Evaluation of Phase I of the Medicare Health Support
Pilot Program Under Traditional FFS Medicare:
18-Month Interim Analysis
Panel Presented by
Nancy McCall, Jerry Cromwell, Kevin Smith
RTI International
AcademyHealth Annual Meeting
Chicago, IL
June 29, 2009
www.rti.org
RTI International is a trade name of Research Triangle Institute
Overview of Medicare Health Support (MHS)
Phase I Pilot
• 3-year Phase I pilot
• Largest randomized trial of population-based chronic care
management
– Roughly 300,000 beneficiaries assigned to intervention/control;
original and refresh populations
• 8 MHS organizations (MHSOs) launched their programs
between August 1, 2005 and January 16, 2006
• Phase I Pilot projects ended between December 31, 2006
and August 31, 2008
– Five MHSOs requested early termination
2
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MHS Phase I Pilot Design
• Intent-to-treat randomized study design
– Roughly 30,000 beneficiaries randomized into each of the
programs
• 20,000 intervention group and 10,000 comparison group
– MHSOs “at risk” for all intervention beneficiaries including those who do
not consent to participate or those they do not contact
– Design provides strong incentives to gain participation by all
eligible beneficiaries in the intervention group
– Beneficiaries may lose and regain eligibility during the pilot
3
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MHS Phase I Population
• Original Population Selection Criteria
– Fee-for-service (FFS)
– Claims-based diagnosis of heart failure and/or diabetes
– CMS Hierarchical Condition Categories (HCC) score >1.35
• Block Randomization Requested by the MHSOs
– 3 categories of HCC risk scores
– Heart failure or not
– Medicaid enrollment
• Refresh population
– Selection Criteria differed modestly
– Excluded from presentation of results
4
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“At Risk” Fee Model
• MHSOs “at risk” for monthly management fees
– Management fees for only those beneficiaries who consent to
participate
– Only during periods of voluntary participation
– Only during periods of eligibility
• Retention of fees is contingent upon
– Achieving savings in Medicare expenditures to offset fees
– Meeting quality improvement and satisfaction thresholds
5
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MHS Interventions
• Care Management
– Nurse-based health advice for the management and monitoring of
symptoms
– Health education
– Health coaching to encourage self-care and management of chronic
health conditions
– Medication counseling
– End-of-life care planning
– Intensive case management
– Home monitoring
– Encourage compliance with evidence-based care guidelines
– Assistance with psychosocial needs
• Primary mode was telephonic with varying degrees of in-person
intervention among the MHSOs and over the course of the pilot
• Limited physician involvement
6
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Participation Rates
Status
Aetna
Healthways
CIGNA
Health
Support
Participation Rate
83%
89%
89%
95%
Never Consented to Participate
Rate
17%
11%
11%
5%
Refused to participate when
contacted by MHSO
13
3
2
4
9
9
Not contacted/unable to be located
Health
Dialog
Green
Ribbon
Health
LifeMasters1
McKesson
XLHealth
84%
76%
82%
74%
16%
24%
18%
26%
03
3
9
4
11
4
13
15
14
15
NOTES:
1 LifeMasters examines months 7-17.
3 The refusal rate for Health Dialog is 0.3 percent.
SOURCE: RTI analysis of Medicare Health Support (MHS) participation data submitted by the MHSOs for the
original population for Months 1 – 18 of the Phase I pilot.
7
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Intervention Activities
Percent distribution of original population participants across number of months of
telephonic support during Months 7–18 of the Medicare Health Support Pilot
MHSO
Aetna
Healthways
CIGNA Health Support
Health Dialog
Green Ribbon Health
LifeMasters
McKesson
XLHealth
Average Number of Months of Telephonic Contact
Risk Strata
Low
Medium
High
All
1.6
3.0
4.2
3.1
5.4
6.2
6.6
5.9
6.2
6.7
7.2
6.5
5.8
6.3
6.5
6.1
3.0
4.1
4.9
4.1
3.7
4.7
5.6
5.3
2.6
3.7
4.6
3.6
3.0
4.1
3.9
3.1
SOURCE: RTI analysis of Medicare Health Support (MHS) participation data and telephonic and in-person
encounter data submitted monthly by the MHSOs for the original population for Months 1 – 18 of
the Phase I pilot.
