plan to increase employee cost-sharing through plan design changes.” Accountable Care: Better health. Better healthcare. Reduced cost to society.
- 22. 811 Traction Ave Los Angeles, CA 90013 360wellness_solutions.net BETTER HEALTH OF LOCAL COMMUNITY. BETTER HEALTHCARE BY MEDICARE COMPLIANT ACO PROVIDERS. AT REDUCED COST TO MEDICARE, MEDICARE HMOs, & any global City ASK THE RIGHT QUESTION HOW DO WE ACHIEVE THE TRIPLE AIM OF HEALTHCARE REFORM?
Editor's Notes
- Health Plans and the Opiod Abuse Crisis By Clive Riddle, April 7, 2017 The Associated Press reports that Dr. Scott Gottlieb, “the doctor nominated to head the powerful Food and Drug Administration told senators Wednesday that his first priority would be tackling the opioid crisis.” What are health plans doing about Opiod Abuse? Last June, the California Health Care Foundation released a report taking the issue on: Changing Course: The Role of Health Plans in Curbing the Opioid Epidemic, along with companion California health plan case studies and an infographic. Nationally, last fall AHIP weighed in, discussing how health plans are Fighting Opioid Abuse With Solutions That Work. So what are some current developments on the health plan Opioid Abuse front? Cigna has just announced that Use of Prescribed Opioids Down Nearly 12 Percent Over 12 Months Among Cigna Customers. Cigna reports that “58 medical groups participating in Cigna Collaborative Care, representing nearly 62,000 doctors, have signed Cigna's pledge to reduce opioid prescribing and to treat opioid use disorder as a chronic condition.” Cigna states that their program works with participating doctors to: (1) Analyze integrated claims data across pharmacy and medical benefits to detect opioid use patterns that suggest possible misuse by individuals, and then notifying their health care providers; (2) Alert doctors when their opioid prescribing patterns are not consistent with CDC guidelines; and (3) Establish a database of opioid quality improvement initiatives for doctors. Cigna also reports that “effective July 1, most new prescriptions for a long-acting opioid that are not being used as part of treatment for cancer or sickle cell disease, or for hospice care, will be subject to prior authorization, and most new prescriptions for a short-acting opioid will be subject to quantity limits.” Last week the Wisconsin Association of Health Plans announced their member plans have jointly committed to combating opioid abuse and addiction in Wisconsin and effective April 1, Wisconsin's community-based health plans are collaborating on new initiatives. The Association members agreed to: (1) support the Association’s Statement of Principles for addressing opioid abuse that “form the basis for sharing information, best practices and evidence-based strategies”; (2) Track morphine equivalent dose and first-time user trends for their individual and employer group members,, generating comparative data to enrich provider education and management of prescription drug formularies and coverage policies; (3) Work with provider partners to support strategies to reduce and control the level of opioid prescribing; (4) Share methodologies, best practices and evidence-based strategies to improve the quality of pain management and opioid prescribing; and (5) Ensure that every member suffering from opioid abuse has access to medically-appropriate treatment options. Two weeks ago BlueCross BlueShield of Western New York released episode four of their Point of Health Audiocast, “Addressing the Opioid Epidemic from a Health Plan Perspective,” aimed at increasing awareness of the issue and engaging stakeholders. FamilyCare Health, a health plan serving Oregon Medicaid and Medicare members, “kicks off its 4-part Opioid Training series for providers on Thursday, April 27, 2017 with ‘Buprenorphine: What we know and what we don’t. Prescribing safely for pain management and opioid dependence.’ “ And last week, Prime Therapeutics, the Blue Cross Blue Shield Association PBM, released two studies,highlighting strategies for addressing opioid epidemic. The first study “analyzed concurrent use of opioids with benzodiazepines”, citing “previous research has shown concurrent use of these two types of drugs can increase the risk of overdose and death,” and “found more than one in six opioid users without cancer – or nine per 1,000 commercially insured members – used these two drugs concurrently for 30 days or more in 2015.” Their second study “found pharmacists based in a PBM or health plan, who do outreach to prescribers, can reduce emergency room visits and controlled substance drug costs among persistent users of controlled substances.” Following the outreach conducted with the study intervention group, “controlled substances drug costs per member for the intervention group dropped from $5,802 to $5,148, while controlled substance drug costs increased for the control group from $3,511 to $3,627 per member. Emergency department visits were 6.4 percent lower in the intervention group, compared with the control group.” SHARE THIS POST POST A COMMENT BY RIDDLE, CLIVE | FRIDAY, APRIL 7, 2017 AT 10:24AM TAGGED CLINICAL & QUALITY, COST & UTILIZATION,
- What Goes into Combating Healthcare Fraud By Claire Thayer, April 27, 2017 According to the National Health Care Anti-Fraud Association, most health care fraud is committed by organized crime groups and a very small minority of dishonest health care provider. The NHCAA tells us that the most common types of fraud include: · Billing for services that were never rendered-either by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place. · Billing for more expensive services or procedures than were actually provided or performed, commonly known as "upcoding"-i.e., falsely billing for a higher-priced treatment than was actually provided (which often requires the accompanying "inflation" of the patient's diagnosis code to a more serious condition consistent with the false procedure code). · Performing medically unnecessary services solely for the purpose of generating insurance payments. · Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments-widely seen in cosmetic-surgery schemes, in which non-covered cosmetic procedures such as "nose jobs" are billed to patients' insurers as deviated-septum repairs. · Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary. · Unbundling - billing each step of a procedure as if it were a separate procedure. · Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract. · Accepting kickbacks for patient referrals. · Waiving patient co-pays or deductibles for medical or dental care and over-billing the insurance carrier or benefit plan (insurers often set the policy with regard to the waiver of co-pays through its provider contracting process; while, under Medicare, routinely waiving co-pays is prohibited and may only be waived due to "financial hardship"). While the U.S. Department of Justice, FBI, CMS and other government entities are busy identifying and tracking down fraud schemes, Deloitte research points out that an emerging area of interest in health care fraud and abuse enforcement is that of relationship scrutiny.