dont these demonstrations ever work? mixed evidence from the four-year medicare coordinated care...
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Don’t These Demonstrations Ever Work? Mixed Evidence from the Four-Year Medicare Coordinated
Care Demonstration
AcademyHealth Annual ConferenceJune 9, 2008
Don’t These Demonstrations Ever Work? Mixed Evidence from the Four-Year Medicare Coordinated
Care Demonstration
AcademyHealth Annual ConferenceJune 9, 2008
Debbie PeikesRandy BrownArnold Chen
Jennifer Schore
Debbie PeikesRandy BrownArnold Chen
Jennifer Schore
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Random Assignment Study DesignRandom Assignment Study Design
Impact analysis (randomized, intent-to-treat design)
– Effects on Medicare service use and cost– Effects on quality of care
Patient satisfactionPhysician satisfactionProcesses of careOutcomes
Synthesis—what works and for whom?
– Implementation analysisDetailed description of enrollment and
interventionsSite visits, phone calls, program MIS data
Impact analysis (randomized, intent-to-treat design)
– Effects on Medicare service use and cost– Effects on quality of care
Patient satisfactionPhysician satisfactionProcesses of careOutcomes
Synthesis—what works and for whom?
– Implementation analysisDetailed description of enrollment and
interventionsSite visits, phone calls, program MIS data
Impacts on Hospitalizations and Costs Over the First
Four Years of Operations
Impacts on Hospitalizations and Costs Over the First
Four Years of Operations
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RoadmapRoadmap
Methods to Measure Impacts Research Sample Impacts
– Hospitalizations– Traditional Part A and B costs– Total costs (with program fees)
The Challenge
Methods to Measure Impacts Research Sample Impacts
– Hospitalizations– Traditional Part A and B costs– Total costs (with program fees)
The Challenge
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MethodologyMethodology
Data: Medicare EDB and SAF for claims through June 2006
Study patients: 18,000 enrollees from programs’ start dates in 2002 through June 2005
Followup observed:
– Maximum followup (for early enrollees): 46 to 51 months
– Average: 29 months [19-36 range] Regression-adjusted for demographics, prior service
use and cost, and presence of 10 chronic conditions
Data: Medicare EDB and SAF for claims through June 2006
Study patients: 18,000 enrollees from programs’ start dates in 2002 through June 2005
Followup observed:
– Maximum followup (for early enrollees): 46 to 51 months
– Average: 29 months [19-36 range] Regression-adjusted for demographics, prior service
use and cost, and presence of 10 chronic conditions
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Programs Enrolled High-Cost PatientsPrograms Enrolled High-Cost Patients
Patients were high-cost
Costs were driven by hospitalizations
Average monthly Medicare expenditures for control group patients during year 1
5 programs: $655 to $9995 programs: $1,000 to $1,9995 programs: $2,000 to $3,999(National average was $570)
Patients were high-cost
Costs were driven by hospitalizations
Average monthly Medicare expenditures for control group patients during year 1
5 programs: $655 to $9995 programs: $1,000 to $1,9995 programs: $2,000 to $3,999(National average was $570)
The Punch Line
Care coordination is not a panacea.
Although 3 of the 15 programs appeared to be cost neutral,
none reduced costs.
The Punch Line
Care coordination is not a panacea.
Although 3 of the 15 programs appeared to be cost neutral,
none reduced costs.
