The Effect of Health Coaching Services on
Changes in Health Care Utilization and
Expenditures for Medicaid Members with
Chronic Conditions
Wen-Chieh Lin, Georgianna Willis, Hung-Lun Chien, & Elizabeth O’Connell
Center for Health Policy and Research, University of Massachusetts Medical School
Kate Staunton Rennie and Louise Bannister
MassHealth Office of Acute and Ambulatory Care
Massachusetts Executive Office of Health and Human Services
Timothy G. Ferris and Heather M. Bottella
Partners Community Healthcare, Inc.
AcademyHealth Annual Research Meeting
June 27,
27 2010
ACKNOWLEDGEMENTS
• Bruce Barton, Robin E. Clark, Ann Lawthers, and
George Reed
Center for Health Policy and Research
University of Massachusetts Medical School
• Marlene Kane
MassHealth Office of Acute and Ambulatory Care
Massachusetts Executive Office of Health and Human Services
• John Chapman, Jennifer Dowd, Allison McDonough,
Tavinder Phull
Phull, and Kristen Solemina
Partners Community Healthcare, Inc.
2
BACKGROUND
• Chronic conditions in non-elderly adult Medicaid enrollees
 High prevalence (>60%); Multiple chronic conditions; High expenditures
• Disease
Di
managementt program
 Commonly used approach for chronic care
g
 Various definitions and varied designs
 Anticipates reduction in health care costs as quality of care improves
• Connection Health Coaching Program
 Established in 2004 by Partners HealthCare System
 Telephone health coaching services provided by a commercial disease
management company
 Targets high risk Massachusetts Medicaid (MassHealth) and Health
Safety Net patients who have one or more qualifying chronic conditions
3
SPECIFIC AIMS
• To examine the effect of the Connection Program
on health
h lth care utilization
tili ti and
d expenditures
dit
 Number of acute hospitalizations
 Number
N b off emergency d
department
t
t (ED) visits
i it
 Number of ambulatory care visits
 Medicaid expenditures
4
METHODS – Design and Data Sources
• A quasi-experimental design
• Study period
 One year before and two years after Connection Program
enrollment
ll
t
• Merged Connection enrollment data and Medicaid
eligibility and claims data
5
METHODS – Study Population
• Medicaid members aged 18 to 64 living in the Boston area
• Connection members
 Enrolled between 1/1/2005 and 12/31/2006
• Comparisons (a two-step matching process)
 Exact matching on major characteristics
 Nearest neighbor matching on the propensity score
• Sample size
 N=865 for each study group with continuous Primary Care Clinician Plan
(PCCP) participation for one year before and after Connection enrollment
 N=662 (Connection, 76.5%) and N=634 (Comparisons, 73.3%) for those
with three years of continuous PCCP participation
 Dropouts were less likely to have disability determined by the Social
Security Administration or Massachusetts Disability Evaluation Services
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METHODS – Statistical Analysis
• Difference-in-differences (DID) analysis
 Examined the difference in changes on outcomes between the
two study groups before and after the enrollment
• Generalized estimating equation
N
Negative
ti bi
binomial
i l regression
i model
d l ffor h
health
lth care utilization
tili ti
 Ordinary linear regression for log-transformed expenditures
• Approaches used to assess potential bias resulting from
“dropouts”
 Inverse p
probability
y weighting
g
g
 Multiple imputations
 Results were similar to those from the model excluding dropouts
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RESULTS
• Connection members (N=662) and Comparisons (N=634)
were similar at baseline
baseline, except for the number of
ambulatory care visits (17.6 vs.19.7, p=0.01)
• Connection members and Comparisons had high disease
burden, hospitalizations, and ED visits at baseline
 3.3 chronic conditions on average
g
 37% had one hospitalization and 18% had two or more
hospitalizations
 20% had two ED visits and 45% had three or more ED visits
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Annuall Health
A
H lth Care
C
Utilization
Utili ti and
d
Expenditures at Baseline (Unadjusted)
Measures
Connection Members
Comparisons
(N=662)
(N=634)
Mean
(95% CI)
Mean
(95% CI)
P‐value
Acute Ac
te
hospitalizations
0.90
(0.81‐ 0.99)
0.84
(0.75, 0.92)
0.29
ED visits
4.74
(4.27‐ 5.21)
4.59
(4.12‐ 5.05)
0.59
Ambulatory care visits
17.60
(16.30‐ 18.91)
19.68
(18.36‐ 20.99)
0.01
$19,620
($18,053‐$21,186)
$18,681
($17,310‐$20,052)
0.40
Medical expenditures
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Change in Acute Hospitalization
Change in Acute Hospitalizations1
Year
One year pre
Connection Members
Comparisons
(N=662)
(N=634)
Effect of the Connection Program2
IRR
IRR 95% CI
95% CI
IRR
95% CI
95% CI
Ratio of IRRs
Ratio of IRRs
95% CI
95% CI
1
NA
1
NA
1
NA
One year post
One year post
0 55* (0.47,0.64)
0.55
(0 47 0 64)
0 60* (0.49,0.73)
0.60
(0 49 0 73)
0 92
0.92
(0 72 1 18)
(0.72,1.18)
Two years post
0.60* (0.51,0.71)
0.63* (0.53,0.75)
0.95
(0.75,1.21)
* P
P‐value
value < 0.05
< 0 05
1Change is shown using adjusted incidence rate ratios (IRR) with one year pre as the reference time period.
