1. Altarum Institute integrates independent research and client-centered consulting to deliver comprehensive, systems-based solutions that improve health and health care. A nonprofit, Altarum serves clients in both the public and private sectors. For more information, visit www.altarum.org Trends in Military Health System Costs for Colorectal Cancers, FY07-FY14 Michelle Kloc, PhD, MSN, RN Diana D. Jeffery, Ph.D. Joe Dorris, M.A. Harry Burke, M.D., Ph.D. Presentation for APHA Session 3300.1: “Best Practices and Innovations in Cancer Care Delivery Models”

2. 2 Research Team  Altarum Institute  Michelle Kloc, Ph.D., MSN, RN [michelle.kloc@altarum.org]  Joe Dorris, MA  Department of Defense  Office of the Assistant Secretary of Defense (Health Affairs), Defense Health Agency, Clinical Division Diana Jeffery, Ph.D.  Uniformed Services University of the Health Sciences Harry Burke, MD, Ph.D.

3. 3 Presenter Disclosures The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Michelle Kloc Diana D. Jeffery, Ph.D. Joe Dorris, M.A. Harry Burke, M.D., Ph.D. “No relationships to disclose”

4. 4 Disclaimer  The opinions expressed herein are those of the authors, and are not necessarily representative of the opinions or policies of the Department of Defense (DOD); or the United States Army, Navy, Marine Corps, Air Force, or Coast Guard

5. 5 Overview of Colorectal Cancers  What are Colorectal Cancers?  A cancer of the colon or rectum, located at the digestive tract's lower end  Most colorectal cancers start as a non-cancerous polyp – a growth that starts in the inner lining of the colon or rectum and grows toward the center. Only certain types of polyps (called adenomas) can become cancer.  Over 95% of colon and rectal cancers are adenocarcinomas. These are cancers that start in gland cells, like the cells that line the inside of the colon and rectum.  Risk Factors for Colorectal Cancers  Age  History of ulcerative colitis or Crohn’s disease  Family history of colorectal cancer  Cooking meats at very high heat  Eating diets high in red or processed meats

6. 6 Colorectal Cancer Statistics  Prevalence  Colorectal cancer is the second most common cancer found in men and women in this country 1  Colorectal cancer is the #2 cancer killer in the US among cancers that affect both men and women 2  Approximately 132,700 new colorectal cancers diagnosed each year 3  Direct Costs  The mean total colon cancer cost per Medicare patient 1 year after diagnosis was $29,196. 4  Average 1-year costs for veterans who predominately used Medicare was $39,136; for veterans who predominately use VA was $36,146; and for dual users was $44,264. All were statistically significantly different. 5

7. 7 Objective  To examine the trends in costs for colorectal cancer patients receiving care in the Military Health System (MHS), by age group and gender from fiscal years (FY) 2007 – 2014

8. 8 Study Design Study Population  Study Population  MHS beneficiaries ages 18 to 64, residing within the United States, were included only if they had accessed the healthcare system within the FY.  Included individuals were assigned to one of three groups based upon the system of care in which their healthcare occurred: Direct Care (DC) – if all healthcare for a FY occurred in military treatment facilities Purchased Care (PC) – if all healthcare for a FY occurred in a civilian network facility Both Systems (Both) – if healthcare for a FY occurred in both military and civilian facilities

9. 9 Study Design Data and Analysis  Data  Principle ICD-9 codes for claims paid by TRICARE in FY07-14 were obtained from the MHS Master Data Repository  Cancer diagnoses were identified using the Agency of Healthcare Research and Quality (AHRQ) Clinical Classification Software algorithm  HEDIS-based measures A beneficiary was considered to have a cancer if they had a minimum of: –a) 2 outpatient visits within a FY with the same ICD-9, and/or –b) 1 inpatient admission for a given ICD-9.  Costs were standardized to 2014 dollars  Analysis  Descriptive statistics and time-series linear regression models were used to analyze the data.  Regression models controlled for beneficiary category, sponsor Service branch, age group, gender, comorbids, and TRICARE plan.  Costs were standardized to 2014 dollars