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Small Overall Effects on Hospitalizations
Small Overall Effects on Hospitalizations
Overall, hospitalizations down 4.5% (p=0.02), driven by sizable differences in 4 programsOverall, hospitalizations down 4.5% (p=0.02), driven by sizable differences in 4 programs
Large and statistically significant reductions in 2:
– Mercy -17% (p=0.02)– Georgetown -24% (p=0.06)
Moderate but not statistically significant differences in 2:
– Health Quality Partners (HQP) -14% (p=0.13)– QMed -7% (p=0.38)
Large and statistically significant reductions in 2:
– Mercy -17% (p=0.02)– Georgetown -24% (p=0.06)
Moderate but not statistically significant differences in 2:
– Health Quality Partners (HQP) -14% (p=0.13)– QMed -7% (p=0.38)
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Most Programs Had No Discernible Effects on Hospitalizations
Most Programs Had No Discernible Effects on Hospitalizations
Rest of estimates not statistically significant:
2 had favorable differences but small samples 3 had unfavorable differences of +4 to +12% 6 had differences between –3 and 3%
Rest of estimates not statistically significant:
2 had favorable differences but small samples 3 had unfavorable differences of +4 to +12% 6 had differences between –3 and 3%
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Three Programs Are Likely Cost Neutral
Three Programs Are Likely Cost Neutral
Only 1 program had a statistically significant reduction in Part A and B costs, and none reduced total costs including fees.Only 1 program had a statistically significant reduction in Part A and B costs, and none reduced total costs including fees.
* Indicates p<0.10; Cost neutral = total costs (regular Medicare costs plus program fees) of the treatment group are statistically comparable to regular Medicare costs of the control group.
HQP 739 -14 -14* +0.3(-$100 vs. $102)
QMed 706 -7 -11 -0.2(-$81 vs. $81)
Mercy 463 -17* -9 +11.3*(-$113 vs. $248)
Georgetown 114 -24* -13 -3.7(-$335 vs. $242)
# in Medicare Total CostsTreatment Part A + B (Part A and B Savings
Program Group Hospitalizations Costs vs. Fee Paid)
Impact as a % of Control Group Mean
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Many Programs Increased Total CostsMany Programs Increased Total Costs
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3 3
0
1
2
3
4
5
6
7
8
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Increased Costs >10% Probably Not Cost Neutral Cost Neutral
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No Favorable Effects on Total CostsNo Favorable Effects on Total Costs
Pooled total costs are 11 percent higher
Same results when we trimmed outliers
Savings didn’t emerge over time
Pooled total costs are 11 percent higher
Same results when we trimmed outliers
Savings didn’t emerge over time
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Why Doesn’t CC Control Costs Better? An Illustration of the Funnel Effect
Why Doesn’t CC Control Costs Better? An Illustration of the Funnel Effect
Best case scenario, for voluntary (opt-in) model:
Average of 1 hospitalization per year
50% theoretically preventable
30% actually prevented
= 15% of hospitalizations avoided
Best case scenario, for voluntary (opt-in) model:
Average of 1 hospitalization per year
50% theoretically preventable
30% actually prevented
= 15% of hospitalizations avoided
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Funnel Effect Illustration for 1,000 Enrollees
Funnel Effect Illustration for 1,000 Enrollees
(Assumes 1 hosp/person yr) Best Case Actual Overall
Decrease in hosp 15% 4.5%
Gross savings (@$11,000/hosp)
$1.65M $0.50M
Fees:$155 pmpm $1.86M $1.86M
Increased cost $0.21M $1.36M
Cost-neutral fee $138 $41
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Context for FindingsContext for Findings
Consistent with results from other CMS demonstrations
Much harder for population-based programs. Say only 25% engage. Cost-neutral fees:
– if decrease in admits is 15%: $35 pmpm– if decrease in admits is 4.5%: $10 pmpm
Fees paid were double the average monthly Medicare payments for regular office visits ($70)
Consistent with results from other CMS demonstrations
Much harder for population-based programs. Say only 25% engage. Cost-neutral fees:
– if decrease in admits is 15%: $35 pmpm– if decrease in admits is 4.5%: $10 pmpm
Fees paid were double the average monthly Medicare payments for regular office visits ($70)
Impacts on Quality of CareImpacts on Quality of Care
