The Net Fiscal Impact Of A Chronic Disease Management Program: Indiana Medicaid

A cluster-based approach for integrating clinical management of Medicare beneficiaries with multiple chronic conditions

Background

Approximately 28% of adults have ≥3 chronic conditions (CCs), accounting for two-thirds of U.S. healthcare costs, and often having suboptimal outcomes. Despite Institute of Medicine recommendations in 2001 to integrate guidelines for multiple CCs, progress is minimal. The vast number of unique combinations of CCs may limit progress.

Methods and findings

To determine whether major CCs segregate differentially in limited groups, electronic health record and Medicare paid claims data were examined in one accountable care organization with 44,645 Medicare beneficiaries continuously enrolled throughout 2015. CCs predicting clinical outcomes were obtained from diagnostic codes. Agglomerative hierarchical clustering defined 13 groups having similar within group patterns of CCs and named for the most common CC. Two groups, congestive heart failure (CHF) and kidney disease (CKD), included 23% of beneficiaries with a very high CC burden (10.5 and 8.1 CCs/beneficiary, respectively). Five groups with 54% of beneficiaries had a high CC burden ranging from 7.1 to 5.9 (descending order: neurological, diabetes, cancer, cardiovascular, chronic pulmonary). Six groups with 23% of beneficiaries had an intermediate-low CC burden ranging from 4.7 to 0.4 (behavioral health, obesity, osteoarthritis, hypertension, hyperlipidemia, ‘other’). Hypertension and hyperlipidemia were common across groups, whereas 80% of CHF segregated to the CHF group, 85% of CKD to CKD and CHF groups, 82% of cancer to Cancer, CHF, and CKD groups, and 85% of neurological disorders to Neuro, CHF, and CKD groups. Behavioral health diagnoses were common only in groups with a high CC burden. The number of CCs/beneficiary explained 36% of the variance (R² = 0.36) in claims paid/beneficiary.

Conclusions

Identifying a limited number of groups with high burdens of CCs that disproportionately drive costs may help inform a practical number of integrated guidelines and resources required for comprehensive management. Cluster informed guideline integration may improve care quality and outcomes, while reducing costs.

Effects of Medicaid disease management programs on medical expenditures: Evidence from a natural experiment in Georgia

In recent decades, most states' Medicaid programs have introduced disease management programs for chronically ill beneficiaries. Interventions assist beneficiaries and their health care providers to appropriately manage chronic health condition(s) according to established clinical guidelines. Cost containment has been a key justification for the creation of these programs despite mixed evidence they actually save money. This study evaluates the effects of a disease management program in Georgia by exploiting a natural experiment that delayed the introduction of high-intensity services for several thousand beneficiaries. Expenditures for medical claims decreased an average of $89 per person per month for the high- and moderate-risk groups, but those savings were not large enough to offset the total costs of the program. Impacts varied by the intensity of interventions, over time, and across disease groups. Heterogeneous treatment effect analysis indicates that decreases in medical expenditures were largest at the most expensive tail of the distribution.

Clinical metric and medication persistency effects: evidence from a Medicaid care management program

The objective was to estimate clinical metric and medication persistency impacts of a care management program. The data sources were Medicaid administrative claims for a sample population of 32,334 noninstitutionalized Medicaid-only aged, blind, or disabled patients with diagnosed conditions of asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes, or heart failure between 2005 and 2009. Multivariate regression analysis was used to test the hypothesis that exposure to a care management intervention increased the likelihood of having the appropriate medication or procedures performed, as well as increased medication persistency. Statistically significant clinical metric improvements occurred in each of the 5 conditions studied. Increased medication persistency was found for beta-blocker medication for members with coronary artery disease, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and diuretic medications for members with heart failure, bronchodilator and corticosteroid medications for members with chronic obstructive pulmonary disease, and aspirin/antiplatelet medications for members with diabetes. This study demonstrates that a care management program increases the likelihood of having an appropriate medication dispensed and/or an appropriate clinical test performed, as well as increased likelihood of medication persistency, in people with chronic conditions.