www.rti.org
8
Independent Evaluation
• Legislation provided for a Phase II if the independent
evaluation indicated
– Improvements in clinical quality of care and beneficiary satisfaction
and achievements in Medicare savings targets
• RTI conducting independent evaluation with a focus on
–
–
–
–
Implementation and Evolution of MHS programs
Quality and Health Outcomes
Beneficiary and Provider Satisfaction
Financial Outcomes
• Intent-to-treat randomized study design and a difference-indifferences evaluation framework
9
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Conceptual Framework
INTERVENTION
Pilot Period Severity
+
Chronic(+)
Beneficiary
Characteristics
Acute(+)
Base Year
Severity
+
Pilot Period
Cost and
Utilization
+
Base Year
Cost and
Utilization
Regression-to-mean(-)
10
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Independent Evaluation
• Presentation today is based on the first 18 months of experience
for the original populations and reported in the October 2008
Report to Congress
• Analyses of the full Phase I pilot are being finalized and will be
reported to Congress by CMS
• Using the full evaluation analyses, the Secretary will make the
final determination if legislative conditions for expansion have
been met. At mid-point, the Secretary determined that there was
insufficient evidence to move forward with a Phase II expansion
11
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Effects of Medicare Health Support (MHS)
Phase I Pilot Programs on Beneficiary
Functioning, Self-Management, and
Experience of Care
Kevin Smith, Nancy McCall, and Shulamit Bernard
RTI International
Presented at
AcademyHealth Annual Research Meeting
Chicago IL
June 29, 2009
www.rti.org
Objectives of MHS Survey
 Conduct beneficiary survey to assess patientreported outcomes that are not available from
administrative or claims data
 For each MHS program, estimate intervention effects
for multiple outcomes
13
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MHS Phase I Pilot Survey Design
 Survey conducted for the original population of each
MHS Organization
 In each MHS program, drew random sample of:
– 800 intervention beneficiaries
– 800 control beneficiaries
 Same instrument used for both intervention/control
 Designed to detect group differences as small as 5%
 Pre-post mail survey
– Pre = Month 6 after program start
– Post = Month 18 of program
– 2nd mailing, telephone follow-up
www.rti.org
14
MHS Survey Outcomes
 1. Experience of Care
– Helped to cope with condition
– Number of helpful topics discussed with team
– Quality of communication with team
 2. Self-Management
– Planning, setting health goals
– Self-efficacy ratings – 8 activities
– Self-care frequency – 8 activities
15
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MHS Survey Outcomes
 3. Physical and Mental Function
–
–
–
–
Physical Health Composite (RAND PHC)
Mental Health Composite (RAND MHC)
PHQ-2 (anhedonia, depressed mood)
Activities of Daily Living (ADLs)
16
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Analysis Methods
 Analyses conducted separately for each of 7 MHS
programs
 LifeMasters not included in the analysis due to withdrawal
from the pilot prior to follow-up survey
 Examined follow-up response propensity
 Analyses weighted for follow-up attrition
 MHS intervention effects estimated by ANCOVA:
– Group indicator (intervention/control)
– Baseline value of outcome
17
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MHS Survey Response Rates
 70.0% for baseline survey
 77.8% for follow-up survey
 Less likely to respond if:
– Poorer health (HCC risk score)
– Aged 80 years or older
– Aged < 65 years (disabled)
 No group differences in follow-up response rates
18
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ANCOVA Analysis Example
Mean Physical Health Composite (PHC) Scores
Group
N
Baseline
Follow-up
Change
Effect
Intervention
329
32.86
32.42
-0.44
0.43
(SE=0.51)
Control
419
32.82
31.96
-0.86
19
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MHS Survey Experience of Care Effects
Statistically significant intervention effect
Aetna Healthways CIGNA
Health care team helped
beneficiary cope with
chronic condition
Number of helpful
discussion topics
Quality of
communication with
health care team
+
Health
Dialog McKesson GRH XLHealth
++
++
++
++
++
+
NOTES:
1. Statistical significance determined using Analysis of Covariance: positive intervention effect denoted as + p<.05, ++ p<.01;
negative intervention effect denoted as - p<.05, -- p<.01
SOURCE: RTI Analysis of Medicare Health Support original population beneficiary baseline and follow-up surveys conducted
between March 1, 2006 and June 30, 2006 and March 5, 2007 through July 30, 2007.