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Two Main Types of MeasuresTwo Main Types of Measures
Measures for Impact Estimation– Both treatments and controls
Descriptive Measures– Treatment group only – Perceptions of:
Treatment group patientsPhysicians of treatment group patients
Measures for Impact Estimation– Both treatments and controls
Descriptive Measures– Treatment group only – Perceptions of:
Treatment group patientsPhysicians of treatment group patients
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Perceptions of Treatment Group Patients
Perceptions of Treatment Group Patients
Patients Generally Liked the Programs– Support/monitoring– Service arrangement– Care coordinators’ general education skills– Adherence assistance
Same 2 or 3 Programs Tended to Be Above Average Across Measures
Patients Generally Liked the Programs– Support/monitoring– Service arrangement– Care coordinators’ general education skills– Adherence assistance
Same 2 or 3 Programs Tended to Be Above Average Across Measures
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Perceptions of Patients’ Physicians
Perceptions of Patients’ Physicians
Physicians Generally Liked Programs – Effects on medical practice– Patient self-management– Care coordination– Physician-patient relations– Care coordinators’ clinical competence– Patients’ outcomes– Would recommend to colleagues, patients
Same 1 or 2 Programs Tended to Be Above Average Across Measures
Physicians Generally Liked Programs – Effects on medical practice– Patient self-management– Care coordination– Physician-patient relations– Care coordinators’ clinical competence– Patients’ outcomes– Would recommend to colleagues, patients
Same 1 or 2 Programs Tended to Be Above Average Across Measures
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T-C Comparisons: Process of Care Measures
T-C Comparisons: Process of Care Measures
Receipt of:
Program services --Patient survey
Health education --Patient survey
Recommended clinical --Medicare claimsservices– For example, hemoglobin A1c testing
Receipt of:
Program services --Patient survey
Health education --Patient survey
Recommended clinical --Medicare claimsservices– For example, hemoglobin A1c testing
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T-C Comparisons: Outcome MeasuresT-C Comparisons: Outcome Measures
Patient knowledge -- Survey Patient adherence -- Survey Unmet needs -- Survey Functioning -- Survey Health-related quality of life -- Survey Satisfaction with care -- Survey Mortality -- EDB Potentially avoidable -- Claims hospitalizations
Patient knowledge -- Survey Patient adherence -- Survey Unmet needs -- Survey Functioning -- Survey Health-related quality of life -- Survey Satisfaction with care -- Survey Mortality -- EDB Potentially avoidable -- Claims hospitalizations
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MethodologyMethodology
Multiple Measures and Demonstration SitesHigh Potential for Type I Errors
Sought Patterns Within or Across Programs:– Program with differences in multiple measures?– Multiple programs with differences in similar
measures?– Directions of significant differences: ’s = ’s?– Magnitude of estimated effect?
Multiple Measures and Demonstration SitesHigh Potential for Type I Errors
Sought Patterns Within or Across Programs:– Program with differences in multiple measures?– Multiple programs with differences in similar
measures?– Directions of significant differences: ’s = ’s?– Magnitude of estimated effect?
+ –
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Summary: Some Impacts on Process Measures
Summary: Some Impacts on Process Measures
Patient awareness of Large impactsprograms
Reports of receiving Large impactseducation
Preventive services Scattered effects
Patient awareness of Large impactsprograms
Reports of receiving Large impactseducation
Preventive services Scattered effects
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Summary: Minimal Impacts on Outcome Measures
Summary: Minimal Impacts on Outcome Measures
Self-reported adherence: 0 Unmet needs 0 Function 0 Health-Related Quality of Life 0 Patient satisfaction Scattered effects Mortality 0 Potentially preventable Scattered effects
hospitalizations
Self-reported adherence: 0 Unmet needs 0 Function 0 Health-Related Quality of Life 0 Patient satisfaction Scattered effects Mortality 0 Potentially preventable Scattered effects
hospitalizations
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Now What?Now What?
