June 2012 Eric Christensen Patient-centered Medical Home (PCMH)/ Medical Home Port (MHP) Evaluation (with emphasis on chronic conditions, particularly

June 2012

Eric Christensen

Patient-centered Medical Home (PCMH)/Medical Home Port (MHP) Evaluation

(with emphasis on chronic conditions, particularly diabetes)

Overview

• Context– MHS/Navy Medicine moving rapidly to PCMH/MHP models

– Literature shows the potential of PCMHs, but success is not automatic

– “78% of health spending is devoted to people with chronic conditions”*

• Purpose– Assess the impact of the Bethesda PCMH on access, quality, and cost

– Assess whether the MHP model is effective for different patient types and in different settings

• Outcome– Resource allocation should consider the effectiveness of MHP model

– Which populations to target first with MHP* Anderson and Horvath, “The Growing Burden of Chronic Disease in America,” Public Health Reports, 2004, 119(3):263-270

2

Topics/outline

• Results on access and quality– HEDIS metrics

– Patient satisfaction survey

• Results on use and costs– Overall

– Chronic versus non-chronic patients

– By chronic condition

• Clinical Practice Guidelines (CPGs) adherence—diabetes

• Note– Some slides use NNMC and others WRNMMC as some of the work was

completed before the Bethesda-Walter Reed merger

– Results in this brief are for the WRNMMC internal medicine MHP

3

WRNMMC HEDIS scores (pre- and post-implementation)

HEDIS measure Pre-period Post-periodFavorable

(unfavorable) difference

HbA1c test 84.5% 91.8% 7.3%

HbA1c > 9.0 25.9% 17.6% 8.3%

LDL screening 78.2% 88.6% 10.5%

LDL-C value < 100 mg/dl 53.3% 66.1% 12.9%

Asthmatics appropriately prescribed 93.9% 96.1% 2.2%

Pap smear test 80.6% 87.4% 6.8%

Mammography screening 75.3% 82.8% 7.5%

Colorectal cancer screening 60.7% 68.5% 7.8%

4

Note: The values for the pre-period are monthly averages for January-May 2008 compared to February-December 2009 for the post-period. The transition period was from June 2008 through January 2009.

PCMH impact on access and patient satisfaction

82.0

73.4

74.3

75.0

75.8

89.2

90.0

91.8

88.3

75.6

68.4

78.4

69.9

64.6

63.9

70.1

86.5

87.1

88.2

83.7

73.6

61.9

0 20 40 60 80 100

Satisfied with healthcare at clinic

High rating of PCM

Access composite (getting care quickly)

Able to see PCM when needed

Satisfied with ease of scheduling appts

Provider communication composite

PCM listens carefully Often to Always

PCM explains things Often to Always

Customer service (office staff)

Trust in PCM composite (PCAS)

Patient activation composite (level 4)

Walter Reed PCMH Comparison site* Patient Activation Measure -13 is copyrighted by Insignia Health, LLC

*

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How to increase satisfaction and PCM rating?

• Those reporting high levels of access and provider communication report high satisfaction and PCM rating– Access (OR: 2.1; CI: 1.4-3.2)

– Provider communication (OR: 1.9; CI: 1.2-3.0)

• Implies that increasing access and provider communication will increase satisfaction and PCM rating– But, how to do this?

• Drivers of access– Ease of scheduling appointments (OR: 4.6; CI: 3.0-7.0)

– Ability to get appt for routine care when needed (OR: 4.4; CI: 3.2-6.2)

– Ability to get appt for urgent care when needed (OR: 3.7; CI: 2.5-5.5)

• Drivers of provider communication– PCM listens carefully (OR: 13.5; CI: 6.4-28.4)

– PCM provides complete and accurate info (OR: 12.9; CI: 5.2-31.9)

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Use and cost analysis

• Conducted retrospective data analysis (FY07-10)– Transition period from June 2008 to January 2009

• Used differences-in-differences approach• Used two-step process for analyzing health care use and costs

– Step 1: binary regression for user or non-user of a particular service

– Step 2: OLS regression for amount of services for users only

• Used NMC Portsmouth, NMC San Diego, and NHP Pensacola internal medicine clinics as comparison sites

• Focused on chronic conditions– Diabetes, hypertension, hyperlipidemia, chronic obstructive pulmonary

disease (COPD), coronary artery disease (CAD), and mental health

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PCMH impact on use – all enrollees

8

-10%

-5%

0%

5%

10%

15%

20%

25%

30%

Inpatientadmissions

Inpatient days ER visits Specialty careencounters

Primary careencounters

Change in probability of use Change in amount of use for users Change in average use

Primary care use has increased. Presumably this has resulted in reductions elsewhere. For example, the probability of ER use and inpatient admissions are down, but average length of stay has increased (likely due to better management of less severe cases).

PCMH impact on use – chronic patients

9

-10%

-5%

0%

5%

10%

15%

20%

25%

30%

Inpatientadmissions




The results for chronic patients are similar to the results across all patients. The differences are that the increase in primary care is greater and specialty care use is down for chronic patients relative to the results across all patient.