10. 10 Demographic Descriptive Statistics of Colorectal Cancer Diagnosed Individuals MinMin FYMaxMax FYAverage NAverage % Gender Male3,489FY143,771FY093,67348.38% Female3,772FY074,499FY104,20855.43% Age Group 18 to 30129FY07760FY093975.23% 31 to 44721FY08823FY0976910.13% 45 to 646,485FY146,850FY106,71488.45% Beneficiary Category Active Duty426FY08736FY095747.56% Active Duty Family Members398FY07778FY095617.40% Retirees/Retiree Family Members6,005FY146,414FY106,25082.34% Other176FY07222FY112052.70% Service Air Force2,255FY132,441FY092,36931.21% Army2,725FY073,278FY093,02139.79% Coast Guard147FY07180FY141672.20% Marines422FY07529FY094626.09% Navy1,733FY081,949FY091,82524.04% Total7,197FY078,122FY097,591100.00%

11. 11 Results Trends in Colorectal Cancer Non-Pharmacy Costs By FY14, non-pharmacy costs highest for ages 18-30 Non-pharmacy costs experienced a dramatic decrease in FY09 for several age groups Males ages 18 to 30 have had consistently higher non-pharmacy costs than other gender-age groups

12. 12 Results Trends in Colorectal Cancer Pharmacy Costs By FY14, Pharmacy costs highest for ages 45-64, closely followed by ages 31 to 44 Pharmacy costs have been consistently higher for males ages 18-44 than other gender-age groups Pharmacy costs for males ages 18-44 have generally consistently increased over time

13. 13 Results Time-Series Regression: Non-Pharmacy Costs Model DC-OnlyPC-OnlyBoth Systems Coef.P>|t|Coef.P>|t|Coef.P>|t| Age 31 to 44 1484.180.607-4364.140.36920163.61<0.001 Age 45 to 64 2760.960.273-9968.640.02910340.230.003 Comorbid 390.580.7023935.920.000220.630.797 Heart DX 13599.38<0.0011956.760.03611396.420.000 Diabetes 283.960.866-3011.21<0.001-1115.470.412 COPD -245.310.9153532.93<0.0019135.50<0.001 Asthma -3563.600.222-5616.72<0.0011615.470.494 Arthritis -2586.600.272-5830.35<0.001-3250.200.047 Back DX 1843.860.24144.150.9521077.320.390 Mood DX 6519.590.002674.310.4983339.230.033 Other Mental DX -329.770.89710111.67<0.0013730.760.092 Female-3102.640.081-2108.000.092-9694.92<0.001 time_female29.560.926-190.730.289261.310.400 time_31to44510.870.374722.310.432-1747.690.021 time_45to64756.180.118756.400.372-884.890.189 time-1199.160.021-960.020.266-124.160.861 _cons22801.510.00026219.750.00018970.620.000 Per person non- pharmacy costs for Colorectal Cancer statistically significantly decreased over time for DC-Only users. Presence of comorbid diagnoses significantly impacts costs in PC-Only and Both Systems. FEMALES COSTS WERE LOWER THAN MALES….

14. 14 Results Time-Series Regression: Pharmacy Costs Model DC-OnlyPC-OnlyBoth Systems Coef.P>|t|Coef.P>|t|Coef.P>|t| Age 31 to 442876.940.021430.860.0882265.69<0.001 Age 45 to 641908.070.1161166.640.1501610.010.014 Comorbid-1418.56<0.001553.23<0.001321.230.029 Heart DX3116.940.018354.610.0261134.45<0.001 Diabetes2767.700.000861.66<0.001934.14<0.001 COPD1448.210.140899.770.000773.990.011 Asthma1153.470.353418.860.063324.440.423 Arthritis1176.940.240104.530.498-5.080.986 Back DX1508.520.024990.58<0.001391.510.068 Mood DX2745.390.0021464.25<0.0011320.95<0.001 Other Mental DX798.690.4621392.07<0.001-225.870.552 Female396.400.687116.030.760-532.350.251 time_female-434.790.023-122.650.0830.970.991 time_31to44-402.000.105-194.200.222-146.010.263 time_45to64-139.910.564-225.980.138-82.750.524 time68.230.773392.800.0165.690.965 _cons6848.330.000-36.290.9672252.000.002 Per person pharmacy costs for Colorectal Cancer statistically significantly increased over time for PC-Only users. Presence of comorbid diagnoses significantly impacts pharmacy costs in all systems of care.

