Gregory D. Berg

Utilization and Financial Outcomes of an Asthma Disease Management Program Delivered to Medicaid Members: Results of a Three-Group Comparison Study

BackgroundAlthough various studies have reported the financial outcomes of disease management programs for commercial populations, few have addressed the outcomes for Medicaid recipients. McKesson Heath Solutions (MHS) disease management programs support clients whose members have serious chronic illnesses including asthma, diabetes, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, and mental health conditions. This study describes financial outcomes of the MHS asthma disease management program by evaluating changes in health services utilization measures for Medicaid members who participated in the asthma disease management program.ObjectiveTo analyze and describe medical care utilization for asthma patients enrolled in a Medicaid managed care organization located in the eastern US.MethodsMedicaid participants were identified and referred to the asthma program by the healthcare plan. Two comparison groups were used in the study to more reliably assess program impact. The first comparison group included members who were referred to the program, but who chose not to participate. The second group included members who were identified through medical claims data, but who were not contacted or referred to the program by the plan. All eligible participants with at least 30 days of program participation, and all non-participants with at least 30 days of effective plan enrollment in the pre- and post-program periods were included in the study.The utilization rates for the three groups were compared in the pre- and post-program periods. The effect of group membership on inpatient admissions (IP), emergency department (ED) visits, and hospital outpatient department/physician office (MD) visits was analyzed using Poisson regressions. The regression analyses controlled for baseline levels of utilization, demographics, and relative risk scores generated by DxCG® software (manufactured by DxCG® in Boston, Massachusetts, USA).ResultsWhile the MHS asthma disease management program has created positive financial outcomes for commercial populations, this study extends that scope to include a Medicaid population as well. 313 Medicaid participants experienced significant decreases in IP admissions and ED visits following program implementation. Participants also experienced decreased MD visits between the pre-program and program periods; however, their post-program MD visits were not reliably predicted by group membership after controlling for demographic differences and relative risk scores.ConclusionsThe experience of the MHS asthma disease management program demonstrates its efficacy and relevance to Medicaid populations. This study strongly suggests that a structured asthma program may create positive financial outcomes while promoting enhanced self-management through continued support, education, and patient involvement.

Cigarette demand and tax policy for race groups in South Africa

This paper calculates cigarette demand for race groups in South Africa. Elasticities are the most important information a tax policy analyst can have. Elasticities determine how the tax base will change with a change in the tax rate and thus how government revenues will respond to the tax. Elasticities also determine the excess burden that consumers will bear as a result of the tax. As such, own price, crossprice, and expenditure elasticities are calculated along with government revenue maximizing tax rates, and total and excess burdens. Parametric and semiparametric estimation techniques are used and compared. Results show that a tax on cigarettes will discourage nonsmokers from starting to smoke and mainly raise revenue from current smokers. Furthermore, it is found that consumption behaviours between groups are different implying different government revenue maximizing tax rates for each group affecting the distribution of income.

A matched-cohort study of utilization outcomes for an adult medicaid population enrolled in an asthma disease management program.

Few studies have examined the clinical and utilization impact of asthma disease management programs for Medicaid beneficiaries. This study examines utilization and clinical outcomes for an adult group of low- to moderate-risk patients with asthma. Propensity scores are used to construct matched samples of treated-control pairs in order to establish equivalent comparison groups and evaluate the effects of program participation. During the program period, the participants experienced 33.3% fewer hospitalizations, 42% fewer bed days, 87% fewer asthma-related admissions, fewer ED visits, and higher rates of medication usage than those for matched controls, suggesting the beneficial impact of participation for Medicaid program participants.

Clinical and Utilization Outcomes for a Pediatric and Adolescent Telephonic Asthma Care Support Program: A Propensity Score-Matched Cohort Study