2Change in Connection Members divided by change in Comparisons for each follow‐up time period.
Note: The unadjusted average number of hospitalizations for one year pre was 0.90 for Connection Members and 0 84 for Comparisons
Members and 0.84 for Comparisons.
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Change in ED Visits
Change in ED Visits1
Year
One year pre
Connection Members
Comparisons
(N=662)
(N=634)
Effect of the Connection Program2
IRR
IRR 95% CI
95% CI
IRR
95% CI
95% CI
Ratio of IRRs
Ratio of IRRs
95% CI
95% CI
1
NA
1
NA
1
NA
One year post
One year post
0 89* (0.80,0.98)
0.89
(0 80 0 98)
0 81* (0.72,0.90)
0.81
(0 72 0 90)
1 10
1.10
(0 94 1 28)
(0.94,1.28)
Two years post
0.92
0.77* (0.68,0.87)
1.20*
(1.02,1.42)
(0.83,1.03)
* P
P‐value
value < 0.05
< 0 05
1Change is shown using adjusted incidence rate ratios (IRR) with one year pre as the reference time period.
2Change in Connection Members divided by change in Comparisons for each follow‐up time period.
Note: The unadjusted average number of ED visits for one year pre was 4.74 for Connection Members and 4 59 for Comparisons
4.59 for Comparisons.
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Change in Ambulatory Care Visits
Change in Ambulatory Care Visits1
Year
Connection Members
Comparisons
(N=662)
(N=634)
Effect of the Connection Program2
IRR
IRR 95% CI
95% CI
IRR
95% CI
95% CI
Ratio of IRRs
Ratio of IRRs
95% CI
95% CI
One year pre
1
NA
1
NA
1
NA
One year post
One year post
0 91
0.91
(0 82 1 01)
(0.82,1.01)
0 94
0.94
(0 88 1 01)
(0.88,1.01)
0 96
0.96
(0 85 1 09)
(0.85,1.09)
Two years post
0.94
(0.81,1.09)
0.91
(0.79,1.04)
1.04
(0.85,1.26)
* P
P‐value
value < 0.05
< 0 05
1Change is shown using adjusted incidence rate ratios (IRR) with one year pre as the reference time period.
2Change in Connection Members divided by change in Comparisons for each follow‐up time period. Note: The unadjusted average number of ambulatory care visits for one year pre was 17.60 for Connection Members and 19 68 for Comparisons
Members and 19.68 for Comparisons.
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Change in Medical Expenditures
Change in Medical Expenditures1
Connection Members
Comparisons
p
(N=662)
(N=634)
Effect of the Connection Program
ec o e Co ec o
og a 2
Proportion
95% CI
Proportion
95% CI
Ratio of proportions
95% CI
One year pre
1
NA
1
NA
1
NA
y
p
One year post
0.70*
((0.66,0.75)
,
)
0.67*
((0.61,0.74)
,
)
1.04
((0.93,1.17)
,
)
Two years post
0.70*
(0.63,0.77)
0.68*
(0.61,0.76)
1.03
(0.89,1.20)
Year
* P‐value < 0.05
1Change is shown using adjusted ratios with one year pre as the reference time period.
2Change in Connection Members versus change in Comparisons for each follow‐up time period.
Note: The unadjusted average medical expenditures for one year pre was $19,620 for Connection Members and $18,681 for Comparisons; the median was $14,449 for Connection Members and $14,194 for Comparisons.
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SUMMARY OF FINDINGS
• Connection Program did not demonstrate statistically
significant effects on acute hospitalizations,
hospitalizations
ambulatory care visits, and medical expenditures
• Decrease in ED visits for Connection members was
significantly less than that for Comparisons during the
g
enrollment
second yyear after Connection Program
• Results were similar to those from models using
inverse probability weighting and multiple imputations
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LIMITATIONS
• Not fully certain about unbiased comparison
b
because
off potentially
t ti ll unobserved
b
d ffactors
t
• No information on Comparisons’ participation
in similar programs
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DISCUSSION
• Adequate level of intervention and continuous
“
“engagement”
t”
• Length of time needed to observe changes in
outcomes of interest
g may
y not be realistic
• Immediate cost-savings
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POLICY IMPLICATIONS
• Program design, implementation, and evaluation
 Target population
 Essential components for the program
 Levels of intervention
 Rigorous evaluations
• Patient Protection and Affordable Care Act
 Chronic disease management
g
 Primary care-centered medical homes for Medicaid
members with chronic conditions
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• Improving Quality of Care for Medicaid Members with
Chronic Diseases Through Health Coaching Services
Willis G, Lin W-C, Chien H-L, O’Connell E, Staunton Rennie K,
Bannister L, Ferris TG, and Bottella HM
Poster Session C, # 1167
6:30 pm to 8:00 pm, Monday, June 28
• Questions or comments: wen.lin@umassmed.edu
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