No Substantial, Broad Quality Impacts
Recall: Programs Could Be Cost-Saving or Cost Neutral and Improve Quality– Go back and examine quality results for
potentially cost-neutral programs– HQP, QMed, Mercy (at a lower fee), Geo*
* Georgetown dropped out before the demonstration ended and is not considered viable due to small enrollment
No Substantial, Broad Quality Impacts
Recall: Programs Could Be Cost-Saving or Cost Neutral and Improve Quality– Go back and examine quality results for
potentially cost-neutral programs– HQP, QMed, Mercy (at a lower fee), Geo*
* Georgetown dropped out before the demonstration ended and is not considered viable due to small enrollment
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Favorable Impacts on Process Measures for the 3 Selected Programs
Favorable Impacts on Process Measures for the 3 Selected Programs
Receipt of Health Education
Clinical Preventive Services
HQP All 5 topics HgbA1c
QMed Diet None
Mercy All 5 topics Urine protein
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Favorable Impacts on Outcome and T-Only Measures for 3 Selected Programs
Favorable Impacts on Outcome and T-Only Measures for 3 Selected Programs
Patient-Reported Outcomes
Potentially Avoidable
Hosps T-Group Satisfaction
HQP Providers keep in touchExplanations of treatmentExercise regularlyEmotional distress
None Patients: Support/monitoring Service arranging General ed skills Adherence assist
QMed Explanations of treatmentQuit smoking
None
Mercy Providers keep in touchExplanations of side effectsExplanations of treatmentEmotional distress
Yes, among
CHF patients
Physicians: Service arranging Care coordination
What Features DistinguishSuccessful Programs?
What Features DistinguishSuccessful Programs?
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No Structural DistinctionsNo Structural Distinctions
HQP Mercy QMed Other 9*
Organization Type
Quality improvement
provider Hospital DM provider Various
Location Rural PA Rural Iowa Northern CA 3 rural;6 nonrural
Negotiated Fee (PMPM) $108 $257 $96 $244 (median)
CC’s Minimum Education RN RN w/BSN LPN RN
CC’s Caseload 106 50 150 40 to 155
CCs Stationed Near MDs Yes Yes No 3 yes; 6 no
# of Ways Planned to Involve MDs (7 possible)
2 4 6 3.9
MDs Paid for Participation No No Only for review
7 yes; 2 no
* The 9 programs exclude 3 that were unable to enroll enough patients over the 4 years to be considered viable.
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No Distinguishing Patient
Characteristics
No Distinguishing Patient
Characteristics
HQP Mercy QMed Other 9
# of Target Diagnoses 4 6 1 (CAD) 3 have 1; 6 have 3+
Patients with CAD 35% 65% 50% 68%
Patients with CHF 11% 62% 40% 57%
Patients with Diabetes 25% 33% 26% 40%
Patients with COPD 13% 53% 14% 36%
Prior Hospitalizations/Year 0.4 1.1 0.4 1.2
Medicare Costs/Month $721 $1,197 $790 2 < $900;2 > $2,000
CAD = Coronary artery disease
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No Distinguishing InterventionsNo Distinguishing Interventions
HQP Mercy QMed Other 9
Behavior - Change Models Yes No No 6 yes; 3 no
Telemonitoring No No No 1 yes; 8 no
Total Contacts PMPM 2.2 1.4 1.2 2.3 (median)
In-Person Contacts PMPM 0.9 1.0 0.1 0.4 (median)
Source of Info on Hospital Review admit list
Review admit list
Patient only Mostly patient only
Info on Rx Changes from Providers/Pharmacies
No No Yes (chart review)
3 yes; 6 no
Pharmacist Help Available No Yes Yes 5 yes; 4 no
Effort to Improve MD Adherence to Guidelines
MD called if patient’s
care deviates
Patients taught to remind
physicians
Report compares all
care to guidelines
3 yes; 6 no
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Programs Excel in Different DomainsPrograms Excel in Different Domains
Domains HQPHQP MercyMercy QMed
Staffing Program 22 11 5
Conducting Initial Assessment 11 3 5
Identifying Problems & Planning Care 3 11 4
Educating Patients 11 11 4
Improving Coord. & Communication 22 11 4
Improving Provider Practice 4 5 11
Arranging Services & Resources 4 22 4
Using IT & Electronic Systems 5 4 4
Monitoring Patients 22 4 22
Quality Management & Outcome Measurement
3 4 22
Note: 1 = top quintile (3 programs); 5 = bottom quintile. Shaded cells are top 2 quintiles.
