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Patient Engagement: Motivation as the Tipping Point
Understanding how patient motivation changes the care management approach
May 8, 2014
Speakers
Kim Jayhan
Senior Director, Solutions Architect & Consulting,
LexisNexis 
Population Health Management 2
Today’s Topic
Patient Engagement: Motivation as the Tipping Point
Understanding how patient motivation changes the care management approachUnderstanding how patient motivation changes the care management approach
The ACA and other health reform initiatives have driven the need to use analytics to 
enhance the care management experience. As workflows change and new approaches 
are explored, patient motivation becomes the “tipping point” of success in surfacing 
true opportunities for reduced and avoidable costs. This session will explore how to 
combine analytics, using patient motivation as a cornerstone, and incorporating greater 
insights into the clinical workflows, resulting in successful engagements.insights into the clinical workflows, resulting in successful engagements.
Population Health Management 3
tip∙ping point
noun
the point at which a series of small changes orthe point at which a series of small changes or 
incidents becomes significant enough to cause 
a larger, more important change.
“That is the paradox of the epidemic: that in order to create one contagious 
movement, you often have to create many small movements first.”
“The tipping point is that magic moment when an idea, trend, or social 
behavior crosses a threshold, tips, and spreads like wildfire.”
“If you want to bring a fundamental change in people's belief and behavior...you 
need to create a community around them, where those new beliefs can be 
practiced and expressed and nurtured.”
Population Health Management 4
Source:  Malcolm Gladwell, The Tipping Point: How Little Things Can Make a Big Difference
AgendaWhat We Will Discuss Today
The 
h ll
• Common Problems – Chronic Diseases
• Avoidable Costs – Sources
• Impact from Non‐Adherence/Non‐ComplianceChallenge • Impact from Non‐Adherence/Non‐Compliance
• Improved Analytics to Stratify & Manage Patients
The 
Opportunity
• Improved Analytics to Stratify & Manage Patients
• Intervene with Patients to Avoid Increased Risk & Cost
• Clinical Integration, Data Sharing & Technology to Engage Patients
• Reductions in Cost/Resources
• Increased Compliance
The Impact
• Increased Compliance
• Avoidance of Disease/Worsening Conditions
• Healthier Populations
Population Health Management 5
The Challenge
Population Health Management
Challenges: Common Problems Contributing to High Costs/Risks
• An estimated 26.7% of Adults in the U.S. were reported to be obese in 2009.
o Annual healthcare cost of obesity in U.S. (2008) was $147 billion/year
o Approximately 300,000 deaths per year directly related to obesity
• More than 1/3 of Adults have 2 or more major risk factors for heart disease.
o Leading cause of morbidity, mortality and health care spending/utilization
• Diabetes is 7th leading cause of death in U.S.
o $116 billion in total U.S. healthcare system costs in 2007
o Nearly 24 million Americans have diabetes
o Approximately 5.7 million have diabetes, but don’t know it.o Approximately 5.7 million have diabetes, but don t know it.
o Approximately 186,300 individuals younger than 20 have either Type 1 or Type 2 diabetes.
• Tobacco use is the largest cause of preventable morbidity and mortality in the U.S.
o 430 000 deaths each yearo 430,000 deaths each year
o 1 in 5 Adults and 1 in 5 HS Students Smoke, in spite of declined use
o For every person that dies from smoking related disease, 20 more people have 
at least one serious disease related to its use.
7
Source: Vital Signs: State‐Specific Obesity Prevalence Among Adults ‐‐‐ United States, 2009
Source:  Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using Medicines More Responsibly. Report by the IMS Institute for Healthcare Informatics.
Population Health Management
The World of Healthcare is ChangingBeyond Chronic Conditions, Challenges Loom Large
• B b B A l ti C Mi i hifti• Baby Boomers ‐ As population ages, Case Mix is shifting 
away from more profitable to less profitable care
• Legislation now provides for significant expansion in• Legislation now provides for significant expansion in 
Medicaid coverage, including Dual Eligibles
• Triple Aim and Health Reform are driving focus onTriple Aim and Health Reform are driving focus on
Outcomes, Patient Satisfaction and Reduced Costs
8Population Health Management
What is Avoidable?
