1. June 2012 Eric Christensen Patient-centered Medical Home (PCMH)/ Medical Home Port (MHP) Evaluation (with emphasis on chronic conditions, particularly diabetes)

2. Overview Context –MHS/Navy Medicine moving rapidly to PCMH/MHP models –Literature shows the potential of PCMHs, but success is not automatic –“78% of health spending is devoted to people with chronic conditions”* Purpose –Assess the impact of the Bethesda PCMH on access, quality, and cost –Assess whether the MHP model is effective for different patient types and in different settings Outcome –Resource allocation should consider the effectiveness of MHP model –Which populations to target first with MHP * Anderson and Horvath, “The Growing Burden of Chronic Disease in America,” Public Health Reports, 2004, 119(3):263-270 2

3. Topics/outline Results on access and quality –HEDIS metrics –Patient satisfaction survey Results on use and costs –Overall –Chronic versus non-chronic patients –By chronic condition Clinical Practice Guidelines (CPGs) adherence—diabetes Note –Some slides use NNMC and others WRNMMC as some of the work was completed before the Bethesda-Walter Reed merger –Results in this brief are for the WRNMMC internal medicine MHP 3

4. WRNMMC HEDIS scores (pre- and post-implementation) HEDIS measurePre-periodPost-period Favorable (unfavorable) difference HbA1c test84.5%91.8%7.3% HbA1c > 9.025.9%17.6%8.3% LDL screening78.2%88.6%10.5% LDL-C value < 100 mg/dl53.3%66.1%12.9% Asthmatics appropriately prescribed93.9%96.1%2.2% Pap smear test80.6%87.4%6.8% Mammography screening75.3%82.8%7.5% Colorectal cancer screening60.7%68.5%7.8% 4 Note: The values for the pre-period are monthly averages for January-May 2008 compared to February-December 2009 for the post-period. The transition period was from June 2008 through January 2009.

5. PCMH impact on access and patient satisfaction 5

6. How to increase satisfaction and PCM rating? Those reporting high levels of access and provider communication report high satisfaction and PCM rating –Access (OR: 2.1; CI: 1.4-3.2) –Provider communication (OR: 1.9; CI: 1.2-3.0) Implies that increasing access and provider communication will increase satisfaction and PCM rating –But, how to do this? Drivers of access –Ease of scheduling appointments (OR: 4.6; CI: 3.0-7.0) –Ability to get appt for routine care when needed (OR: 4.4; CI: 3.2-6.2) –Ability to get appt for urgent care when needed (OR: 3.7; CI: 2.5-5.5) Drivers of provider communication –PCM listens carefully (OR: 13.5; CI: 6.4-28.4) –PCM provides complete and accurate info (OR: 12.9; CI: 5.2-31.9) 6

7. Use and cost analysis Conducted retrospective data analysis (FY07-10) –Transition period from June 2008 to January 2009 Used differences-in-differences approach Used two-step process for analyzing health care use and costs –Step 1: binary regression for user or non-user of a particular service –Step 2: OLS regression for amount of services for users only Used NMC Portsmouth, NMC San Diego, and NHP Pensacola internal medicine clinics as comparison sites Focused on chronic conditions –Diabetes, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), and mental health 7

8. PCMH impact on use – all enrollees 8

9. PCMH impact on use – chronic patients 9

10. PCMH impact on use – non-chronic patients 10

11. PCMH impact on cost – all enrollees 11

12. PCMH impact on cost – chronic patients 12

13. PCMH impact on cost – non-chronic patients 13

14. Cost impacts associated with chronic enrollees Chronic Non- chronicTotal Change attributable to chronic enrollees Estimated costs per enrollee PMPY without PCMH$3,136$750 PMPY with PCMH$2,803$697 Change in dollars-$333-$53 Change in percentages-10.6%-7.1% Average PMPY change by percent of enrollees with chronic conditions 40%-$16580.7% 50%-$19386.2% 60%-$22190.4% 14