Health care savings with the patient-centered medical home: Community Care of North Carolina's experience

This study evaluated the financial impact of integrating a systemic care management intervention program (Community Care of North Carolina) with person-centered medical homes throughout North Carolina for non-elderly Medicaid recipients with disabilities during almost 5 years of program history. It examined Medicaid claims for 169,676 non-elderly Medicaid recipients with disabilities from January 2007 through third quarter 2011. Two models were used to estimate the program's impact on cost, within each year. The first employed a mixed model comparing member experiences in enrolled versus unenrolled months, accounting for regional differences as fixed effects and within physician group experience as random effects. The second was a pre-post, intervention/comparison group, difference-in-differences mixed model, which directly matched cohort samples of enrolled and unenrolled members on strata of preenrollment pharmacy use, race, age, year, months in pre-post periods, health status, and behavioral health history. The study team found significant cost avoidance associated with program enrollment for the non-elderly disabled population after the first years, savings that increased with length of time in the program. The impact of the program was greater in persons with multiple chronic disease conditions. By providing targeted care management interventions, aligned with person-centered medical homes, the Community Care of North Carolina program achieved significant savings for a high-risk population in the North Carolina Medicaid program.

Dose-response effects for disease management programs on hospital utilization in Illinois Medicaid

The objective of this study is to estimate a dose-response impact of disease management contacts on inpatient admissions. Multivariate regression analysis of panel data was used to test the hypothesis that increased disease management contacts lower the odds of an inpatient admission. Subjects were 40,452 members of Illinois' noninstitutionalized Medicaid-only aged, blind, or disabled population diagnosed with asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes, and/or heart failure. All members are also in the state's Illinois Health Connect program, a medical home strategy in place for most of the 2.4 million Illinois Medicaid beneficiaries. The statistical measure is the odds ratio, which is a measure of association between the monthly inpatient admission indicator and the number of contacts (doses) a member has had for each particular disease management intervention. Statistically significant contacts are between 8 and 12 for heart failure, between 4 and 12 contacts for diabetes, and between 8 and 13 contacts for asthma. Total inpatient savings during the study period is estimated to be $12.4 million. This study shows the dose-response pattern of inpatient utilization improvements through the number of disease management contacts.

Economic impact of a Medicaid population health management program

A population health management program was implemented to assess growth in health care expenditures for the disabled segment of Georgia's Medicaid population before and during the first year of a population health outcomes management program, and to compare those expenditures with projected costs based on various cost inflation trend assumptions. A retrospective, nonexperimental approach was used to analyze claims data from Georgia Medicaid claims files for all program-eligible persons for each relevant time period (intent-to-treat basis). These included all non-Medicare, noninstitutionalized Medicaid aged-blind-disabled adults older than 18 years of age. Comparisons of health care expenditures and utilization were made between base year (2003-2004) and performance year one (2006-2007), and of the difference between actual expenditures incurred in the performance year vs. projected expenditures based on various cost inflation assumptions. Demographic characteristics and clinical complexity of the population (as measured by the Chronic Illness and Disability Payment System risk score) actually increased from baseline to implementation. Actual expenditures were less than projected expenditures using any relevant medical inflation assumption. Actual expenditures were less than projected expenditures by $9.82 million when using a conservative US general medical inflation rate, by $43.6 million using national Medicaid cost trends, and by $106 million using Georgia Medicaid's own cost projections for the non-dually eligible disabled segment of Medicaid enrollees. Quadratic growth curve modeling also demonstrated a lower rate of increase in total expenditures. The rate of increase in expenditures was lower over the first year of program implementation compared with baseline. Weighted utilization rates were also lower in high-cost categories, such as inpatient days, despite increases in the risk profile of the population. Varying levels of cost avoidance could be inferred from differences between actual and projected expenditures using each of the health-related inflation assumptions.

The structure and content of telephonic scripts found useful in a Medicaid Chronic Disease Management Program

In 2003, the Indiana Office of Medicaid Policy and Planning launched the Indiana Chronic Disease Management Program (ICDMP), a programme intended to improve the health and healthcare utilization of 15,000 Aged, Blind and Disabled Medicaid members living with diabetes and/or congestive heart failure in Indiana. Within ICDMP, programme components derived from the Chronic Care Model and education based on an integrated theoretical framework were utilized to create a telephonic care management intervention that was delivered by trained, non-clinical Care Managers (CMs) working under the supervision of a Registered Nurse. CMs utilized computer-assisted health education scripts to address clinically important topics, including medication adherence, diet, exercise and prevention of disease-specific complications. Employing reflective listening techniques, barriers to optimal self-management were assessed and members were encouraged to engage in health-improving actions. ICDMP evaluation results suggest that this low-intensity telephonic intervention shifted utilization and lowered costs. We discuss this patient-centred method for motivating behaviour change, the theoretical constructs underlying the scripts and the branched-logic format that makes them suitable to use as a computer-based application. Our aim is to share these public-domain materials with other programmes.