www.rti.org
20
MHS Survey Self-Management Effects
Statistically significant intervention effect
Aetna
Percent helped set goals
Percent helped make a plan
Health
Healthways CIGNA Dialog McKesson GRH XLHealth
+
+
+
++
+
+
+
NOTES:
1. Statistical significance determined using Analysis of Covariance: positive intervention effect denoted as + p<.05, ++ p<.01;
negative intervention effect denoted as - p<.05, -- p<.01
SOURCE: RTI Analysis of Medicare Health Support original population beneficiary baseline and follow-up surveys conducted
between March 1, 2006 and June 30, 2006 and March 5, 2007 through July 30, 2007.
21
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MHS Survey Self-Efficacy Effects
Statistically significant intervention effect
Aetna
Take all medication
Plan meals and snacks
Manage blood sugar level
Check feet for sores
Exercise 2-3 times weekly
Limit salt
Weight yourself
Limit fluids
Health
Healthways CIGNA Dialog McKesson GRH XLHealth
+
+
+
+
+
NOTES:
1. Statistical significance determined using Analysis of Covariance: positive intervention effect denoted as + p<.05, ++ p<.01;
negative intervention effect denoted as - p<.05, -- p<.01
SOURCE: RTI Analysis of Medicare Health Support original population beneficiary baseline and follow-up surveys conducted
between March 1, 2006 and June 30, 2006 and March 5, 2007 through July 30, 2007.
22
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MHS Survey Self-Care Frequency Effects
Statistically significant intervention effect
Health
Aetna Healthways CIGNA Dialog McKesson GRH XLHealth
Medications taken
-++
Blood sugar tested
30 minutes of exercise
Feet checked
++
+
+
Followed healthy eating plan
+
Weight measured
Salt limited
Fluids limited
++
NOTES:
1. Statistical significance determined using Analysis of Covariance: positive intervention effect denoted as + p<.05, ++ p<.01;
negative intervention effect denoted as - p<.05, -- p<.01
SOURCE: RTI Analysis of Medicare Health Support original population beneficiary baseline and follow-up surveys conducted
between March 1, 2006 and June 30, 2006 and March 5, 2007 through July 30, 2007.
www.rti.org
23
MHS Survey Physical/Mental Function Effects
Statistically significant intervention effect
Health
Aetna Healthways CIGNA Dialog McKesson GRH XLHealth
PHC score
MHC score
PHQ-2 score
Percent PHQ-2 positive screen
Number of ADLs – difficult to do
+
+
Number of ADLs– receiving help
NOTES:
1. Statistical significance determined using Analysis of Covariance: positive intervention effect denoted as + p<.05, ++ p<.01;
negative intervention effect denoted as - p<.05, -- p<.01
SOURCE: RTI Analysis of Medicare Health Support original population beneficiary baseline and follow-up surveys conducted
between March 1, 2006 and June 30, 2006 and March 5, 2007 through July 30, 2007.
www.rti.org
24
MHS Survey Summary
 Few significant MHS intervention effects were found
for multiple self-reported outcomes
 Programs had most success in helping beneficiaries
set health goals
 Improvements in frequency of self-care activities
occurred in only 6 of 56 analyses
 Physical and mental function declined slightly over
the course of the follow-up year in all programs
25
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Conclusions
 MHS had few meaningful effects on self-care
activities or functioning
 Limited success may be attributable to lack of
consistent interaction with many MHS participants
 Most beneficiaries were probably already aware of
self-management recommendations for their chronic
conditions
26
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Quality of Care and Health Outcomes:
An Interim Evaluation of Medicare Health
Support (MHS) Phase I Pilot Results
Presented by
Nancy McCall, Sc.D.
