Effect of the ExactCare medication care management model on adherence, health care utilization, and costs.

Abstract

BACKGROUND: Multimorbidity and polypharmacy are common in the United States and are associated with greater risk of disease-related complications and higher health care costs. ExactCare has implemented a high-touch approach that includes home visits, comprehensive ongoing medication reviews, patient education, medication reconciliation, medication compliance packaging, and electronic reminders and trackers. OBJECTIVE: To test whether the ExactCare program improves medication adherence and reduces health care utilization and costs. METHODS: Using a national database from a large U.S. insurer, we identified Medicare Advantage plan members in 8 states from 2007 to 2018 who had both medical and prescription drug coverage. The index year for an ExactCare patient was identified using the date of the first prescription filled by ExactCare, with the previous year being the baseline. All patients without a prescription from an ExactCare pharmacy were considered potential comparison patients. To propensity match ExactCare and comparison patients, the probability of ExactCare participation was modeled using a logistic regression based on demographics, state, year, urban status, Medicaid eligibility, low-income subsidies, comorbidities, and baseline utilization and costs. Multivariate regression analysis was conducted to generate a difference-in-differences estimate of program effect for the matched pairs as well as patient-level fixed effects, while adjusting for additional time-varying characteristics. Adherence outcomes included the proportion of days covered for oral diabetic medications, antihypertensives, and hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins). Utilization outcomes included emergency department (ED) visits, hospitalizations, and skilled nursing facility (SNF) admissions, hospitalization days, and SNF days. Cost outcomes included total cost of care, prescription drug cost, hospital inpatient cost, and SNF cost. RESULTS: ExactCare patients (N = 701) were propensity-matched to comparison patients (N = 1,395) using the nearest 1:2 match approach, with an average follow-up period of 6.6 and 5.4 years for ExactCare and comparison patients, respectively. One year of ExactCare participation was associated with statistically significant increases in adherence to statins (8.4 percentage points; P < 0.001) and antihypertensive drugs (4.9 percentage points; P < 0.001), but the increase in adherence for diabetes drugs was not statistically significant. ExactCare participation was associated with statistically significant decreases in SNF admission rates (-67 SNF stays per 1,000 member-years; P = 0.011), inpatient days (-857 days per 1,000 member-years; P = 0.022), and SNF days (-1,801 days per 1,000 member-years; P = 0.002), but not with the rates of ED visits or hospital admissions. Each year of ExactCare participation was associated with increases in prescription drug costs ($30 per-member per month [PMPM]; P = 0.006) and decreases in total costs (-$196 PMPM; P = 0.023) and medical costs (-$226 PMPM; P = 0.008), largely attributable to decreases in hospital inpatient costs (-$119 PMPM; P = 0.001) and SNF costs (-$30 PMPM; P = 0.007). CONCLUSIONS: ExactCare s medication care management model was associated with improved medication adherence and an approximately $2,400 per member per year reduction in total cost of care, representing a 5% reduction in average costs. DISCLOSURES: This study was funded by ExactCare Pharmacy under a contract with RAND that grants the study authors sole responsibility for data management, study design, data analysis, manuscript drafting, and the decision to publish. The sponsor had no role in the study design and manuscript drafting. All data analysis was conducted by the study authors. A draft manuscript was reviewed by the sponsor, but the study authors made final decisions regarding the content and study conclusions. Shetty, Chen, and Liu are employed by RAND. Rose has nothing to disclose.