The ROI for Diabetes and Coronary Artery Disease

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The ROI for Diabetes and Coronary Artery Disease Powered By Docstoc
					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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