Michael F' Montijo, MD, MPH, FACP

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Health Care Disparities in Medicare Health Support

• Michael F. Montijo, MD, MPH, FACP
• Senior Vice President American Healthways
• April 27, 2005

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Growing Prevalence of Chronic Conditions
141 M
125 M
Source RAND
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70 Million Americans with Multiple Chronic
Conditions in 2010
70 Million
60 Million
Source RAND
4
Beneficiaries With 5 or More Chronic Conditions
Account for Two-Thirds of Medicare Spending
Source Medicare 5 Sample, 2001
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Medicare Spending
Overall Medicare spending grew from 3.3 billion
in 1967 to nearly 241 billion in 2001.
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Public Health Model Population Management

• Greatest improvements in health over the past
  1000 years were public health initiatives
  (measured in life span).
• Tenants of the Public Health Model
• Primacy for prevention
• Dependence on science
• Quest for equity and social justice
• Interdependence

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Public Health Model Population (Disease)
Management

• Primacy for prevention
• Wellness programs primary prevention
• Disease management programs secondary and
  tertiary prevention
• Dependence on science
• Evidence based medicine interventions based
  upon high level evidence

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Public Health Model Population (Disease)
Management

• Quest for equity and social justice
• Population based approach all with
  condition/disease in the program
• Interdependence
• Comprehensive approach involvement with
  numerous stakeholders delivery system,
  community, government, etc.

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Population (Condition/Disease) Management

• Concept of incrementally moving a population
  and resultant impact on the health of the
  population
• Emergence of chronic diseases/conditions
• Rising prevalence
• Significant contribution of behaviors to
  incidence/control
• Evidence based interventions
• Ability to identify a population accurately
• Efficiently and effectively engage the population

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Disease/Condition Management

• Identify population with target disease/condition
  that has the prerequisite characteristics
• Touch the the vast majority of the population
  concept of critical mass
• Meaningfully interact with individuals
• Address the patient holistically
• Have positive intent, credibility and the human
  touch

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American Healthways

• Founded 1981
• Operate the most sophisticated disease management
  call centers in the country
• Every care enhancement program designed to
  support the patient-physician relationship

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Medicare Chronic Care Improvement Pilot
Medicare Health Support
Medicare Modernization Act
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What is the Medicare Health Support?
Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 Title VII Sec. 721
Under Tradition Fee for Service Subtitle C
Voluntary Chronic Care Improvement

• Ten three year randomized controlled studies of
  chronic care management
• Conditions Heart Failure and Complex Diabetes
  (95 have co-morbidities)
• Size per program 20,000 beneficiaries in
  intervention group, 10,000 beneficiaries in
  control group
• Awardees have 100 risk for fees to improve costs
  a net 5 over control group and quality and
  satisfaction measures at risk too.
• Pilot may be expanded to entire nation after two
  years

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What is Medicare Health Support (cont.)?

• 9 awards announced 12/8/04
• American Healthways MD and DC
• Lifemasters Oklahoma
• CIGNA/American Healthways Georgia (northern
  counties)
• Humana/Pfizer Central FL
• Aetna/Lifemasters Greater Chicago area
• United/VNA NYC (Queens and Brooklyn)
• Health Dialog PA
• McKesson MS
• ExcelleHealth TN
• Start dates Late Summer/Fall 2005

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Why Maryland and District of Columbia?

• Medicare Quality Ranking MD 25th, DC 37th
• National Poverty Ranking MD 37th, DC 49th
• Heart Failure Prevalence MD 12, DC 7
• Diabetes Prevalence MD 18, DC 11
• Per Cent African American MD 22(30), DC
  85(92)
• Number of Beneficiaries with conditions MD
  53,720, DC 6,200
• Utilization higher then national average
• Cost per beneficiary 10 higher then national
  average
• Use of Hospice MD 44th, DC 29th

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Medicare Health Support - MD/DC

• Using the Medicare 5 sample data MD DC
• Year 1999 used for identification per the
  Medicare Health Support Program criteria
• Beneficiaries followed from 2000 to 2003

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Medicare Health Support MD/DC

• 55 are Female
• 19 are 85 years old or older
• 63 are 75 years old or older
• 48 have Heart Failure
• 52 have Complex Diabetes
• They each spend on average 11 days in the
  hospital or SNF each year
• A high acuity patient with Heart Failure spends
  on average over 35 days in the hospital or SNF
  each year
• Approximately 1.5 die each month

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Medicare Health Support MD/DC

• Hospice usage
• lt4 die enrolled in a Medicare certified Hospice
  program
• Variation is 2-18 by county
• lt 15 for non-MHS
• Average LOS is 4 days, 9 days non-MHS
• Diabetes process measures
• HbA1c annually 70 (52-80)
• HbA1c semiannually 32 (18-58)
• Lipid panel annually 62 (22-88)

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Medicare Health Support MD/DC

• Heart Failure
• Almost 50 die within 2 years
• Avg. of 12 Rxed meds
• Avg. of 6 physicians in past 12 months
• Ace/ARB/HI usage approx. 50
• Beta Blocker usage approx. 25

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Medicare Health Support MD/DC

• Some Early Findings
• Historical equivalent to the control population
  demonstrates significant care gaps.
• Early analysis of subpopulations demonstrates
  wide variation of care especially end of life.
• Early analysis demonstrates wide variation of
  care in urban versus rural areas.
• Overrepresentation of minority groups in the
  program

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Medicare Health Support MD/DC

• Opportunities
• Randomized controlled study of a very frail
  elderly population
• Sub analysis at the zip code level to understand
  disparities and outcomes of program at this level
  will it close some of the gaps?
• Understand quality metrics for this rarely
  studied population
• Historical undertaking with FFS Medicare and
  opportunity to quickly evolve to the entire
  national population with similar disorders of
  over 10-12 million people.

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American Healthways Medicare Health Support
Program

• Disease Management for 72
• Telephonic, RNs
• Outbound scheduled calls
• Geriatric Assessments
• Safety, cognitive, depression, prognosis
• Improve adherence to physician care plan
• Patient empowerment
• Intensive Case Management for 20
• Telephonic and Face to Face, RNs and Geriatric
  NPs
• High risk for hospitalization
• Coordination with physician(s)
• Coordinate community resources

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American Healthways CCI Program (cont.)

• Long Term Care Management for 8
• Face-to-Face in NHs, RNs and Geriatric NPs
• End-of-Life Planning, Pain Palliative Care,
  Hospice referral
• Early detection of potentially reversible causes
  of hosp admissions

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Modifications of AMHC Programs for CCIP

• Senior Assessment
• Cognitive screen
• Senior depression screen
• Safety screen
• Prognostic indicator
• High risk for hospitalization indicator
• Enhanced EOL/Pain Palliative Care/Hospice
  Module
• Institutionalized Beneficiary Program
• Pharmacy Management - excelleRx
• Enhanced Use of Community Resources
• Outreach and Consent Program
• Enhanced Physician Components

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