Managing CongestiveHeart Failure in
the Medicare Risk Population
The health issues
a
of our growing population of elderly patients present
challenge and an opportunity to improve care.
Recent
changes in the Health Care
Financing Administration's Medicare program have opened new
opportunities for managed care organizations (MCOs). In fact, the Medicare Risk
Program may be one of the last remaining frontiers for many MCOs.
Any new population presents a range
of challenges. Wellpoint Pharmacy Management, a pharmacy benefits manager
(PBM) responsible for 15 million lives, prepared itself to deal with a geriatric population's existing health problems and futures
William]. Waugh, Pharm.D.
filled with increasing illness by seeking
out possible models in existing programs.
Wellpoint's approach applied the traditional principles of managed care to this
new group of members. An executive team
of pharmacists and physicians reviewed
statistics about the elderly in general, and
Disease State Management and Outcomes Research,
Wellpoint Pharmacy Management, Calabasas Hills,
CA
AUTHOR CORRESPONDENCE: William}. Waugh,
Pharm.D., DirectOl; Disease State Management and
Outcomes Research. Wellpoint Pharmacy Management, 2700.1 Agoum Road, #325, Ca/abasas Hills,
CA 91361
CopylightlJ) 1999, Academy oj Managed Care
Pharmacy, Ine. All rightsreserved.
14 Journal of Managed Care Pharmacy
]MCP
interventions: impaired quality of life,
and the occurrence of atrial fibril1ation
in approximately 50% of patients, a
complication that can drain health care
dollars.
Expenditures for treatment of CHF in
the U.S. exceed $10 billion annually (see
Figure 1). Hospitalization accounts for
about $7 billion, and rehospitalization is
a serious concern. Long-term care facilities and physician's office visits consume
ment for congestive heart failure (CHF)
and screening for inappropriate or unne-
especially in reducing hospitalizations."}
Savings potential is even greater when
cessary drug use.
population trends are considered. As the
likelihood of developing CHF increases
Medicare risk population revealed that
CHF is the most common DRG reported,
is Director,
prevalence of CHF doubles with each
decade. Two complications of CHF are
ideal targets for managed care program
savings could be realized: disease manage-
The need f<?rthis plan was based on
two significant findings: 1) analysis of
diagnosis-related groups (DRGs) in the
WILLIAM}. WAUGH, PHARMD,
years after diagnosis. After age 50, the
about 20% of the total! Though drugs,
at $230 million annually, represent only
about 2.3% of total expenditures, drug
treatment employed properly and aggressively could reap significant savings,
the Medicare Risk group in particular, and
identified two areas where considerable
Aut/u}/
The Framingham Study found that the
mortality rate for CHF is high; only 38%
of men and 57% of women survive five
with age (see Figure 2), unless prevention
is emphasized and optimal drug therapy
is prescribed consistently, cases of CHF
can only increase as our population
and 2) data on hospital admissions related
to adverse drug reaction in the elderly,
along with information collected by the
ages.4
National Medical Expenditure (NME) Survey of 1987, showed that inappropriate'
drug use remains a problem in the elderly.
clini,cal guidelines for treatment of CHF
that have been applauded by specialists.l
CONGESTIVE HEART FAILURE
The Agency for Health Care Policy
and Research (AHCPR) has published
Approximately 18 months ago, Wellpoint
developed a disease management program based on these guidelines and sev-
CHF affects more than 2 million Amer-
eral clinical studies. Treatment guidelines also were established for atrial fib-
icans, with 400,000 new cases diagnosed
annually. It is twice as prevalent in men.
rillation because of its high incidence
and cost, and the excellent response of
January/Febru"ry 1999
Vol. 5.
No.1
Managing Congestive Heart Failure in the Medicare Risk Population
Figure 1. Total Direct Expenditures for CHF in the United States
patient outliers are identified to determine
Total Direct Cost: $10 billion annually (in millions of dollars)
where interventions can make the most
impact. Improvement begins with educa-
.
.
.