68% 
of avoidable 
costs
9
Source:  IMS Institute for Healthcare Analytics, Avoidable costs in healthcare study, June 2013
Population Health Management
What is the Impact of Avoidable Costs Due to Medication Non‐Adherence?
68.6% 
Centered on
Two
72.3% 
Hospital 
Related
Two 
Conditions
Costs
10
Source:  IMS Institute for Healthcare Analytics, Avoidable costs in healthcare study, June 2013
Population Health Management
What is the Impact of Delayed Compliance to Measures?
98.3% 
Centered on
Diabetes
86.5% 
Centered on
Hospital &Diabetes Hospital &
Outpatient
Related 
Costs
Population Health Management 11
Source:  IMS Institute for Healthcare Analytics, Avoidable costs in healthcare study, June 2013
Why Expert Care Management is Critical:
Sample Complications Without Interventions
Condition Complication as a Result of Non 
Adherence
Hypercholesterolemia Acute Myocardial Infarction (AMI)Hypercholesterolemia Acute Myocardial Infarction (AMI)
Diabetes Stroke, Renal Disease, Cardiac
H t i A t M di l I f tiHypertension Acute Myocardial Infarction
C ti H t F il (CHF) All li ti lti i dditi lCongestive Heart Failure (CHF) All complications resulting in additional 
inpatient, outpatient, emergency room 
and pharmacy utilization, calculated as 
incremental difference between non‐incremental difference between non‐
adherent and adherent CHF patients
12
Source:  IMS Institute for Healthcare Analytics, Avoidable costs in healthcare study, June 2013
and LexisNexis
Population Health Management
The Opportunity
Population Health Management
Population Health Management through Risk Stratification
• Stratifying patients along a management & intervention Care Spectrum
• Identifying the most actionable patients• Identifying the most actionable patients
• Empowering your patient care through risk predictions
Well 
Members
Well 
Members
Low Risk 
Members
Low Risk 
Members
Medium
Risk 
Members
Medium
Risk 
Members
High Risk 
Multiple 
Disease 
States
High Risk 
Multiple 
Disease 
States
Catastrophic 
Care
Catastrophic 
Care
PreventionPrevention
Prevention 
and Disease 
Management
Prevention 
and Disease 
Management
Disease 
Management
Disease 
Management
Episodic Case 
Mgmt
Episodic Case 
Mgmt
Inpatient
LTC
Inpatient
LTCManagementManagement gg gg
14Population Health Management
Evolving Trends – Impact on Patient Engagement
Out with the OLD……………
In with the NEW
Patient/Consumer Care & Engagement
• Quality vs. Cost Focus Shift
• Patient Rating of Physicians & Experience
In with the NEW……………
• Patient Rating of Physicians & Experience
• More Outreach, More Proactive Care
• Access to care team through email, secured messaging and patient portals
• Wellness Programs Sponsored by Health Plans and Employers (including Benefit Redesigns)
Focus on Diet & Exercise vs MedicationsFocus on Diet & Exercise vs. Medications
Health Coaching
Apps for self management
Web Based Education
• Patient/Member Incentives for Compliance, Improvements and Pro‐active Preventive Care
15Population Health Management
“The tipping point is that magic moment when an idea, trend, or social behavior 
crosses a threshold, tips, and spreads like wildfire.”
Predicted Risks & Costs
Patient Compliance to Evidence Based Protocols 
Patient Motivation
16Population Health Management
“That is the paradox of the epidemic: that in order to create one contagious 
movement, you often have to create many small movements first.”
Surface Opportunities
Patients at Risk
Who Can You Engage & Impact?
Improved Compliance?
Reduced Admissions/Readmissions?
Reduced Costs?
R d d M t lit ?Reduced Mortality?
Downward Shifts in Risk?
Is Patient Engaged?