15. 15 Results Time-Series Regression: Total Costs Model DC-OnlyPC-OnlyBoth Systems Coef.P>|t|Coef.P>|t|Coef.P>|t| Age 31 to 44 4078.700.231-2769.480.58622344.11<0.001 Age 45 to 64 4387.510.140-8484.830.07511657.45<0.001 Comorbid -1023.120.3964488.08<0.001540.880.547 Heart DX 16719.54<0.0012312.970.01812530.88<0.001 Diabetes 3060.270.125-2149.050.006-177.270.901 COPD 1177.250.6664434.80<0.0019909.02<0.001 Asthma -2509.910.466-5197.24<0.0011941.170.432 Arthritis -1463.060.599-5724.73<0.001-3254.680.058 Back DX 3332.140.0731036.420.1751469.760.263 Mood DX 9189.28<0.0012140.080.0404659.000.005 Other Mental DX 437.500.88511505.58<0.0013507.420.130 Female -4041.200.054-2241.780.087-10432.80<0.001 time_female-118.050.755-263.200.162307.470.344 time_31to44162.280.811494.650.607-1874.920.018 time_45to64682.180.232462.150.602-902.830.201 time-1132.380.065-591.210.512-156.180.833 _cons29732.760.00026304.060.00021393.370.000 Per person total costs for Colorectal Cancer marginally statistically significantly decreased over time for DC-Only users. Presence of comorbid diagnoses significantly impacts PC-Only and Both Systems.

16. 16 Summary  Non-pharmacy costs for colorectal cancer patients  decreased non-significantly by 1% between FY07-14.  decreased significantly for users of DC-Only care.  statistically significantly decreased over time for ages 31-64 compared to ages 18-30.  Total pharmacy costs (all scripts)  increased non-significantly  Per person costs increased significantly for PC-only users.  Total costs  Non-significantly increased over time  Significantly decreased for ages 31-64 compared to ages 18-30  Presence of comorbid conditions significantly impacts costs across systems of care, in both positive and negative directions.

17. 17 Conclusions  Changes in per person costs likely relate to updates in clinical guidelines, reimbursement criteria and pharmaceutical treatment options for treatment of Colorectal Cancer  Updates in clinical guidelines and pharmaceutical treatment options may have important cost implications, which may be seen mostly clearly by age group.  Younger age groups less likely to have CRCa screening, as the recommended age for screening is 50 years of age. Advanced stage at diagnosis or more aggressive cancer may explain differences in costs.  Results reflect overall trends to increase CRCa screening.

18. 18 References 1. SEER Cancer Statistics Factsheets: Colon and Rectum Cancer. National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/statfacts/html/colorect.html http://seer.cancer.gov/statfacts/html/colorect.html 2. U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2012 Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2015.United States Cancer Statistics: 1999–2012 Incidence and Mortality Web-based Report. 3. SEER Cancer Statistics Factsheets: Colon and Rectum Cancer. National Cancer Institute. 4. Luo Z, Bradley CJ, Dahman BA, et al. (2009). Colon Cancer Treatment Costs for Medicare and Dually Eligible Beneficiaries. Health Care Financing Review. 31(1): 35-50. 5. Hynes DM, Tarlov E, Lee TA, et al. (2007). VA Colon Cancer Quality and Costs Study: Estimating Healthcare Costs for Colon Cancer. Work done for VA. Last accessed: September 29, 2015. Obtained from: http://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archi ves/hmcs-101712.pdf http://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archi ves/hmcs-101712.pdf