Hospital
Drug
ting patients; intensive patient education
includes case management.
Case managers, all nurses, call patients at least monthly-more often if
the patient is high risk. They prompt
Nursing Home
Physician Office Visits
$1,900
patients when medication refills are due,
remind them that daily weighing can help
detect fluid retention and its complications, and educate patients on symptoms
that should be reported to their physicians. Whenever contact is made, the
case manager sends documentation to
the physician by fax or mail. Case managers track standard outcome measures,
including frequency of office visits, use
Clearly, use of these drugs is
people with CHF to drug therapy. The
goals were to improve quality of life, reduce admissions and readmissions related
to decompensation, and shorten length
a
This program was applied to a group
of state employees in a southeastern
state during its first six months of operation. Though its full impact after 18
tice.
Each plan that adopts our program is
allowed to modify treatment guidelines
of stay
The steps used to identify patients
included risk assessment based on pre-
to meet the concerns of its own advisory
panel of cardiologists and internists. All
plans reviewed the gUidelines; more than
90% accepted them as written. The re-
scription records and presence of an
ICD-9 code for CHF if hospitalization
had occurred; demographic modeling
mainder made small modifications based
on specific demographics of their mem-
by age, gender, and address; and indivi-
bers. Concerns raised
dual patient identification. The treatment
guidelines were simple but thorough,
increased bleeding risk as the average age
of the population rises, and the popula-
emphasizing appropriate drug use. The
best practices identified were the use of
angiotensin converting enzyme (ACE)
tion's ability to tolerate ACE inhibitors.
months has not yet been measured, we
predict a decrease in hospitalizations of
up to 40% within the first year.
DRUGS CONTRAINDICATED
IN THE ELDERLY
by some include
Despite years of information dissemination by various agencies, the problem
of unnecessary drug use in the elderly
still exists. Our research revealed that of
Some plans discussed other, more basic
concerns such as cost and dosing regimen.
inhibitors in all CHF patients to decrease
mortality and the use of low-intensity
Pharmacy and medical claims are ana-
NME Survey's
list of 20 drugs inapelderly
(see Table 1)
the
for
propriate
being
still
used
with alarmmany were
the
lyzed every six months to identify opportunities for improvement. Prescriber and
warfarin (international normalized ratio
[INR] between 2 and 3) in most atrial
Figure 2. Prevalence of Heart Failure by Age
fibrillation patients to decrease incidence of stroke.
Employing a best-practice model ensures quality care and promotes physician
10
8
buy-in. Although firm research supports
the use of both ACE inhibitors and warfarin in CHF patients, use of these agents
has not increased appreciably in the last
~
five years.s As we began the disease
~
management program, both drugs were
used by less than 40% of our patients.
More-over, about 20% of our prescribers did not employ the INR to monitor warfarin, even though the INR is the
of ACE inhibitors, complications, and
number of hospitalizations.
best prac-
_I.&.1988-911
.
..
1976-80
6
OJ
..
u
....
OJ
4
..
.
.
0
~
.
..
2
30
35
40
45
.
.
50
55
60
65
70
75
80
Age
best indicator of its therapeutic efficacy
(
VoL 5, No. 1
January/February 1999
jMCP
Journal of Managed Care Pharmacy
15
Managing Congestive Heart Failure in the Medicare Risk Population
Table 1. Contraindicated Drugs in the Elderly
Suggested Alternative(s)
Drug Name
Reason
diazepam
daytime sedation, risk of falls
-
temazepam, estazolam
chlordiazepoxide
daytime sedation, risk of falls
temazepam, estazolam
f1urazepam
daytime sedation, risk of falls
temazepam, estazolam
meprobamate
daytime sedation, risk of falls
temazeDam, estazolam
pentobarbital
daytime sedation, risk of falls
temazepam, estazolam
secobarbital
daytime sedation, risk of falls
temazepam, estazolam
amitriptyline
anticholinergic effects, risk of
nortriptyline, desipramine
orthostatic hypotension
indomethacin
risk of CNS toxicity
other NSAIDs
chlorpropamide
risk of SIADH syndrome
other hypoglycemics
propoxyphene
risk of CNS & cardiac toxicity
acetamin9phen
pentazocine
risk of CNS & cardiac toxicity
acetaminophen
isoxsuprine
no demonstrated efficacy
cyclandelate
no demonstrated efficacy
dipyridamole
headaches and dizziness
aspirin
cyclobenzaprine
risk of CNS toxicity
acetaminophen
methocarbamol
risk of CNS toxicity
acetaminophen
orphenadrine
.
