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Dont These Demonstrations Ever Work? Mixed Evidence from the Four-Year Medicare Coordinated Care Demonstration AcademyHealth Annual Conference June 9,

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Presentation on theme: "Dont These Demonstrations Ever Work? Mixed Evidence from the Four-Year Medicare Coordinated Care Demonstration AcademyHealth Annual Conference June 9,"— Presentation transcript:

1 Dont These Demonstrations Ever Work? Mixed Evidence from the Four-Year Medicare Coordinated Care Demonstration AcademyHealth Annual Conference June 9, 2008 Debbie Peikes Randy Brown Arnold Chen Jennifer Schore Debbie Peikes Randy Brown Arnold Chen Jennifer Schore

2 1 Random Assignment Study Design Impact analysis (randomized, intent-to-treat design) –Effects on Medicare service use and cost –Effects on quality of care Patient satisfaction Physician satisfaction Processes of care Outcomes Synthesiswhat works and for whom? –Implementation analysis Detailed description of enrollment and interventions Site 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 satisfaction Physician satisfaction Processes of care Outcomes Synthesiswhat works and for whom? –Implementation analysis Detailed description of enrollment and interventions Site visits, phone calls, program MIS data

3 Impacts on Hospitalizations and Costs Over the First Four Years of Operations

4 3 Roadmap 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

5 4 Methodology 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

6 5 Programs 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 $999 5 programs: $1,000 to $1,999 5 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 $999 5 programs: $1,000 to $1,999 5 programs: $2,000 to $3,999 (National average was $570)

7 The Punch Line Care coordination is not a panacea. Although 3 of the 15 programs appeared to be cost neutral, none reduced costs.

8 7 Small Overall Effects on Hospitalizations Overall, 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)

9 8 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%

10 9 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. * 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 *+0.3 (-$100 vs. $102) QMed (-$81 vs. $81) Mercy463-17* * (-$113 vs. $248) Georgetown114-24* (-$335 vs. $242) # inMedicareTotal Costs TreatmentPart A + B(Part A and B Savings ProgramGroupHospitalizationsCostsvs. Fee Paid) Impact as a % of Control Group Mean HQP * QMed Mercy463-17* * (-$113 vs. $248) Georgetown-24*-13 # inTotal Costs TreatmentPart A + B(Part A and B Savings ProgramGroupHospitalizationsCostsvs. Fee Paid) Impact as a % of Control Group Mean +0.3 (-$100 vs. $102) -0.2 (-$81 vs. $81) (-$335 vs. $242)

11 10 Many Programs Increased Total Costs

12 11 No Favorable Effects on Total Costs Pooled total costs are 11 percent higher Same results when we trimmed outliers Savings didnt emerge over time Pooled total costs are 11 percent higher Same results when we trimmed outliers Savings didnt emerge over time

13 12 Why Doesnt 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

14 13 Funnel Effect Illustration for 1,000 Enrollees (Assumes 1 hosp/person yr)Best CaseActual Overall Decrease in hosp 15% 4.5% Gross savings $1.65M $0.50M Fees:$155 pmpm $1.86M Increased cost $0.21M $1.36M Cost-neutral fee $138 $41

15 14 Context 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)

16 Impacts on Quality of Care

17 16 Two Main Types of Measures Measures for Impact Estimation –Both treatments and controls Descriptive Measures –Treatment group only –Perceptions of: Treatment group patients Physicians of treatment group patients Measures for Impact Estimation –Both treatments and controls Descriptive Measures –Treatment group only –Perceptions of: Treatment group patients Physicians of treatment group patients

18 17 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

19 18 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

20 19 T-C Comparisons: Process of Care Measures Receipt of: Program services--Patient survey Health education--Patient survey Recommended clinical--Medicare claims services –For example, hemoglobin A1c testing Receipt of: Program services--Patient survey Health education--Patient survey Recommended clinical--Medicare claims services –For example, hemoglobin A1c testing

21 20 T-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

22 21 Methodology Multiple Measures and Demonstration Sites High 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 Sites High 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? + –

23 22 Summary: Some Impacts on Process Measures Patient awareness ofLarge impacts programs Reports of receivingLarge impacts education Preventive servicesScattered effects Patient awareness ofLarge impacts programs Reports of receivingLarge impacts education Preventive servicesScattered effects

24 23 Summary: Minimal Impacts on Outcome Measures Self-reported adherence:0 Unmet needs0 Function 0 Health-Related Quality of Life 0 Patient satisfactionScattered effects Mortality 0 Potentially preventableScattered effects hospitalizations Self-reported adherence:0 Unmet needs0 Function 0 Health-Related Quality of Life 0 Patient satisfactionScattered effects Mortality 0 Potentially preventableScattered effects hospitalizations

