1. 1 TennCare Diabetes Program Evaluation Presentation to AcademyHealth Kenton Johnston, MPH, MS, MA June 4, 2007 An Individually-Matched Control Group Evaluation of a Disease Management Program to Improve Quality and Control Costs in a Diabetic Medicaid Population

2. 2 Overview Research Objective: Evaluate diabetes disease management program for state Medicaid (TennCare) population Outcomes of interest: diabetic quality of care and medical cost savings (Inpatient & Prof/Outpatient) Outline: Program Description Study Design Findings Limitations, Conclusions, Implications TennCare Diabetes Program Evaluation

3. 3 Program Description Outcome of diabetes treatment highly dependent on self-care Non-adherence to recommended regimens an obstacle to improved health status Medicaid population tends to exhibit higher utilization & costs, as well as poorer health outcomes CareSmart Diabetes Disease Management (DM) Program – developed internally by BCBST for TennCare population For Type 1 and Type 2 diabetics Program: behavior change & health education, self- management, personalized telephone coaching, compliance with ADA clinical practice guidelines, and PCP support Member consent obtained for enrollment in program TennCare Diabetes Program Evaluation

4. 4 Study Design – Individual Matching With Propensity Model Methodological toolbox for DM program evaluation Randomized controlled trials Population based pre-post methodology Predictive modeling Control group matching (individual, group) Problem: finding a good control group not easy Solution: Individually-matched controls using propensity scores (matched pairs cohort study) Propensity score is continuous number that represents individual probability of being in study group Propensity score reduces entire set of covariates to one score for easy individual matching This approach allows for smaller n TennCare Diabetes Program Evaluation

5. 5 Study Design – Population & Methods Study and control group member criteria Continuously enrolled in TennCare 24-months of 2004-05 Diagnosed with Type 1 or 2 diabetes in 2004 or earlier Not dually eligible – Medicaid only 126 study members enrolled in CareSmart Diabetes Program for at least 6 months in 2005 were individually matched to 126 diabetic controls not enrolled in program in 2004 or 2005 Propensity model covariates: demographics, diseases & comorbidities, quality of care, medical utilization, costs Baseline Period: Jan - Dec 2004 for matching control & study Intervention Period: Jan - Dec 2005 TennCare Diabetes Program Evaluation

6. 6 Study Design – Dependent Variables TennCare Diabetes Program Evaluation Diabetic quality of care operationally defined according to recommended preventive services outlined by ADA Screening for kidney disease First annual HbA1c screening Second annual HbA1c screening Retinopathy screening LDL cholesterol screening Medical services utilization and cost Reported as totals (not specific only to diabetes) Inpatient admissions, inpatient days, inpatient $$$ ER encounters, office visit encounters, Prof/Outpatient $$$ Total $$$ RX utilization & cost data unavailable

7. 7 Findings – Baseline Results TennCare Diabetes Program Evaluation

8. 8 Findings – Intervention Quality Results TennCare Diabetes Program Evaluation Statistically significant positive difference on 4 of 5 measures & on overall score Improvement in both study & control groups from 2004 Propensity matched control group enables us to rule out secular trend as sole cause

9. 9 Findings – Intervention Utilization Results TennCare Diabetes Program Evaluation Statistically significant difference on office visits – study members had higher utilization Office visit finding not surprising given this is the setting for quality measures Inpatient admissions & days lower for study members – not statistically significant ER encounters higher for study members – not statistically significant

10. 10 Findings – Intervention Cost Results TennCare Diabetes Program Evaluation None of the cost findings were statistically significant Inpatient & total costs trending in downward direction for study group Prof/Outpatient costs higher for study group Financial analysisusing control group to calculate expected costsshows program savings impact for study group

11. 11 Limitations TennCare Diabetes Program Evaluation Unable to analyze RX data Psychological or sociological variables not included/available for propensity model potential source of confounding Non-Participation Bias Study members agreed to participate in the program Controls either could not be contacted by telephone or refused to participate We did not control for practice patterns of member providers (data not available for all members) Lab values unavailable on > 50% of study and control population so we were not able to control for these Available HbA1c and LDL values showed HbA1c close to stat sig (.09) difference in baseline period

12. 12 Conclusions & Implications TennCare Diabetes Program Evaluation Conclusions: Improvement in quality in study group was not due solely to general secular trend towards quality, but was also positively impacted by the diabetes program intervention itself Mixed findings for utilization & cost, but may be showing trend in right direction Implications: DM programs can be successful in improving quality of care in chronically diseased state Medicaid populations A matched-pairs cohort study using propensity scores is a valuable tool for evaluating program outcomes in small to medium sized populations

13. 13 Thank You Presentation to AcademyHealth Kenton Johnston, MPH, MS, MA June 4, 2007 E-mail: Kenton_Johnston@BCBST.com TennCare Diabetes Program Evaluation