RTI International
AcademyHealth Annual Meeting
Chicago, IL
June 29, 2009
www.rti.org
Quality of Care and Health Outcomes: An
Interim Evaluation of MHS Phase I Pilot Results
• A common set of NQF endorsed, claims-based Quality
of Care Measures
–
–
–
–
HbA1c screening - diabetes
Cholesterol screening – diabetes/heart failure
Urine protein screening – diabetes
Retinal Eye Exam – diabetes
• Health Outcomes
–
–
–
–
Rate of short-stay, acute care hospitalization
Rate of readmission 30 days post discharge
Rate of ER visits
Mortality
28
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Data for MHS Phase I Pilot Quality of
Care and Health Outcomes Analyses
 All Medicare Part A&B Claims
– All types of services, except hospice
– Claims included during periods of eligibility
• Ineligible – hospice, Medicare Advantage, ESRD, Medicare
becomes secondary payer, or lose Part B enrollment
• Exception – process of care measures includes claims during
periods of ineligibility, if service is provided
 Time Frame
– Full 12 months prior to each MHSO’s Start Date
– Months 7-18 of Pilot Period
• After initial engagement period ended
29
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Analysis of MHS Phase I Pilot Quality of
Care and Health Outcomes
• Quality of care measures
– Mean rates adjusted for periods of ineligibility but all services
included during ineligible period
– Logistic regression model estimated with robust variance to
statistically test the difference-in-differences change in rates of
process of care measures
• Rates of acute care utilization
– Mean rates adjusted for periods of ineligibility
– Negative binomial regression model estimated with robust
variance to statistically test the difference-in-differences change
in rates of hospitalization, readmission, and ER visits
30
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Change in Rate of Cholesterol Screening: Beneficiaries
with Heart Failure During the First 18 Months of MHS
Phase I Pilot: Original Populations
MHSO
Base Rate/100
D-in-D
Pilot Rate/100
Aetna
66
1.2
Healthways
71
4.0*
CIGNA
66
3.5*
Health Dialog
63
2.4*
GRH
75
1.2
LifeMasters
60
2.6*
McKesson
55
0.5
XLHealth
66
-0.1
NOTES: Rates weighted by beneficiary fraction of eligible days in pilot during months 7-18.
D-in-D = Difference-in-differences rate tested with a logistic regression model and robust variance estimation
Statistical Significance <0.05, if rate has an *
SOURCE: Medicare Part A & B Claims, 2004-07.
www.rti.org
31
Change in Rate of Quality of Care Measures for
Beneficiaries with Diabetes During the First 18
Months of MHS Phase I Pilot: Original Populations
LDL-C
HbA1c
Base D-in-D/
Rate/100 100
Base D-in-D/
Rate/100 100
Urine Protein
Eye Exam
Base D-in-D/
Base D-in-D/
Rate/100 100
Rate/100 100
Aetna
76
1.8*
83
0.3
67
0.5
40
1.7
Healthways
81
3.2*
88
2.0*
72
1.7*
38
2.0*
CIGNA
76
3.0*
87
2.4*
72
2.3*
32
0.2
Health Dialog
77
0.0
85
0.6
71
-0.4
42
0.7
GRH
85
0.1
88
1.6*
74
0.9
41
-1.0
LifeMasters
69
2.1*
81
0.8
65
1.4
33
1.7
McKesson
65
2.4*
81
1.5*
66
1.0
32
1.0
XLHealth
75
0.6
87
0.5
70
0.9
32
1.3
NOTES: Rates weighted by beneficiary fraction of eligible days in pilot during months 7-18.
D-in-D = Difference-in-differences rate tested with a logistic regression model and robust variance estimation
Statistical Significance <0.05, if rate has an *
SOURCE: Medicare Part A & B Claims, 2004-07.
www.rti.org
32
Change in Rate of Short-stay, Acute Care
Hospitalizations During the First 18 Months of MHS
Phase I Pilot: Original Populations
Aetna
Healthways
CIGNA
Health Dialog
GRH
LifeMasters
McKesson
XLHealth
All Cause
Base
D-in-D/
Rate/1,000 1,000
935
-21.1
789
17.7
666
3.6
816
20.7
633
10.9
809
8.0
766
2.4
658
-7.3
Heart Failure
Base
D-in-D/
Rate/1,000 1,000
146
-6.2
113
-2.8
100
3.8
132
-7.0
87
3.1
103
2.6
116
5.0
85
1.7
Diabetes
Base
D-in-D/
Rate/1,000 1,000
31
-2.4
29
-3.7
26
-0.3
25
2.2
19
-0.6
27
-0.7
36
4.4
24
2.8
NOTES: Rates weighted by beneficiary fraction of eligible days in pilot during months 7-18.
