MCCD Introduction
A Longitudinal Evaluation of
Care Management for Elders
with Comorbidities
Paul Shelton
Health Systems Research Center
Carle Foundation Hospital
Urbana, IL
Paul.Shelton@carle.com
Carle Healthcare System
Location:
– Urbana, IL
– Largest Provider in Downstate IL
– Integrated Delivery System
Carle Foundation Hospital (295+ Beds)
Carle Clinic Association (300+ MDs)
– 9 Branch Clinics (Primary Care Network)
– Main Clinic in Urbana Specialty Care
Health Alliance Medical Plans
– MCO owned by CCA
Medicare Coordinated Care Demonstration (CMS)
– Began April 2002, scheduled to end April 2008
– 15 National Sites, 12 still participating
Improve Clinical Health Status, SelfSelf-Management
Practices and Satisfaction for Beneficiaries with Chronic
Health Conditions
Maintain ‘Budget Neutrality’
Neutrality’ in Total Medicare Costs
MCCD Eligibility Criteria
Medicare Parts A & B
Chronic Conditions: Afib,
Afib, CAD, CHF, COPD, Diabetes
3+ MD Visits and/or Hospitalization in Previous 12
Months
Not Enrolled in Medicare HMO, Use Hospice Services,
Have End Stage Renal Disease, Live in a Nursing Home
Enrolled over 3,200 Beneficiaries since April 2002;
PMPM $ for Each Intervention Patient Enrolled
Methods
Carle’
Carle’s Care Management Model
~ 18 Years Experience Developing Primary Care Teams
(4 Medicare Demonstrations)
Based on Core Components of the Chronic Care Model
– Combination of Case & Disease Management
– Primary Care Teams: PCPs/RN/Patient
2005 Added Registered Dietitian to the Team
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Clinical Guidelines/Standing Orders
Focus on SelfSelf-Management Education
Clinical Information System for Patient Tracking, Clinical
Interventions and Outcomes Reporting
Medical Director Advisory Team
PCPs Reimbursed for Patient Involvement (Team
Conferences)
Design: Randomized Clinical Trial (Patient Level)
Study Population:
– Enrolled April 2002 – April 2003
– Used Carle for Laboratory Testing
– Control Group = 1,140; Intervention Group = 1,161
Key Outcomes:
– SelfSelf-Management Behaviors (Self(Self-Report)
– Clinical Health Status:
Laboratory Testing Rates & Therapeutic Control Levels for Lipids,
Lipids,
HbA1c (Electronic)
Hypertension Control (Chart Review)
– Total Medicare $ (Medicare Claims 12/2005)
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Analytical Strategy
Our Thinking Was …
Increased Primary Care Access …
– Increased Testing Rates and SelfSelf-Management
Education…
Education…
– Would Lead to …
– Increased Therapeutic Control Rates …
– Decreased Hospitalization and Emergency Room
Utilization Rates …
– Budget Neutrality in Total Medicare Costs …
Baseline Characteristics
No Differences Between Groups
Typical MCCD Participant:
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Age = 76.0 + 7.0
Female = 53%
Lives Alone = 30%
Fair/Poor Health = 31%
5+ Daily Medications = 63%
ADL Limitations = 1.0 + 1.5
CAD = 50%; Diabetes = 39%; CHF = 21%; COPD = 29%
Chronic Conditions = 1.6 + 0.9
MD Visits = 3.1 + 5.1; 30% Hospitalized
Results
Clinical Health Status:
– 13% Increase in Blood Pressure Control (p
(p<.05)
– No Difference in Therapeutic Control Rates
18% Increase in LDL Control
6% Increase in HbA1c Control
Medicare Utilization and Costs
– No Differences in Hospitalization Rates
– Intervention Was Not Budget Neutral (Increased Part B$)
– Patient SubSub-Groups (Potential Budget Neutrality)
AllAll-Cause Mortality; No Baseline MD Visits; 10+ Baseline Visits; 2+
Chronic Conditions; 2+ Chronic Conditions & Baseline
Hospitalization
Analytical Strategy
12 Month Evaluation Periods
– Based on Patient Enrollment Date
IntentIntent-toto-Treat Approach
Adjust for Baseline Characteristics That the Literature
Has Shown to Influence Outcomes
Results
SelfSelf-Management Behaviors (48 Months)
– 19% Increase in Ann Foot Exams (DM; p<.01)
– 20% Increase in Daily Weighing (CHF; p<.01)
Laboratory Testing Rates
– Lipids: 12% Increase in Overall Testing Rates (p
(p<.05)
Increase Related to Those Not Tested at Baseline
Once Tested 80% ReTested
No Significant Differences After 24 Months
– HbA1c: 5% increase in Overall Testing Rates
Increase Related to Those Not Tested at Baseline
Once Tested 86% ReTested
No Significant Differences After 12 Months
Conclusions
Intervention has Influenced Physician Behavior/Practice
Patterns (Lost Control Group After 36 Months)
Clinical Outcomes May Not be Appropriate for Elderly
Change Enrollment Criteria: 2+ Chronic Conditions,
Prior Hospitalizaitons,
Hospitalizaitons, No Lab Testing and MD Visits
More Emphasis on Medication Management and
Transitional Care
Palliative/EndPalliative/End-ofof-Life Care
Graduated PMPM Capitation Payment Scale
– Watchful Waiting/Monitoring Category
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