Evaluate Opportunities
Evaluate Performance of 
Programs or Initiatives
Can you engage the patient?
Predictions
Non Compliance
Medication
Clinical Measures
Underlying Risks
Design Care 
Management Programs/ 
Interventions
Operate Programs or 
Initiatives
Motivation
Access to Care
Education
Identify Providers
Collaboration
Transparency
Data Sharing
Outreach
How to engage the patient?
Data Sharing
Monitor Patient Engagement
17Population Health Management
“If you want to bring a fundamental change in people's belief and behavior ... 
you need to create a community around them, where those new beliefs can be practiced and 
expressed and nurtured.”
UTILIZATION‐DRIVEN STRATIFICATION ANALYTICS‐DRIVEN STRATIFICATION
Looking at future risk
Episode‐Driven
Looking at past risk
Condition‐Driven
Diabetes
3402
All 
Three
Diabetes
2999
Hypertension
2163
vs.
DiabetesDiabetes
Hypertension
2163
3402
1265
3402
2163
Hyperlipidemia
1902
$$$$$
Highly 
Motivated 
326
Risk Driver 
Heart 
Disease
410
Risk Driver
Kidney 
Disease
312
Analytics Driven Stratification Results
TriMorbid Population (1265)
(Diabetic, Hypertensive, Hyperlipidemia)
• Highly Motivated  (326)
Ri k D i H t Di (410)$$$$$ • Risk Driver – Heart Disease (410)
• Risk Driver – Kidney Disease (312)
18Population Health Management
Analytics as the Change Agent
Create specific program tracks that focus on WHERE the 
opportunity actually is for improvements & cost savings 
( ‘tri‐morbid’ diabetics population in this example)(  tri morbid  diabetics population in this example).  
Use Motivation Index & Gaps in Care Impact Prediction to StratifyUse Motivation Index & Gaps in Care Impact Prediction to Stratify 
for Low Touch Program(s).
Engage Care Management.
Employ Clinical Integration & Data Sharing for Hospital Partners,
Physicians & Ancillary Providers.
Measure Impact to Outcomes & Costs/ Avoidable Costs.
Physicians & Ancillary Providers.
19Population Health Management
Impact of Starting with Highly Motivated Patients
Stratification first on Highly Motivated, then on Predicted Cost Changes
Risk Category # Highly  Avg Total  Avg Forecasted  % Change
Motivated 
Members
Cost Cost
Risk Category 5 (High) 290 $40,956 $39,338 ‐4.1%
Risk Category 4 632 $8 719 $13 022 33 0%Risk Category 4 632 $8,719 $13,022 33.0%
Risk Category 3 589 $3,389 $7,478 54.7%
Risk Category 2 312 $1,787 $4,796 62.7%*
Risk Category 1 (Low) 137 $1,296 $2,512 48.4%
ALL HIGHLY MOTIVATED 1,960 $10,265  $13,206  22.3%
Approximately $1.1m opportunity at level 2*
20Population Health Management
The Future
Predicted Risks & Costs
Patient Compliance to Evidence Based Protocols p
Patient Motivation
Public Data & Its Influence to Patient Risk
21Population Health Management
The Impact
Population Health Management
“The tipping point is that magic moment when an idea, trend, or social behavior 
crosses a threshold, tips, and spreads like wildfire.”
Factors Contributing to 
Higher Adherence
• Lower costs for generics for 
major chronic conditions
• Education & Awareness – Impact 
of Non Adherence
• Technology/Analytics Enabling
Targets for Non Compliance
• Changes in Reimbursement Models• Changes in Reimbursement Models
Rewards for Compliance & 
Quality
23Population Health Management
Improvements in First Year Program
FIRST YEAR OF
CARE MANAGEMENT
Created a Provider 
and Health Plan 
Partnership to:
• Improve care processes
Developed “Disease 
Bundles” to Measure 
Progress
Example: Preventive care
Identified Cases 
Using Predictive 
Analytics and 
Post‐discharge 
PROGRAM
• Improve care processes 
and outcomes for the 
individuals and the 
population
• Improve the quality and 
Example: Preventive care 
bundle that includes 
diseases such as cancer, 
lipid, diabetes and 
chlamydia screening and 
g
Information
Uses risk ranking and 
mover identificationAnalytics using 
compliance and 
DECREASED 
TOTAL 
MEDICAL COST
IMPROVED 
OVERALL 
COMPLIANCE
efficiency of care immunization
DECREASED 
ADMISSIONS
motivation focused on 
improving compliance, 
and resulted in 
exceeding goals, while  MEDICAL COSTCOMPLIANCE
75 %
decreasing inpatient 
resources and 
impacting overall  
costs.