PCMH impact on use – non-chronic patients

10

-10%

-5%

0%

5%

10%

15%

20%

25%

30%

Inpatientadmissions




Most of what we observe across all patients is driven by or is a reflection of the experiences of chronic patients as there is almost no statistical impact on the use metrics for non-chronic patients. The exception is specialty care. Non-chronic patients have a higher probability of using specialty care with the PCMH model than without the PCMH model.

PCMH impact on cost – all enrollees

-20%

-18%

-16%

-14%

-12%

-10%

-8%

-6%

-4%

-2%

0%Pharmacy costs Ancillary costs PMPQ costs


For pharmacy and ancillary costs, both the probability of use and the amount of use for users decreased substantially. For PMPQ, the decrease is a result of a change in the amount of use for users and not a change in the probability of use of the Military Health System overall.

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PCMH impact on cost – chronic patients

-20%

-18%

-16%

-14%

-12%

-10%

-8%

-6%

-4%

-2%



The results for chronic patients are similar to the results acrossall patients, but of a greater magnitude.

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PCMH impact on cost – non-chronic patients

-20%

-18%

-16%

-14%

-12%

-10%

-8%

-6%

-4%

-2%



The results for non-chronic patients are generally of a lesser magnitude than for chronic patients.

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Cost impacts associated with chronic enrollees

ChronicNon-

chronic Total

Change attributable to chronic enrollees

Estimated costs per enrollee

PMPY without PCMH $3,136 $750

PMPY with PCMH $2,803 $697

Change in dollars -$333 -$53

Change in percentages -10.6% -7.1%

Average PMPY change by percent of enrollees with chronic conditions

40% -$165 80.7%

50% -$193 86.2%

60% -$221 90.4%

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WRNMMC PCMH impact by condition

DiabetesHyper-tension

Hyper-lipidemia COPD CAD

Mental health

Inpatient admissions -10.8%

Inpatient days 20.2% 19.0% 36.0%

ER visits -13.5%

Specialty care -3.6% -0.5% 3.4%

Primary care 40.3% 32.0% 32.1% 46.3% 49.3% 24.8%

Pharmacy -17.0% -16.1% -17.0% -10.3% NA* -1.4%

Ancillary -16.2% -19.1% -15.2% -24.0% -24.1% -14.1%

PMPQ -10.5% -11.1% -10.0% -10.1% -8.2%

WRNMMC enrollees 1,595 7,098 7,207 960 659 2,426

*Model would not converge.

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Diabetes CPG metrics

• Screening/exam– HbA1c exam (at least yearly)

– Eye exam (every two years)

– Lipid (LDL-C) screening (yearly)

– Nephropathy (yearly)

• Level/control– HbA1c control (> 9.0%)

– Lipid control (LDL-C < 100 mg/dL)

– Blood pressure control

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Diabetes CPG adherence rates—HbA1c exam

17

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Comparison sites WRNMMC non-PCMH

WRNMMCPCMH

2007 2010 Medicare benchmark

Diabetes CPG adherence rates—eye care

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


WRNMMCPCMH


Diabetes CPG adherence rates—lipid control

19

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


WRNMMCPCMH


Diabetes CPG adherence rates—nephropathy

20

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


WRNMMCPCMH


Are changes in CPG adherence rates significant?

• Controlling for demographic differences and other chronic conditions, PCMH patients are more likely to have yearly nephrology and lipid control panels than patients at control sites

• HbA1c results are not meaningful because of the change in coding practice at WRNMMC in 2010

• Eye exams are recommended every two years, but with a 1-year comparison (2007 to 2010), there is a significant decline in patients receiving eye exams

21

ProcedureOdds ratio for

post-PCMHSignificance

Nephrology 1.26 0.025

Lipid control 1.20 0.045

22

Staff survey – continuity and coordination of care

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Never or rarely Sometimes or often Very often or always

Comparison clinics NNMC PCMH

• How often do you feel that you can exercise autonomy as opposed to having to utilize a standard procedure?

– The question was only asked of providers

Enrollment status of diabetics (Navy catchment areas)

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Chronic disease burden• “78% of health spending is devoted to people with chronic conditions. Quality medical care

for people with chronic conditions requires a new orientation toward prevention of chronic disease and provision of ongoing care and care management to maintain health status and functioning.”

