The ROI for Diabetes and Coronary Artery Disease by sammyc2007

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									Can Underuse Measures Reduce
            Cost?
  The ROI for DM using P4P

    Howard Beckman, MD, FACP
        Medical Director, RIPA
    Clinical Professor of Medicine
    University of Rochester SM&D
                Introduction
• Objective – To determine whether a P4P
  program to improve DM quality of care
  generates a positive return on investment (ROI)
• Rationale – Employers and Health Plans want to
  know if investing in improving quality results in
  sufficient financial savings to justify the
  investment
• Funding: Rewarding Results, a joint initiative of
  the Robert Wood Johnson Foundation, The
  Commonwealth Fund and the California
  Healthcare Foundation.
                       Design
• Historical Control
• Participants
  – Rochester IPA – 3200 physician community wide
    panel
  – Excellus BCBSRA Blue Choice HMO - 300,000
    members (50% of commercial market)
• Patient identification – Continuously enrolled
  Blue Choice members from 2000-2004 aged 18-
  75 with HEDIS like criteria for DM and CAD
• Exclusion criteria – Any patient with total yearly
  costs >$100,000 for any of the study years, lack
  of pharmacy benefit
              Intervention
• Individual Physician Profiling program –
  Three reports per year including registry of
  eligible DM,CAD and Asthma patients with
  sequential updates.
• Profiling linked to educational program and
  provider rep visits to review data and an
  incentive program (P4P)
• No other new Diabetes initiatives in the
  community during the study period
       Profile Quality Measures
• DM measures:
    Two HbA1c test/yr
    One LDL/yr
    One UA or MA yearly
    Diabetic retinal exam yearly
    Yearly flu shot
• CAD measures:
    One LDL/yr
    Statin Treatment if MI or angioplasty
    ACEI/ARB if MI
              Intervention
• P4P program
  – Varied 10% withhold return + shared savings
  – Chronic diseases determines 20% of return
  – Return varied 50-150% of amount contributed
  – Staff assistance available on request
  – For average FTE PCP – P4P return varied
    between $4-12,000 based on performance
      The Stages of Change - PFP
                    Blind Fury & Silent Rage



                                          Anger
Emotion


                                               Agitation


                                                       Bargaining


           Denial                          1-2 yrs           Acceptance

H Beckman, MD, RIPA, 2004     Time
                Calculating ROI

• Cost of care – Total yearly costs paid by plan for each
  identified patient using plan’s admin data base. Included
  – E&M, pharmacy, surgical, ancillary, facility and other
• Identify cost of care trend for the target population during
  baseline phase 2000/2001 and 2001/2002
• Project costs during intervention years 2003 and 2004
• Compare projected costs based on trend to actual costs
• Compare cost trends in each of the sub-categories of
  E&M, Surgery, Hospital, Ancillary and other
• Profiling/P4P yearly total cost – software, staff,
  production - $1,150,000
       Key Study Endpoints
• Primary – ROI calculated as year by year
  total cost of care for Diabetes patients
  against a 2 year rolling trend as %, PMPM
  and absolute dollars/cost of the
  profiling/P4P program
• Secondary – Identification of major areas
  of savings, if any
Results
                   Expected vs Actual Costs for 2003 and
                                   2004

                                                                     %
                       Trend          Actual    Target    Actual    Diffe   PMPM       Est. ’04 Impact on
         Trend 2003/   2002/   2 yr    2003      2004      2004     renc    Differen     Diabetic Mbrs.
            2002       2001    Avg    PMPM      PMPM      PMPM        e        ce       Benefit Expense

Phys        1.12       1.10    1.11   $127.05   $140.51   $136.26   0.97     -$4.25          -$739,842

IP          1.11       1.25    1.18   $96.37    $113.65   $105.95   0.93     -$7.70        -$1,339,712

Non IP      1.10       1.12    1.11   $125.63   $139.46   $136.71   0.98     -$2.75          -$477,808

RX          1.14       1.21    1.17   $186.81   $218.85   $215.40   0.98     -$3.45          -$600,722

Total       1.12       1.17    1.14   $535.86   $611.98   $594.32   0.97    -$17.66        -$3,071,708
                      2 Year Rolling Trend for Diabetes Expense


                                     * Forecasted 2003 = Average Trend * Actual 2002

                   Average           *Forecasted 2003      Actual 2003         PMPM         Total Allowed    Plan Savings
                (01/00+02/01)

Year 1             13.85%                         $546             $536          $10.37         $1,994,420     $1,894,471
Total

                                     * Forecasted 2004 = Average Trend * Actual 2003

                   Average           *Forecasted 2004      Actual 2004         PMPM         Total Allowed    Plan Savings
                (02/01+03/02)

Year 2             14.21%                         $612             $594          $17.70         $3,078,014     $2,923,760
Total



  During the study phase the profile was estimated to cost approximately $1,150,000 per year.
             ROI Determination for Diabetes

      Profile ROI           2003           2004

Annual Savings on Trend   1,894,471      2,923,760
Annual Cost
                          1,150,000      1,150,000

ROI                         1.6:1          2.5:1
            Study Limitations


•   Single product and region
•   Absence of a control group
•   Declining HMO population
•   Large yearly variation in costs
                Future Work
• Determine what specific behaviors contributed to
  the Diabetes Savings – changed prescribing
  patterns, using more statins, hospital aversion
  programs
• Identify practice variables between higher and
  lower scoring practitioners in Diabetes and CAD
• Determine how a similar multi-faceted
  intervention works in other geographic and
  economic locations
                Conclusions
• The introduction of a multifaceted incentive
  system for an HMO product in a modest size
  metropolitan community resulted in savings
  against a rolling trend of between 1.9-2.9 million
  dollars a year for Diabetes alone
• The largest savings was from decreased
  inpatient costs
• The return on investment (ROI) for the diabetes
  program was alone 1.6 in year 1 and 2.5 in year
  2. Adding in CAD, the ROI in 2004 was 4.3
• Results need to be replicated with control
  groups to confirm that P4P programs more than
  pay for themselves

								
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