ObjectiveTo investigate the effect of an asthma care support program for patients under the age of 18 years.Study designA 1:1 matched cohort study design was used. The purpose of matching is to find a similar comparison group in terms of observable variables. The propensity score method of matching was used to find a suitable comparison cohort, which is similar at baseline to the treatment cohort. For each treatment cohort member, a comparison cohort member was selected on the basis of having the closest estimated propensity score. Once a comparison cohort was defined, variables were compared at baseline year to ensure the similarity of the two groups. The Kruskal-Wallis test was used for comparison of variables between the treatment and comparison cohorts due to the non-Gaussian distribution of variables. Finally, variables were compared during the program year to estimate the treatment effects of the disease management program.Patient groups318 asthma care support program participants and 318 matched non-participants.Main outcome measuresThe rates of medical service utilization including rates of hospitalization, emergency department (ED) visits, and selected clinical indicators including allergen immunotherapy, chest x-rays, influenza vaccinations, and pneumococcal vaccinations.ResultsBaseline matching resulted in no statistically significant difference between the treatment and matched cohorts. However, during the program period the treatment cohort had 35.6% fewer inpatient admissions (p = 0.045), 32.5% fewer ED visits (p = 0.007), 56.7% fewer asthma-related inpatient admissions (p = 0.008), 50.8% fewer asthma-related ED visits (p < 0.0001), 26.8% fewer chest x-rays (p = 0.036), and 51.6% more influenza immunizations (p = 0.046).ConclusionsWhere controlled randomized clinical trials cannot be performed, the use of propensity scores provides an alternative for the purpose of estimating a treatment effect using observational data. The current study employed a propensity score-matching methodology to select a subset of comparison units most comparable to treatment units. It documented the beneficial clinical outcomes of pediatric and adolescent participation in an asthma care support program which suggested a beneficial impact of monitoring, education, and more rigorous adherence to action plans for program participants.

Evaluation of an Asthma Disease Management Program in a Medicaid Population

In 2002, an asthma disease management program was initiated in Washington State in the US. The program was designed for clients of the state’s Medicaid program, which provides health coverage for qualified low-income state residents. In response to the escalating cost of healthcare and because of concerns about the quality of care, the Washington State Legislature mandated implementation of this disease management program as a pilot project to assist individuals to improve their health. Medicaid administrators used a carefully designed process to identify client needs and to obtain proposals for disease management programs.The asthma program seeks to narrow the gap between the standards of care and its practice. In particular, the program aims to provide patients with a richer understanding of asthma and how to control it. This is accomplished through disease education, symptom awareness and management, trigger avoidance, self-monitoring, and education on recommended medication strategies. The program is based on the US National Institutes of Health’s published guidelines on the optimal treatment of asthma.Enrollment of Medicaid clients into the asthma program began in April 2002. This article describes three approaches to evaluation of the first 3 years of the program: (i) 3 years of self-reported client data; (ii) an independent evaluation of the first year’s changes in utilization and quality of care; and (iii) an actuarial analysis of cost effectiveness. The first study used vendor-reported data collected during initial and follow-up assessments. The authors of this first study also reported the results of a satisfaction survey conducted on behalf of the vendor. The independent evaluation conducted by the University of Washington relied on medical record review and claims analysis, and reported statistical analysis of pre/post comparisons. The actuarial study also reported pre/post comparisons using an analysis of claims per member per month in periods before the program started and at 1 and 2 years of program operations.Clients were assessed according to several dimensions of health including self-management, symptoms, functional status, medication management, and trigger management. Numerous interventions were provided to study participants including access to round-the-clock telephone consultation with a registered nurse, self-care education, alerts sent to the primary provider, and symptom issue follow-up. The asthma disease management program outcomes provide evidence of initial success for those clients who completed the reassessment process. The results of the first 3 years of participation in the program indicate trends toward improved health status and client satisfaction with the program. Long-term evaluation will be necessary to determine if the program reduces costs and closes the quality chasm. If successful, this program could serve as a model for programs with similar clients and similar challenges.

An application of kernel-based versus one-to-one propensity score matching for a nonexperimental causal study: example from a disease management program evaluation

Objective: To discuss and compare kernel-based matching with one-to-one propensity score matching applied to disease management. Data sources: Administrative claims data from a US Medicaid fee for service plan. Study design: Matched two group analyses using both kernel-based matching and one-to-one propensity score matching. This comparison is applied to the estimation of diabetes disease management treatment effects. Principle findings: Kernel-based matching is found to be better than one-to-one propensity score matching when there is no sufficient number of potential controls from which to draw a matched cohort but similar when there is a sufficient number of potential controls. Matching was applied in the context of a diabetes disease management program that showed an increase in management of each persons medical care through the disease management program. Conclusions: The approach provides a methodology for researchers to evaluate healthcare service innovations without a randomized trial design and delineates the requirements for a matched analysis. Matching was applied in the context of a disease management program showing better patient management through the disease management program.

Diabetes Disease Management Results in Hispanic Medicaid Patients

Objectives. To investigate outcomes of a telephonic nursing disease management program for Medicaid patients with diabetes residing in Puerto Rico. Study design. A 12-month, matched-cohort study. Study population. Four hundred and ninety (490) intervention group members matched to 490 controls. Intervention. Disease management diabetes program. For those in the intervention group, the disease management program customized a self-management intervention plan. Main outcome measures. Medical service utilization, including hospitalizations, emergency department visits, physician evaluation and management visits, selected clinical indicators, and financial impact. Results. The intervention group showed significant effects compared with the control group, including a 48% reduction in inpatient bed days, and a 23% increase in ACE inhibitor use, resulting in a return on investment estimate of 3.8:1. Conclusions. The study demonstrates that a nursing disease management program for diabetes can significantly improve hospitalizations, drug compliance, and vaccinations in a Hispanic Medicaid population.