D-in-D = Difference-in-differences rate tested with a negative binomial regression model and robust variance
estimation. Statistical Significance <0.05, if rate has an *
SOURCE: Medicare Part A & B Claims, 2004-07.
www.rti.org
Change in Rate of Readmissions and Emergency
Room (ER) Visits During the First 18 Months of MHS
Phase I Pilot: Original Populations
Aetna
Healthways
CIGNA
Health Dialog
GRH
LifeMasters
McKesson
XLHealth
All Cause Readmission
Base
D-in-D/
Rate/1,000
1,000
436
-2.9
402
7.3
316
-3.0
343
51.9*
270
38.2
329
43.8
337
-4.4
312
-7.1
All Cause ER Visits
Base
D-in-D/
Rate/1,000
1,000
732
-9.3
988
0.3
1,214
38.8
849
11.1
790
43.0
1,134
98.6*
1,448
34.7
1,213
31.1
NOTES: Rates weighted by beneficiary fraction of eligible days in pilot during months 7-18.
D-in-D = Difference-in-differences rate tested with a negative binomial regression model and robust variance estimation
Statistical Significance <0.05, if rate has an *
SOURCE: Medicare Part A & B Claims, 2004-07.
www.rti.org
Mortality Rates During the First 18 Months
of MHS Phase I Pilot: Original Populations
Healthways
CIGNA Health Support
Health Dialog
Green Ribbon Health
LifeMasters
McKesson
XLHealth
Mortality rate
Intervention Comparison
(%)
(%)
15.3
15.3
13.4
13.4
14.1
14.3
17.1
16.0
15.5
15.7
15.2
15.6
13.6
13.5
14.6
14.7
Difference
0.0
0.0
-0.2
1.1*
-0.2
-0.4
0.1
-0.1
NOTES:
1.Statistical significance testing of differences in the original populations’ mortality rates between intervention and comparison beneficiaries is
conducted using a t-test. * p<.05
SOURCE: RTI Analysis of Medicare Health Support original populations’ mortality using the Medicare Enrollment Database and the MHS daily
eligibility file.
www.rti.org
Quality of Care and Health Outcomes:
Next 18 Months
 Evaluate last 18 months of Phase I Pilot period
quality of care and health outcomes
– Sustainability of quality of care improvements
 Explore rates of acute care utilization for other
ambulatory care sensitive conditions
36
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Medicare Health Support (MHS) Phase I
Pilot Medicare Savings:
An Interim Evaluation of Pilot Results
Presented by
Jerry Cromwell, PhD
RTI International
AcademyHealth Annual Meeting
Chicago, IL
June 29, 2009
www.rti.org
Medicare Savings: An Interim Evaluation
of MHS Phase I Pilot Results
• Savings on Medicare Part A&B Costs
• Success in Achieving Medicare Budget Neutrality (BN)
– Net Savings: Gross Savings – Monthly Management Fees
– Budget Neutrality requires RoI = > 0
• Savings on Beneficiaries who Participate or Not
– MHSOs at risk for Intervention Beneficiaries who
refuse/unreachable
• Savings by Disease Cohort: Heart Failure, Diabetes
• Regression-to-Mean among Chronically Ill Beneficiaries
38
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Data for MHS PBPM Cost Analyses
• All Medicare Part A&B Claims for Intervention &
Comparison Populations
– Any claim in U.S. (not just MHSO target area)
– Claims for all diseases (not just heart failure/diabetes)
– Excluding ineligible claims (e.g., hospice, M+A)
• Time Frame
– Full 12 months prior to each MHSO’s Start Date
– Through first 18-months (1/2) of Pilot Period
• Attrition: 1-1.5% per Month
39
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Constructing Average PBPM Costs
• Actuarial PBPM Cost: All payments / All eligible months
– No variance or statistical testing
• Evaluation (RTI) PBPM Cost: Beneficiary level PBPMs