15. WRNMMC PCMH impact by condition Diabetes Hyper- tension Hyper- lipidemiaCOPDCAD Mental health Inpatient admissions-10.8% Inpatient days20.2%19.0%36.0% ER visits-13.5% Specialty care-3.6%-0.5%3.4% Primary care40.3%32.0%32.1%46.3%49.3%24.8% Pharmacy-17.0%-16.1%-17.0%-10.3%NA*-1.4% Ancillary-16.2%-19.1%-15.2%-24.0%-24.1%-14.1% PMPQ-10.5%-11.1%-10.0%-10.1%-8.2% WRNMMC enrollees1,5957,0987,2079606592,426 *Model would not converge. 15

16. Diabetes CPG metrics Screening/exam –HbA1c exam (at least yearly) –Eye exam (every two years) –Lipid (LDL-C) screening (yearly) –Nephropathy (yearly) Level/control –HbA1c control (> 9.0%) –Lipid control (LDL-C < 100 mg/dL) –Blood pressure control 16

17. Diabetes CPG adherence rates—HbA1c exam 17

18. Diabetes CPG adherence rates—eye care 18

19. Diabetes CPG adherence rates—lipid control 19

20. Diabetes CPG adherence rates—nephropathy 20

21. Are changes in CPG adherence rates significant? Controlling for demographic differences and other chronic conditions, PCMH patients are more likely to have yearly nephrology and lipid control panels than patients at control sites HbA1c results are not meaningful because of the change in coding practice at WRNMMC in 2010 Eye exams are recommended every two years, but with a 1-year comparison (2007 to 2010), there is a significant decline in patients receiving eye exams 21 Procedure Odds ratio for post-PCMH Significance Nephrology1.260.025 Lipid control1.200.045

22. 22 Staff survey – continuity and coordination of care How often do you feel that you can exercise autonomy as opposed to having to utilize a standard procedure? –The question was only asked of providers

23. Enrollment status of diabetics (Navy catchment areas) 23

24. Chronic disease burden “78% of health spending is devoted to people with chronic conditions. Quality medical care for people with chronic conditions requires a new orientation toward prevention of chronic disease and provision of ongoing care and care management to maintain health status and functioning.” –Health spending attributable to people with chronic conditions  1 or more conditions: 88% for prescriptions, 72% for physician visits, 76% for inpatient  2 or more conditions: 67% for prescriptions, 48% for physician visits, 56% for inpatient Source: Anderson and Horvath, “The Growing Burden of Chronic Disease in America,” Public Health Reports, 2004, 119(3):263-270 24

25. Pharmacy Variation Utilization and variation for maintenance and scheduled drugs Nevin Aragam, CNA Analysis and Solutions

26. Outline We investigate Navy pharmacy utilization and variation for FY 2011 to identify and understand patterns among our population of maintenance and scheduled pharmaceutical users  Methods  All drugs  Maintenance drugs  Scheduled drugs FOR OFFICIAL USE ONLY 26

27. Methods FY 2011 PDTS via MDR Used catchment area of record to identify the eligible populations surrounding navy catchment regions Identified all eligible beneficiaries in FY 2011 using DEERS and the demographic information from the most recent FM the beneficiary appeared Maintenance drugs are identified with the MDR PDTS field Maintenance Drug = ‘Y’ Scheduled drugs and identified using the MDR PDTS field DEA Class = 1, 2, 3, 4, or 5* FOR OFFICIAL USE ONLY 27 * note, there were no drugs identified as having DEA class 1 in PDTS

28. All pharmacy age distribution FOR OFFICIAL USE ONLY 28 Age distribution for all pharmacy users

29. FOR OFFICIAL USE ONLY 29 All pharmacy utilization 30 day supplies per 1,000 Navy region beneficiaries by age 60,000 30 days supplies implies the average 80 year old takes about 5 medications daily

30. FOR OFFICIAL USE ONLY 30 Popular fill source AD beneficiaries fill almost exclusively at MTF pharmacies Active duty family members and retirees fill mostly at MTFs and a sizable proportion at retail pharmacies Retirees and their dependents fill fairly evenly across MTFs and retail pharmacies Source System ADADFMRET RETDEP/ OtherTotal Direct93.6%61.3%48.4%40.1%53.8% Retail5.3%37.4%40.6%50.9%39.2% Mail order0.3%0.7%6.4%5.3%4.1% Other0.8%0.6%4.5%3.6%3.0% Total100.0% Source: MHS Data Repository (MDR PDTS table FY2011).

