TennCare Diabetes Program Evaluation

1. TennCare Diabetes Program Evaluation An Individually-Matched Control Group Evaluation ofa Disease Management Program to Improve Quality and Control Costs in a Diabetic Medicaid Population Presentation to AcademyHealth Kenton Johnston, MPH, MS, MA June 4, 2007

2. Overview TennCare Diabetes Program Evaluation Research Objective: • Evaluate diabetes disease management program for state Medicaid (TennCare) population • Outcomes of interest: diabetic quality of care and medical cost savings (Inpatient & Prof/Outpatient) Outline: • Program Description • Study Design • Findings • Limitations, Conclusions, Implications

3. Program Description TennCare Diabetes Program Evaluation • Outcome of diabetes treatment highly dependent on self-care • Non-adherence to recommended regimens an obstacle to improved health status • Medicaid population tends to exhibit higher utilization & costs, as well as poorer health outcomes • CareSmart Diabetes Disease Management (DM) Program – developed internally by BCBST for TennCare population • For Type 1 and Type 2 diabetics • Program: behavior change & health education, self-management, personalized telephone coaching, compliance with ADA clinical practice guidelines, and PCP support • Member consent obtained for enrollment in program

4. Study Design – Individual Matching With Propensity Model TennCare Diabetes Program Evaluation • Methodological “toolbox” for DM program evaluation • Randomized controlled trials • Population based pre-post methodology • Predictive modeling • Control group matching (individual, group) • Problem: finding a good control group not easy • Solution: Individually-matched controls using propensity scores (matched pairs cohort study) • Propensity score is continuous number that represents individual probability of being in study group • Propensity score reduces entire set of covariates to one score for easy individual matching • This approach allows for smaller “n”

5. Study Design – Population & Methods TennCare Diabetes Program Evaluation • Study and control group member criteria • Continuously enrolled in TennCare 24-months of 2004-05 • Diagnosed with Type 1 or 2 diabetes in 2004 or earlier • Not dually eligible – Medicaid only • 126 study members enrolled in CareSmart Diabetes Program for at least 6 months in 2005 were individually matched to 126 diabetic controls not enrolled in program in 2004 or 2005 • Propensity model covariates: demographics, diseases & comorbidities, quality of care, medical utilization, costs • Baseline Period: Jan - Dec 2004 for matching control & study • Intervention Period: Jan - Dec 2005

6. Study Design – Dependent Variables TennCare Diabetes Program Evaluation • Diabetic quality of care operationally defined according to recommended preventive services outlined by ADA • Screening for kidney disease • First annual HbA1c screening • Second annual HbA1c screening • Retinopathy screening • LDL cholesterol screening • Medical services utilization and cost • Reported as totals (not specific only to diabetes) • Inpatient admissions, inpatient days, inpatient $$$ • ER encounters, office visit encounters, Prof/Outpatient $$$ • Total $$$ • RX utilization & cost data unavailable

7. Findings – Baseline Results TennCare Diabetes Program Evaluation

8. Findings – Intervention Quality Results TennCare Diabetes Program Evaluation • Statistically significant positive difference on 4 of 5 measures & on overall score • Improvement in both study & control groups from 2004 • Propensity matched control group enables us to rule out secular trend as sole cause

9. Findings – Intervention Utilization Results TennCare Diabetes Program Evaluation • Statistically significant difference on office visits – study members had higher utilization • Office visit finding not surprising given this is the setting for quality measures • Inpatient admissions & days lower for study members – not statistically significant • ER encounters higher for study members – not statistically significant

10. Findings – Intervention Cost Results TennCare Diabetes Program Evaluation • None of the cost findings were statistically significant • Inpatient & total costs trending in downward direction for study group • Prof/Outpatient costs higher for study group • Financial analysis—using control group to calculate expected costs—shows program savings impact for study group

11. Limitations TennCare Diabetes Program Evaluation • Unable to analyze RX data • Psychological or sociological variables not included/available for propensity model potential source of confounding • “Non-Participation Bias” • Study members agreed to participate in the program • Controls either could not be contacted by telephone or refused to participate • We did not control for practice patterns of member providers (data not available for all members) • Lab values unavailable on > 50% of study and control population so we were not able to control for these • Available HbA1c and LDL values showed HbA1c close to stat sig (.09) difference in baseline period

12. Conclusions & Implications TennCare Diabetes Program Evaluation • Conclusions: • Improvement in quality in study group was not due solely to general secular trend towards quality, but was also positively impacted by the diabetes program intervention itself • Mixed findings for utilization & cost, but may be showing trend in right direction • Implications: • DM programs can be successful in improving quality of care in chronically diseased state Medicaid populations • A matched-pairs cohort study using propensity scores is a valuable tool for evaluating program outcomes in small to medium sized populations

13. Thank You TennCare Diabetes Program Evaluation Presentation to AcademyHealth Kenton Johnston, MPH, MS, MA June 4, 2007 E-mail: Kenton_Johnston@BCBST.com