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

9

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: rbrown@mathematica-mpr.com

http://www.mathematica-mpr.com/health/bestprac.asp

Email: rbrown@mathematica-mpr.com