Key Highlights
- Slashed cost of office-administered drugs by over $1 million
- Elevated patient experience, extending in-home services to a significantly larger member base
- Armed with critical information, ATRIO wielded substantial leverage in contract negotiations with hospitals
ATRIO Health Plans is an organization owned by several providers in and around Salem, Oregon. It has almost 30,000 members, and 90% are Medicare enrollees.
The challenge
As with every health plan, ATRIO is constantly looking for ways to improve patient care and the bottom line.
The approach
When ATRIO made the strategic decision to invest in data analytics and began using Milliman MedInsight, then-Chief Medical Officer Dr. Tom Culhane quickly identified segments of their data that warranted a closer look.
The following three categories are areas where Dr. Culhane saw an opportunity, delved deeper, and acted:
Controlling the ballooning cost of office-administered drugs
With the cost of office-administered drugs peaking at $6.5 million, Dr. Culhane wanted to know what was driving the surge. “When costs are out of whack, it’s either the cost of the drugs, the utilization of those drugs, or an unwillingness to switch to lower cost alternatives,” he said.
He built a custom report in MedInsight to determine which of the following three drivers was inflating the cost of office-administered drugs the most:
- Was ATRIO paying too much for the drugs it administered in the office?
- Were doctors administering more drugs in the office than necessary?
- Were there lower-cost alternative drugs that should be substituted?
Prioritizing valuable case management resources
ATRIO’s four Independent Practice Associations (IPAs) handle case management across six counties in Western and Southern Oregon. With limited resources, it’s important that the right patients receive monitoring and assistance. Dr. Culhane wanted a surefire method for identifying the patients who would benefit most from case management.
Case management is largely driven by the desire to manage risk, which means it’s helpful to know how individual patients compare. While tracking current risk is fairly straightforward, it only provides a snapshot of a patient’s risk level today. Identifying areas with the most opportunity means zeroing in on patients who are likely to become risky in the future.
Dr. Culhane used data from the Milliman Advanced Risk Adjusters to rank his patients by prospective risk and created a list of the top 25 riskiest members in each region. With a list of members in hand, the case management teams in each IPA were ready to optimize for site of service and promote preventive care.
Comparing data to benchmarks
ATRIO was tracking and analyzing its own data quite effectively, but Dr. Culhane realized that even the most comprehensive data is missing context without benchmarks. He took advantage of MedInsight’s benchmarking capabilities—the most comprehensive in the industry—to learn more about how ATRIO’s data compared to wider trends.
The solution
Controlling the ballooning cost of office-administration drugs
The MedInsight Claims Report revealed that the lack of substitutions was the largest culprit. By examining the highest performing doctors in their network, ATRIO discovered that many were already using lower-cost alternative drugs. For example, one doctor was using a drug to treat macular edema that was ten times less expensive than the standard medication, despite having comparable outcomes.
Through conversations with providers, working with their IPAs and better data monitoring, ATRIO successfully reduced the cost of office-administered drugs by over $1 million.
Outcomes
- Identified the trend of increasing spend on office-administered drugs
- Negotiated lower prices for office-administered drugs
- Developed a system for tracking unnecessary office-administered drugs
- Identified lower-cost substitution drugs
- Decreased the cost of office-administered drugs by $1,049,950
Prioritizing valuable case management resources
Case managers with access to MedInsight ran various reports at the member level and found opportunities to shift care to home visits, instead of a hospital setting. Patients usually prefer the ease of home visits, especially if mobility is an issue, and there are significant cost savings for all parties.
In addition to home visits, case managers were encouraged to track preventive care measures. A Healthcare Effectiveness Data and Information Set (HEDIS) score is part of every member profile in MedInsight. This simple metric shows recommended preventive care so case managers can proactively schedule diabetes screenings, cholesterol screenings, and other measures—preferably at the same time to maximize every visit.
Outcomes
- Reduced hospital admissions by identifying and managing patients with the highest risk
- Improved the patient experience by offering in-home services to more members
- Avoided long-term costs by improving preventive care with HEDIS scores
- Made each office visit more efficient by identifying HEDIS opportunities in advance
Comparing data to benchmarks and spotting anomalies
While the benchmark data revealed several areas for further review, one that caught his eye was emergency department admissions. He was concerned to see his overall ED admits increasing year over year, but learned that the industry is seeing the same trend.
Next, Dr. Culhane dove a little deeper within MedInsight and examined the coding trends over the years. It became clear that ED coding was shifting towards more severe cases, but there was no evidence to show that the population was getting sicker. Instead he pinpointed a single hospital that recently began to consistently code its patients as level five, the most severe classification. Armed with the ad-hoc tool, MedInsight Query Express®, and the benchmarks that revealed just how extreme the variation was, ATRIO had more leverage when negotiating with providers.
Outcomes
- Identified a growing trend of higher emergency room admissions
- Confirmed that increased ED admits are a macro trend, not a fluke within ATRIO
- Discovered wide variance across providers in how they code ED visits
- Provided information and leverage for contract negotiations with hospitals
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