Care for chronic illness in Australian general practice - focus groups of chronic disease self-help groups over 10 years: implications for chronic care systems reforms

BACKGROUND

Chronic disease is a major global challenge. However, chronic illness and its care, when intruding into everyday life, has received less attention in Asia Pacific countries, including Australia, who are in the process of transitioning to chronic disease orientated health systems.

AIM

The study aims to examine experiences of chronic illness before and after the introduction of Australian Medicare incentives for longer consultations and structured health assessments in general practice.

METHODS

Self-help groups around the conditions of diabetes, epilepsy, asthma and cancer identified key informants to participate in 4 disease specific focus groups. Audio taped transcripts of the focus groups were coded using grounded theory methodology. Key themes and lesser themes identified using a process of saturation until the study questions on needs and experiences of care were addressed. Thematic comparisons were made across the 2002/3 and 1992/3 focus groups.

FINDINGS

At times of chronic illness, there was need to find and then ensure access to 'the right GP'. The 'right GP or specialist' committed to an in-depth relationship of trust, personal rapport and understanding together with clinical and therapeutic competence. The 'right GP', the main specialist, the community nurse and the pharmacist were key providers, whose success depended on interprofessional communication. The need to trust and rely on care providers was balanced by the need for self-efficacy 'to be in control of disease and treatment' and 'to be your own case manager'. Changes in Medicare appeared to have little penetration into everyday perceptions of chronic illness burden or time and quality of GP care. Inequity of health system support for different disease groupings emerged. Diabetes, asthma and certain cancers, like breast cancer, had greater support, despite common experiences of disease burden, and a need for research and support programs.

CONCLUSION

Core themes around chronic illness experience and care needs remained consistent over the 10 year period. Reforms did not appear to alleviate the burden of chronic illness across disease groups, yet some were more privileged than others. Thus in the future, chronic care reforms should build from greater understanding of the needs of people with chronic illness.

An evaluation of educational outreach to improve evidence-based prescribing in Medicaid: a cautionary tale

RATIONALE, AIMS AND OBJECTIVES

Evidence suggests that educational outreach ('academic detailing') improves evidence-based prescribing. We evaluated the impact of an academic detailing programme intended to increase new statin prescriptions.

METHODS

In a 2 x 2 factorial design we evaluated the effect of an academic detailing programme with/without telephonic care management for patients. Eligible patients were continuously enrolled Medicaid members at high risk for cardiovascular disease utilization who were not receiving statin medication in the 18 months prior to the intervention. All primary care prescribers assigned to these patients were randomized by clinic to academic detailing. Two trained nurses provided the detailing to prescribers, including specific discussion about the use of statins in this high-risk patient population. Nurses left the prescribers with a summary of clinical practice guidelines, a one-page detailing sheet and a list of patients under the care of the prescriber who were candidates for statins. The primary outcome was the incidence of a new statin prescription claim during the 6-month intervention period and the subsequent 6 months. Logistic regression models were used to estimate main effects of the interventions and to adjust for potential confounding variables in the study.

RESULTS

Forty-eight clinics were randomized, effectively randomizing a total of 284 patients and 128 prescribers. Among the 284 patients, 46 (16%) received a new statin claim during the evaluation period. Controlling for significant bivariate associations, the academic detailing intervention had no significant effect on new statin prescriptions compared with the control group (odds ratio = 0.8, 95% confidence interval: 0.4-1.6, P = 0.5).

CONCLUSION

Among this Medicaid population at high risk for cardiovascular events, an academic detailing programme to increase statin prescriptions was not effective. To assist others to learn from our failed effort, we identify and discuss critical elements in the design and implementation of the programme that could account for these results.