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Programs Report Varied Reasonsfor Success
Programs Report Varied Reasonsfor Success
HQP Focus on patient goals and preferencesFocus on patient goals and preferences Mitigate medical errors through attention to care transitions Mitigate medical errors through attention to care transitions
and communicationand communication Provide targeted group and in-home interventions on weight Provide targeted group and in-home interventions on weight
control, balance, exercise, and self-carecontrol, balance, exercise, and self-care Standardize training and protocols; monitor CC performanceStandardize training and protocols; monitor CC performance Discover unmet needs quicklyDiscover unmet needs quickly MDs cooperate with chart review; fast response to CCsMDs cooperate with chart review; fast response to CCs
Mercy Provide frequent face-to-face contactProvide frequent face-to-face contact Conduct in-home assessmentConduct in-home assessment Screen to determine need for social services/supportScreen to determine need for social services/support Identify symptoms early; change Rx quicklyIdentify symptoms early; change Rx quickly Patients reveal nonadherence to CC but not MDPatients reveal nonadherence to CC but not MD
QMed Recommend Rx changes to MDs, leading to lower BP and Recommend Rx changes to MDs, leading to lower BP and lipids, which reduce hospitalizations lipids, which reduce hospitalizations
What Does it All Mean? What’s Next?
What Does it All Mean? What’s Next?
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So What Did We Learn? So What Did We Learn?
Value of DM/care coordination still unclear:– A few programs show promise, if replicable– Some proven models weren’t tested here
No single necessary or best approach
More in-person contacts better outcomes
Best target population may be medium severity
Value of DM/care coordination still unclear:– A few programs show promise, if replicable– Some proven models weren’t tested here
No single necessary or best approach
More in-person contacts better outcomes
Best target population may be medium severity
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Ongoing WorkOngoing Work
Three programs to be extended:– HQP, QMed, Mercy (at a reduced fee)– Very different models and challenges– CMS evaluation required
Two follow-up studies under way:– Extend time frame and depth (HCFO)– Test effects of intervention changes and
identify best practices (MCCPRN)
Three programs to be extended:– HQP, QMed, Mercy (at a reduced fee)– Very different models and challenges– CMS evaluation required
Two follow-up studies under way:– Extend time frame and depth (HCFO)– Test effects of intervention changes and
identify best practices (MCCPRN)
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Extending Time Frame and Depth: HCFO Study Tasks
Extending Time Frame and Depth: HCFO Study Tasks
Collect detailed on-site information on the 3 cost-neutral interventions
Add data for 7/06-12/07 (up to 5 years total)
Estimate effects on readmissions
Estimate effects for key subgroups
Examine effects of contamination and critical mass
Collect detailed on-site information on the 3 cost-neutral interventions
Add data for 7/06-12/07 (up to 5 years total)
Estimate effects on readmissions
Estimate effects for key subgroups
Examine effects of contamination and critical mass
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Testing Intervention Changes and Defining Best Practices: MCCPRN Testing Intervention Changes and Defining Best Practices: MCCPRN
Includes 8 MCCD sites
Test sites’ pre-specified hypotheses about different effects over time and subgroups
Develop consensus best practices
Design demo to test best practice model
Goal: Use existing sites as ongoing laboratory for rapid testing
Includes 8 MCCD sites
Test sites’ pre-specified hypotheses about different effects over time and subgroups
Develop consensus best practices
Design demo to test best practice model
Goal: Use existing sites as ongoing laboratory for rapid testing
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For More InformationFor More Information
http://www.mathematica-mpr.com/health/bestprac.asp
Email: [email protected]
http://www.mathematica-mpr.com/health/bestprac.asp
Email: [email protected]