Diabetes 
bundle
Coronary 
disease
bundle
Preventive
care
bundle
30 %
20 % 7 %
*Results are measured 
across the entire 
ReadmissionsAdmissions
15 %
25 %
bundle bundle
population of patients
24Population Health Management
Case Study: Identify the populations where you can have the greatest impact
Focused Disease Management and Outreach Program
High Risk for 
Emergency Room 
Services
Children and Adults 
with Asthma
Disabled Adults 
with Chronic or 
Complex Disease  ServicesCo p e sease
Issues
2.3M 
population
260,000 
Enrolled in Program
25Population Health Management
Using Motivation to Drive Improvements
FOR 
PARTICIPANTS 
WITH 
ASTHMA:
FOR PARTICIPANTS 
WITH DIABETES:
• 36% improvement 
in retinal eye
FOR PARTICIPANTS WITH 
CORONARY ARTERY 
DISEASE:
• 26% improvement in
FOR PARTICIPANTS WITH HEART 
FAILURE AND/OR COPD:
• 41% improvement in spirometry 
testing in COPD
• 33% 
reduction in 
inpatient 
utilization for 
asthma
in retinal eye 
examinations
• 11% improvement 
in testing for kidney 
damage
11% i t
26% improvement in 
reported rate of 
vaccination for 
pneumococcal infections 
(pneumonia)
9% i t i
g
• 21% improvement in reported 
rate of vaccination for 
pneumococcal infections 
(pneumonia) 
• 15% improvement in rate of betaasthma
• 20% 
improvement 
of use of 
written 
• 11% improvement 
in statin (cholesterol 
lowering Rx)
• 10% improvement 
in aspirin use
• 9% improvement in 
statin (cholesterol 
lowering Rx)
• 8% improvement in 
cholesterol testing
• 15% improvement in rate of beta 
blocker medication use
Net savingsNet savingsaction plans 
for persons 
with asthma
• 9% improvement in 
cholesterol testing
$169 Milli
$262 Million
4th Year Savings
Net savings Net savings 
ofof$569 $569 
MillionMillion
$34 Million
1st Year Savings
$104 Million
2nd Year Savings
$169 Million
3rd Year Savings
26Population Health Management
Conclusion
Population Health Management
“There is a simple way to package information that, under the right 
circumstances, can make it irresistible. All you have to do is find it.”
tip∙ping point
noun
the point at which a series of small changes or incidents becomes significant enough to cause a larger, more important change.
State of the
Art
Innovative
Strategies
Vast
Comprehensive
Better Outcomes
Art
Technology
StrategiesComprehensive
Data
+ + =
• Reduce wasteful spending
• Optimize operational 
efficiencies
• Improve patient health
28Population Health Management
Q&A
Source:  Malcolm Gladwell, The Tipping Point: How Little Things Can Make a Big Difference
29Population Health Management
Contact 
Kim Jayhan
Senior Director, Solutions Architect & Consulting
LexisNexis Risk SolutionsLexisNexis Risk Solutions
800.869.0751
kjayhan@medai.com
LinkedIn Group: LexisNexis Health Care Solutions
Twitter: @LexisHealthCareTwitter: @LexisHealthCare
This presentation in part or in whole cannot be copied, altered, or reproduced in any way without written consent from LexisNexis Risk Solutions.
30Population Health Management

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