– PBPM = all payments/(eligible days/30.4 days)
• Extreme Variation in Beneficiary PBPMs
–
–
–
–
$0<= 18-month PBPM Cost >$200,000
CV[pbpm] = Std Dev PBPM/Mean PBPM: 1.5 to 2+
Primary source of high PBPMs: < 1-month eligibility
No outlier trims
• Implications for Analysis
– Very large sample sizes required to test small savings
– Need to weight observations by fraction of eligible days
www.rti.org
40
Analyses of MHS Phase I Pilot PBPM
Savings
• Tabular Differences in Intervention (I) vs. Comparison
(C) PBPM Growth Rates
– Calculate change in base & 18-mn PBPMs by beneficiary
– Determine average change in PBPMs: I vs. C
– Perform t-tests of mean differences in I vs. C
• Mean differences in changes = Gross savings
• 1.96*SE = minimum detectable differences
41
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Analyses of MHS Phase I Pilot PBPM
Savings (cont)
• Multivariate ANCOVA Regression
–
–
–
–
PBPMpilot = a + b*I + c*PBPMbase + d*Z
Reg-to-Mean Effect = c – 1
b = Intervention Effect | Z, reg-to-mean
Z factors out “noise,” narrows CIs of estimates b + c
42
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6/29/2009
MHS Phase I Pilot Mean PBPM Costs,
Intervention Sample
Difference
MHSO
Aetna
Base Year
18-Month Pilot
15 Months (%)
Annual
$1,407
$1,726
$319 (23%)
$3,828
Healthways
1,287
1,618
331 (26)
3,972
CIGNA
1,039
1,257
218 (21)
2,616
Health Dialog
1,157
1,411
253 (22)
3,036
GRH
1,132
1,427
295 (26)
3,540
LifeMasters
1,199
1,459
260 (22)
3,120
McKesson
1,119
1,354
235 (21)
2,820
XLHealth
1,063
1,365
302 (28)
3,624
NOTES: Mean PBPMs weighted by beneficiary fraction of eligible days in 18-month period . Percent of pilot.
SOURCE: Medicare Part A & B Claims, 2004-07.
43
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Medicare Savings in MHS Phase I Pilot
at 18 Months
$50
$38
$40
$26
Savings ($)
$30
$26
$20
$10
Healthways
Health
CIGNA Dialog
-$10 Aetna
$1
McKesson
GRH
XLHealth
LifeMasters
-$20
-$17
$0
-$13
-$30 -$26
-$40
www.rti.org
NOTES: Negative values imply savings
SOURCE: Medicare Part A & B claims, 2004 to 2007
-$29
44
Medicare Savings & Fees, Percent of Comparison
PBPM, MHS Phase I Pilot, 18 Months
10.0%
9.3
8.4
8.2
8.0%
7.5
6.9
5.9
6.0%
4.7
5.4
4.0%
2.1
2.0%
1.5
1.2
1.0
0.0
0.0%
Aetna
-2.0%
Healthways
-1.6
CIGNA
Health
Dialog
-1.9
GRH
LifeMasters McKesson XLHealth
-2.7
-4.0%
Savings as % of Comparison PBPM
SOURCE: Medicare Part A & B claims, 2004-07.
www.rti.org
Monthly Fee % of Comparison PBPM
45
Medicare Savings among Intervention
Participants and Non-Participants
MHSO
Aetna
Healthways
CIGNA
Health Dialog
GRH
LifeMasters
McKesson
XLHealth
Participation
Rate
83%
89
89
95
84
76
82
74
PBPM Savings
Never
Participants
Participants
Minus
Minus
Comparison
Comparison
-$47
$105
3
246*
-23
75
19
326*
-32
82
17
118*
-11
63
-51
46
NOTES: *p<.05
SOURCE: Medicare Part A & B claims, 2004 – 2007 ; MHS daily eligibility file.
46
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Difference in Intervention-Comparison PBPM
Increases Growth Rates by Disease Category
MHSO
Aetna
Healthways
CIGNA
Health Dialog
GRH
LifeMasters
McKesson
XLHealth
All
Beneficiaries
-1.5%
1.6
-1.0
1.9
-1.2
2.7
0.0
-2.1
All
Heart Failure
-1.9%
-1.1
0.5
3.8
-1.9
2.0
-0.1
-4.4
All
Diabetes
0.4%
2.6
-2.3
1.0
-0.6
3.5
-1.3
-0.4
NOTES: Difference in PBPM increases divided by comparison PBPM. All heart failure, all diabetes
includes beneficiaries with both diseases. No changes significant at p<.05.