25 24 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

26 25 Favorable Impacts on Process Measures for the 3 Selected Programs Receipt of Health Education Clinical Preventive Services HQPAll 5 topicsHgbA1c QMedDietNone MercyAll 5 topics Urine protein

27 26 Favorable Impacts on Outcome and T-Only Measures for 3 Selected Programs Patient-Reported Outcomes Potentially Avoidable HospsT-Group Satisfaction HQPProviders keep in touch Explanations of treatment Exercise regularly Emotional distress NonePatients: Support/monitoring Service arranging General ed skills Adherence assist QMedExplanations of treatment Quit smoking None MercyProviders keep in touch Explanations of side effects Explanations of treatment Emotional distress Yes, among CHF patients Physicians: Service arranging Care coordination

28 What Features Distinguish Successful Programs?

29 28 No Structural Distinctions HQPMercyQMedOther 9* Organization Type Quality improvement providerHospitalDM providerVarious LocationRural PARural IowaNorthern CA3 rural; 6 nonrural Negotiated Fee (PMPM)$108$257$96$244 (median) CCs Minimum EducationRNRN w/BSNLPNRN CCs Caseload to 155 CCs Stationed Near MDsYes No3 yes; 6 no # of Ways Planned to Involve MDs (7 possible) MDs Paid for ParticipationNo 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.

30 29 No Distinguishing Patient Characteristics HQPMercyQMedOther 9 # of Target Diagnoses461 (CAD)3 have 1; 6 have 3+ Patients with CAD35%65%50%68% Patients with CHF11%62%40%57% Patients with Diabetes25%33%26%40% Patients with COPD13%53%14%36% Prior Hospitalizations/Year Medicare Costs/Month$721$1,197$7902 < $900; 2 > $2,000 CAD = Coronary artery disease

31 30 No Distinguishing Interventions HQPMercyQMedOther 9 Behavior - Change ModelsYesNo 6 yes; 3 no TelemonitoringNo 1 yes; 8 no Total Contacts PMPM (median) In-Person Contacts PMPM (median) Source of Info on HospitalReview admit list Patient onlyMostly patient only Info on Rx Changes from Providers/Pharmacies No Yes (chart review) 3 yes; 6 no Pharmacist Help AvailableNoYes 5 yes; 4 no Effort to Improve MD Adherence to Guidelines MD called if patients care deviates Patients taught to remind physicians Report compares all care to guidelines 3 yes; 6 no

32 31 Programs Excel in Different Domains DomainsHQPMercyQMed Staffing Program215 Conducting Initial Assessment135 Identifying Problems & Planning Care 314 Educating Patients114 Improving Coord. & Communication214 Improving Provider Practice 451 Arranging Services & Resources 424 Using IT & Electronic Systems 544 Monitoring Patients242 Quality Management & Outcome Measurement 342 Note: 1 = top quintile (3 programs); 5 = bottom quintile. Shaded cells are top 2 quintiles.

33 32 Programs Report Varied Reasons for Success HQP Focus on patient goals and preferences Focus on patient goals and preferences Mitigate medical errors through attention to care transitions and communication Mitigate medical errors through attention to care transitions and communication Provide targeted group and in-home interventions on weight control, balance, exercise, and self-care Provide targeted group and in-home interventions on weight control, balance, exercise, and self-care Standardize training and protocols; monitor CC performance Standardize training and protocols; monitor CC performance Discover unmet needs quickly Discover unmet needs quickly MDs cooperate with chart review; fast response to CCs MDs cooperate with chart review; fast response to CCs Mercy Provide frequent face-to-face contact Provide frequent face-to-face contact Conduct in-home assessment Conduct in-home assessment Screen to determine need for social services/support Screen to determine need for social services/support Identify symptoms early; change Rx quickly Identify symptoms early; change Rx quickly Patients reveal nonadherence to CC but not MD Patients reveal nonadherence to CC but not MD QMed Recommend Rx changes to MDs, leading to lower BP and lipids, which reduce hospitalizations Recommend Rx changes to MDs, leading to lower BP and lipids, which reduce hospitalizations

34 What Does it All Mean? Whats Next?

35 34 So What Did We Learn? Value of DM/care coordination still unclear: –A few programs show promise, if replicable –Some proven models werent 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 werent tested here No single necessary or best approach More in-person contacts better outcomes Best target population may be medium severity

36 35 Ongoing 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)

37 36 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

38 37 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

39 38 For More Information health/bestprac.asp health/bestprac.asp


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