Clinical and Utilization Outcomes for a Heart Failure Care Support Program: A Matched-Cohort Study

ObjectiveTo investigate the effect of a heart failure disease management program for patients ≥18 years of age enrolled in a commercial health plan.BackgroundDisease management provides a framework for managing the chronic illness of large populations. Evaluating the comparative benefits of disease management program participation remains a central challenge for researchers, clinicians, and administrators. A growing consensus in the field of disease management is that more rigorous methodologies are required to assess program outcomes. However, many heart failure disease management programs have been evaluated by the use of non-experimental designs (pre-/post-methodologies), or matching and stratification methods that have been used with limited success.MethodsTo investigate the program effects of a heart failure care support program, we conducted a matched-cohort study on 521 participants using propensity scores. This methodology constructed matched samples of treated and control pairs for a wide range of observed characteristics and may reduce the bias in estimates of treatment effects to provide a relatively more accurate assessment of program outcomes. Administrative claims provided the source data for evaluating rates of hospitalizations, emergency department visits, and physician office visits. The study also included selected clinical indicators from administrative claims data to estimate the effects of program enrollment.ResultsParticipants exhibited significantly fewer cardiac-related inpatient admissions and bed days compared with those for matched cohorts. A greater proportion of participants received cardiography testing and pneumococcal and influenza immunizations compared with matched cohorts. Participants experienced less use of medical services overall, suggesting that there were beneficial effects with monitoring and education for this group.ConclusionsThis study documents the beneficial outcomes of participation in a commercially delivered heart failure care support program. In those cases where controlled randomized clinical trials cannot be performed because of ethical, cost, or feasibility issues, the use of propensity scores provides an alternative for estimating treatment effects based on observational data.

Clinical Metric and Medication Persistency Effects: Evidence from a Medicaid Care Management Program

The objective was to estimate clinical metric and medication persistency impacts of a care management program. The data sources were Medicaid administrative claims for a sample population of 32,334 noninstitutionalized Medicaid-only aged, blind, or disabled patients with diagnosed conditions of asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes, or heart failure between 2005 and 2009. Multivariate regression analysis was used to test the hypothesis that exposure to a care management intervention increased the likelihood of having the appropriate medication or procedures performed, as well as increased medication persistency. Statistically significant clinical metric improvements occurred in each of the 5 conditions studied. Increased medication persistency was found for beta-blocker medication for members with coronary artery disease, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and diuretic medications for members with heart failure, bronchodilator and corticosteroid medications for members with chronic obstructive pulmonary disease, and aspirin/antiplatelet medications for members with diabetes. This study demonstrates that a care management program increases the likelihood of having an appropriate medication dispensed and/or an appropriate clinical test performed, as well as increased likelihood of medication persistency, in people with chronic conditions.

Dose–response effects for depression and Schizophrenia management on hospital utilization in Illinois Medicaid: a multivariate regression analysis

BackgroundThe prevalence of schizophrenia and depression in the United States is far higher among Medicaid recipients than in the general population. Individuals suffering from mental illness, including schizophrenia and depression, also have higher rates of emergency department utilization, which is costly and may not generate the positive health outcomes desired. Disease management programs strive to help individuals suffering from chronic illnesses better manage their condition(s) and seek health care in the appropriate settings. The objective of this manuscript is to estimate a dose–response impact on hospital inpatient and emergency room utilizations for any reason by Medicaid recipients with depression or schizophrenia who received disease management contacts.MethodsMultivariate regression analysis of panel data taken from administrative claims was conducted to test the hypothesis that increased contacts lower the likelihood of all-cause inpatient admissions and emergency room visits. Subjects included 6,274 members of Illinois’ non-institutionalized Medicaid-only aged, blind or disabled population diagnosed with depression or schizophrenia. The statistical measure is the odds ratio. The odds ratio association is between the monthly utilization indicators and the number of contacts (doses) a member had for each particular disease management intervention.ResultsHigher numbers of intervention contacts for Medicaid recipients diagnosed with depression or schizophrenia were associated with statistically significant reductions in all-cause inpatient admissions and emergency room utilizations.ConclusionsThere is a high correlation between depression and schizophrenia disease management contacts and lowered all-cause hospital inpatient and emergency room utilizations.