– Health spending attributable to people with chronic conditions 1 or more conditions: 88% for prescriptions, 72% for physician visits, 76% for inpatient 2 or more conditions: 67% for prescriptions, 48% for physician visits, 56% for inpatient

• Source: Anderson and Horvath, “The Growing Burden of Chronic Disease in America,” Public Health Reports, 2004, 119(3):263-270

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Pharmacy VariationUtilization and variation for maintenance and scheduled drugs

Nevin Aragam, CNA Analysis and Solutions

Outline

• We investigate Navy pharmacy utilization and variation for FY 2011 to identify and understand patterns among our population of maintenance and scheduled pharmaceutical users Methods All drugs Maintenance drugs Scheduled drugs

FOR OFFICIAL USE ONLY

26

Methods

• FY 2011 PDTS via MDR• Used catchment area of record to identify the eligible populations

surrounding navy catchment regions• Identified all eligible beneficiaries in FY 2011 using DEERS and the

demographic information from the most recent FM the beneficiary appeared

• Maintenance drugs are identified with the MDR PDTS field Maintenance Drug = ‘Y’

• Scheduled drugs and identified using the MDR PDTS field DEA Class = 1, 2, 3, 4, or 5*


27* note, there were no drugs identified as having DEA class 1 in PDTS

All pharmacy age distribution


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Age distribution for all pharmacy users


29

All pharmacy utilization

30 day supplies per 1,000 Navy region beneficiaries by age

60,000 30 days supplies implies the average 80 year old takes about 5

medications daily


30

Popular fill source

• AD beneficiaries fill almost exclusively at MTF pharmacies• Active duty family members and retirees fill mostly at

MTFs and a sizable proportion at retail pharmacies• Retirees and their dependents fill fairly evenly across

MTFs and retail pharmacies

Source System AD ADFM RETRETDEP/

Other TotalDirect 93.6% 61.3% 48.4% 40.1% 53.8%Retail 5.3% 37.4% 40.6% 50.9% 39.2%Mail order 0.3% 0.7% 6.4% 5.3% 4.1%Other 0.8% 0.6% 4.5% 3.6% 3.0%Total 100.0% 100.0% 100.0% 100.0% 100.0%

Source: MHS Data Repository (MDR PDTS table FY2011).

Types of maintenance drugs

• Top 5 Maintenance drugs (15% of all maintenance drugs prescribed)

1. IBUPROFEN

2. SIMVASTATIN

3. LISINOPRIL

4. NEXIUM

5. LIPITOR


31


32

Maintenance drug age distribution

Age distribution for maintenance pharmaceutical users


33

Maintenance drug utilization

30 day supplies of maintenance drugs per 1,000 Navy region beneficiaries by age

50,000 30 days supplies implies the average 80 year old takes about 4

maintenance medications daily


34

Maintenance drug regional variation

High:

NH Pensacola (13,307 30 day

supplies)

Low:

NCA MSMA (9,460 30 day supplies)

High/Low: 1.41

(Beneficiaries in NH Pensacola use 1.4

times as many maintenance drugs as those in the NCA

MSMA)Regional variation for maintenance drug prescriptions per 1,000 beneficiaries

Scheduled drugs


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Schedule

Abuse potentia

l

Accepted

medical use

Likelihood of psychological

or physical Dependence

Examples

I High No No accepted safety for use

Heroin, LSD, marijuana

II High Yes High Amphetamine (Adderall®),

methamphetamine (Desoxyn®), cocaine

III Moderate Yes Moderate Vicodin®, Tylenol with codeine®, ketamine

IV Low Yes Limited Alprazolam (Xanax®), diazepam (Valium®)

V Low Yes Limited Robitussin AC®,Phenergan with Codeine®

Types of scheduled drugs

• Top 5 Scheduled drugs (55% of all schedules drugs prescribed)

1. HYDROCODONE-ACETAMINOPHEN

2. ZOLPIDEM TARTRATE

3. OXYCODONE-ACETAMINOPHEN

4. ALPRAZOLAM

5. DIAZEPAM• Scheduled drugs can also be maintenance drugs:

1. CLONAZEPAM

2. CONCERTA

3. LYRICA

4. ADDERALL XR

5. VYVANSE


36


37

Scheduled drug age distribution

Age distribution for scheduled pharmaceutical users


38

Scheduled drug utilization

30 day supplies of scheduled drugs per 1,000 Navy region beneficiaries by age

1,900 30 days supplies implies the average 80

year old takes about 1.5 scheduled drug

medications daily


39

Scheduled drug regional variation

High:

NH Pensacola (1,073 30 day

supplies)

Low:

NCA MSMA

(567 30 day supplies)

High/Low: 1.89

(Beneficiaries in NH Pensacola use nearly twice as

many scheduled drugs as those in the NCA MSMA)Regional variation for scheduled drug prescriptions per 1,000 beneficiaries


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Questions?

• Nevin Aragam

• [email protected]

Appendix

• Navy region definitions by catchment area DMIS ID:• 0067 0066 0037 0123 - NCA MSMA • 0124 0120 – Tide Water MSMA • 0024 0029 - San Diego MSMA • 0125 126 127 - Puget Sound MSMA • 0104 - NH Beaufort • 0091 - NH Camp Lejeune • 0039 - NH Jacksonville • 0028 - NH Lemoore • 0038 - NH Pensacola • 0030 - NH Twentynine Palms


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Documents

June 2012 Eric Christensen Patient-centered Medical Home (PCMH)/ Medical Home Port (MHP) Evaluation (with emphasis on chronic conditions, particularly