risk of CNS toxicity
trimethobenzamide
no demonstrated efficacy,
risk of drowsiness, diarrhea
other antiemetics
propranolol
risk of CNS toxicity
atenolol, nadolol
methyldopa
risk of CNS toxicitv
atenolol, nadolol
reserpine
risk of CNS toxicity
atenolol, nadolo]
guanethidine
risk of hypotensive episodes
ateno]ol, nadolol
guanadrel
risk of hypotensive episodes
ateno]ol, nadolol
ing frequency in some areas.6 These
drugs can contribute to falls, impair cognition, or cause other distressing adverse
ing the particular agent of concern, and
asking for consideration of an alternative
agent. Three months after the letter was
effects.
sent, we reviewed each case. Another let-
Figure 3 describes our program. In a
three-month baseline study, we identified
patients for whom one or more of these
drugs was prescribed, first approaching pre-
ter then was sent to either thank the
physician for cooperating or, if necessary, again suggest an alternative.
At a plan in the northeast, of the first
500 Medicare Risk patients who enrolled,
15% were taking a contraindicated drug.
scribers rather than patients. Prescribers
received
a
plan-approved letter describ-
of patients. In most cases, the problematic drug was disco"ntinued.
Outcomes are not easy to measure in
this project. It is difficult to determine
how much quality of life improves, or
how many hospitalizations or falls are
prevented. We are working, however, to
find a way to determine indirect costs
and specific patient outcomes.
CONCLUSION
The programs described here were
designed for the aging populations in
our plans; their successes can be applied
to Medicare Risk members as enrollment
risk of CNS toxicity
carisoprodol
After intervention, changes in drug therapy were made for approximately 70%
increases. In CHF disease management,
appropriate and aggressive use of drugs is
an effective way to decrease other costs.
Enhancing the program with case man-
agement services is an important way to
ensure quality care to this fragile population. Reviewing claims for unnecessary
or contraindicated drugs and taking
action with prescribers alleviates the risk
of adverse events.
We plan to expand our contraindicateddrugs program by integrating our data
with medical information, looking for
patient-specific outcomes, examining comorbidities, and using innovative medical
resources. These measures will be incorporated to help quality improvement
programs acquire or maintain National
Committee for Quality Assurance accreditation, and will be reflected in HEDlS
and other performance measures.
....
References
Konstam M, Dracup K, Baker D, et aL Heart
with leftventricular dysfunction. Clinical Practice Guideline
1.
faiJure: evaluation and care of patients
Figure 3. Program Flow
Plan
Approval of
Pre-study
~
3 Months
16
Letter
Follow-up
3 Months
Follow-up
3 Months
UU
Mail
Mail
Letters
Letters
Journal of Managed Care Pharmacy
jMCP
JanuarylFebruary 1999
Final
Analysis
1'Morith
u
No. 11, AHCPR Publication No. 94-0612.
2. Vinson JM, Rich M\V, Shah AS, et aL Early readmission of elderly residents with congestive heart
faiJure. JAm Geriatric Soc. 1990; 38: 1290-95.
HM, Parent EM, Tu N, et aL
Readmission after hospitalization among Medicare
beneficiaries. Arch Intern Med 1997; 157: 99-104.
3. Krumholz
4. National Health and Nutrition Examination
Survey (1976-80 and 1988-91), National Center
for Health Statistics.
5. Stafford RS. Use of ACEI's in CHI' Arch Intern
Med; 157: 2460-64.
Vol. 5, No.1