31. Types of maintenance drugs Top 5 Maintenance drugs (15% of all maintenance drugs prescribed) 1.IBUPROFEN 2.SIMVASTATIN 3.LISINOPRIL 4.NEXIUM 5.LIPITOR FOR OFFICIAL USE ONLY 31

32. FOR OFFICIAL USE ONLY 32 Maintenance drug age distribution Age distribution for maintenance pharmaceutical users

33. FOR OFFICIAL USE ONLY 33 Maintenance drug utilization 30 day supplies of maintenance drugs per 1,000 Navy region beneficiaries by age 50,000 30 days supplies implies the average 80 year old takes about 4 maintenance medications daily

34. FOR OFFICIAL USE ONLY 34 Maintenance drug regional variation High: NH Pensacola (13,307 30 day supplies) Low: NCA MSMA (9,460 30 day supplies) High/Low: 1.41 (Beneficiaries in NH Pensacola use 1.4 times as many maintenance drugs as those in the NCA MSMA) Regional variation for maintenance drug prescriptions per 1,000 beneficiaries

35. Scheduled drugs FOR OFFICIAL USE ONLY 35 ScheduleAbuse potential Accepted medical use Likelihood of psychological or physical Dependence Examples IHighNoNo accepted safety for use Heroin, LSD, marijuana IIHighYesHighAmphetamine (Adderall ® ), methamphetamine (Desoxyn ® ), cocaine IIIModerateYesModerateVicodin ®, Tylenol with codeine ®, ketamine IVLowYesLimitedAlprazolam (Xanax ® ), diazepam (Valium ® ) VLowYesLimited Robitussin AC ®,Phenergan with Codeine ®

36. Types of scheduled drugs Top 5 Scheduled drugs (55% of all schedules drugs prescribed) 1.HYDROCODONE-ACETAMINOPHEN 2.ZOLPIDEM TARTRATE 3.OXYCODONE-ACETAMINOPHEN 4.ALPRAZOLAM 5.DIAZEPAM Scheduled drugs can also be maintenance drugs: 1.CLONAZEPAM 2.CONCERTA 3.LYRICA 4.ADDERALL XR 5.VYVANSE FOR OFFICIAL USE ONLY 36

37. FOR OFFICIAL USE ONLY 37 Scheduled drug age distribution Age distribution for scheduled pharmaceutical users

38. FOR OFFICIAL USE ONLY 38 Scheduled drug utilization 30 day supplies of scheduled drugs per 1,000 Navy region beneficiaries by age 1,900 30 days supplies implies the average 80 year old takes about 1.5 scheduled drug medications daily

39. FOR OFFICIAL USE ONLY 39 Scheduled drug regional variation High: NH Pensacola (1,073 30 day supplies) Low: NCA MSMA (567 30 day supplies) High/Low: 1.89 (Beneficiaries in NH Pensacola use nearly twice as many scheduled drugs as those in the NCA MSMA) Regional variation for scheduled drug prescriptions per 1,000 beneficiaries

40. FOR OFFICIAL USE ONLY 40 Questions? Nevin Aragam AragamN@CNA.org

41. Appendix Navy region definitions by catchment area DMIS ID: 0067 0066 0037 0123 - NCA MSMA 0124 0120 – Tide Water MSMA 0024 0029 - San Diego MSMA 0125 126 127 - Puget Sound MSMA 0104 - NH Beaufort 0091 - NH Camp Lejeune 0039 - NH Jacksonville 0028 - NH Lemoore 0038 - NH Pensacola 0030 - NH Twentynine Palms FOR OFFICIAL USE ONLY 41