SOURCE: Medicare 2004-06 Part A & B claims.
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Medicare PBPM Savings Adjusted for Patient
Characteristics & Regression-to-the-Mean
Regression-to-mean
MHSO
Aetna
Healthways
CIGNA
Health Dialog
GRH
LifeMasters
McKesson
XLHealth
Estimated
Savings
-$2
-18
17
-19
14
-37
3
35
Sim. Increase for PBPM
Effect
-0.58*
-0.65*
-0.64*
-0.66*
-0.62*
-0.62*
-0.60*
-0.61*
50% of Mean
$744
745
1,546
638
650
627
568
621
150% of Mean
-$44
-99
-123
-135
-47
-117
-108
-33
NOTES: * p<.05. Savings: Controlling for beneficiary characteristics and regression-to-the-mean.
Effect: Base year PBPM coefficient minus 1.0.
SOURCE: Medicare Part A and B claims, 2004 to 2007.
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48
Medicare Savings: Next 18 Months
• Complete Savings, Budget Neutrality Analyses
• Analyze Quarterly Trends in PBPMs
• Compare Participants to Comparison Group
• Stratify Savings by Beneficiary Characteristics
• Analyze End of Life Costs
• Calculate RoI and Cost-Effectiveness Ratios
49
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Challenges in the Medicare Health Support
(MHS) Phase I Pilot and Implications for
future Medicare Initiatives
Presented by
Nancy McCall, Sc.D.
RTI International
AcademyHealth Annual Meeting
Chicago, IL
June 29, 2009
www.rti.org
Engaging the Intervention Population
Finding #1: Participation rates ranged from 74% to 95%
Finding #2: MHSOs did not engage the sicker, more
costly, acutely ill beneficiaries.
Barriers to Success:
– High search costs to locate & recruit beneficiaries.
– Challenges in identifying and engaging institutionalized
beneficiaries
51
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Enhancing Beneficiary Self-Management
Behaviors
Finding #3: Beneficiary surveys showed little evidence of
changes in self-efficacy or self-care.
Barriers to Success:
– Nurses must conduct the intervention primarily telephonically;
difficulties building a personal relationship with beneficiaries
– Primarily a frail elderly population with reported high levels of
psychosocial needs and visual and hearing impairments
– Lack of routine clinical data reduced the MHSOs ability to have
up-to-date assessments of patient health status
52
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Improving Quality of Care and Health
Outcomes
Finding #4: Modest improvement in quality process measures.
Finding #5: No intervention reductions in hospitalization, readmission, or ER visit rates.
Finding #6: Vast majority of admissions not directly related to pilot
chronic diseases.
Barriers to Success:
– Little relationship between the primary care provider and the MHSO
– Commercial DM organizations do not provide process-of-care
services ensuring compliance
– Lack of timely clinical information on rapid deterioration in health
– Lack of timely knowledge of hospitalizations to avoid readmissions.
53
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Achieving Financial Savings &
Budget Neutrality
Finding #7: Fees accrued through the first 18-month pilot period far
exceeded savings.
Finding #8: Savings among Participants alone very modest at best
Finding #9: Non-participants very costly
Finding #10: Medicare chronically ill exhibit large regression-to-the-mean
on costs
Barriers to Success:
– Without a reduction in inpatient admissions, no significant reductions in
Medicare expenditures.
– Limited intervention with most costly beneficiaries requires much larger
savings with participants, which has not materialized to date.
– Monthly management fees far too high relative to savings
– Simple pre/post designs biased in favor of success
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Implications for Future Medicare Initiatives
• Greater involvement of primary care physicians and nurses required
– but may not be sufficient
• A holistic, not DM focus, to care management necessary to improve
health outcomes and reduce cost
• Restricting Intervention eligibility by eliminating those least likely to
participate or be unresponsive to care
• More timely flow of diagnostic/therapeutic information to care
managers across multiple care settings
• More modest DM fees in line with limited Medicare savings
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