Multiple chronic conditions at a major urban health system: a retrospective cross-sectional analysis of frequencies, costs and comorbidity patterns.

OBJECTIVE: To (1) examine the burden of multiple chronic conditions (MCC) in an urban health system, and (2) propose a methodology to identify subpopulations of interest based on diagnosis groups and costs. DESIGN: Retrospective cross-sectional study. SETTING: Mount Sinai Health System, set in all five boroughs of New York City, USA. PARTICIPANTS: 192 085 adult (18+) plan members of capitated Medicaid contracts between the Healthfirst managed care organisation and the Mount Sinai Health System in the years 2012 to 2014. METHODS: We classified adults as having 0, 1, 2, 3, 4 or 5+ chronic conditions from a list of 69 chronic conditions. After summarising the demographics, geography and prevalence of MCC within this population, we then described groups of patients (segments) using a novel methodology: we combinatorially defined 18 768 potential segments of patients by a pair of chronic conditions, a sex and an age group, and then ranked segments by (1) frequency, (2) cost and (3) ratios of observed to expected frequencies of co-occurring chronic conditions. We then compiled pairs of conditions that occur more frequently together than otherwise expected. RESULTS: 61.5% of the study population suffers from two or more chronic conditions. The most frequent dyad was hypertension and hyperlipidaemia (19%) and the most frequent triad was diabetes, hypertension and hyperlipidaemia (10%). Women aged 50 to 65 with hypertension and hyperlipidaemia were the leading cost segment in the study population. Costs and prevalence of MCC increase with number of conditions and age. The disease dyads associated with the largest observed/expected ratios were pulmonary disease and myocardial infarction. Inter-borough range MCC prevalence was 16%. CONCLUSIONS: In this low-income, urban population, MCC is more prevalent (61%) than nationally (42%), motivating further research and intervention in this population. By identifying potential target populations in an interpretable manner, this segmenting methodology has utility for health services analysts.

Impact of a geriatric case management program on health plan costs.

We evaluated the impact of HIP, Health Plan of New York's geriatric case management (GCM) program, which is offered to Medicare Advantage members at high risk for high health care costs and utilization. The study design was a comparison of health plan costs for program participants and nonparticipants eligible for the program, controlling for variables predictive of high health care costs measured prior to program enrollment. The GCM program's impact on health care cost was derived from regression models comparing the costs of 101 program participants without exposure to other disease management programs to 1585 eligible nonparticipants, controlling for age, sex, and health care costs in the pre-program period. Net costs or savings from the program were computed as the sum program operation costs and the estimated change in health care costs associated with program participation. Mean annual health care costs for each program participant were $7720 lower than for eligible nonparticipants (P = .0090). The lower health care costs were attributable to the lower costs for inpatient and outpatient hospital and skilled nursing facility settings, exceeding the higher costs for physician office visits and prescription drugs. Estimated program costs were $2755 per member managed by the program, yielding a net savings of $4965 per member enrolled. A GCM program was successfully implemented in a large Medicare Advantage program. The reductions in health care costs achieved through GCM exceeded program costs resulted in meaningful savings for the health plan.

Predicting psychiatric emergency room recidivism.

To address the need to reduce psychiatric emergency-room (ER) recidivism and to promote continuity of care, this study developed a model using administratively obtainable variables to predict psychiatric ER visits in the six months following an index ER visit for a psychiatric condition. Data on member characteristics, preindex psychiatric ER use, index ER information, and postindex utilization for 1,029 adult HMO members visiting the ER for a psychiatric condition were collected and randomly divided in half. A regression model predicting psychiatric ER visits in the six months following the initial psychiatric ER visit was developed in the first data set and tested in the second. In both models, Medicaid insurance coverage, and preindex inpatient admissions for depression or substance abuse were identified as significant predictors of future psychiatric ER utilization. Administratively identifiable variables can be used to identify members at elevated risk of ER recidivism for psychiatric conditions. Through improved identification of risk, case management interventions can be strategically directed to members with the greatest need of services.

Reducing the number of emergency department visits and costs associated with anxiety: a randomized controlled study.

OBJECTIVE: To demonstrate the economic effects of an intervention for members discharged from the emergency department (ED) with anxiety diagnoses. STUDY DESIGN: Randomized controlled study. METHODS: Adults with commercial, Medicare, or Medicaid insurance coverage enrolled in a health maintenance organization and discharged from an ED with anxiety diagnoses were randomly assigned to receive usual care (n = 300) or a stepped-care intervention (n = 307). Psychiatric ED and outpatient visit utilization and cost data identified by claims were collected for 6 months following the initial ED visit. RESULTS: Members assigned to receive the intervention demonstrated significantly fewer ED visits and lower associated facility costs in the 6 months following discharge compared with those assigned to usual care. No significant differences in psychiatric outpatient visit costs were observed. Members receiving usual care made 117 visits to the ED for a psychiatric condition during the follow-up period, for a mean of 0.39 visits per member and a mean facility cost of 118.15 dollars per member, while members receiving case management services made 79 visits to the ED for a psychiatric condition during the follow-up period, for a mean of 0.26 visits per member and a mean facility cost of 70.63 dollars per member. The intervention resulted in a savings of 7.92 dollars in ED costs per member per month for all psychiatric diagnoses during the 6-month study period. CONCLUSION: The case management-based intervention effectively reduced psychiatric ED recidivism and costs for members discharged from the ED with an anxiety diagnosis, without significantly affecting psychiatric outpatient visit costs.

Predicting future hospital utilization for mental health conditions.

To develop a model using administrative variables to predict number of days in the hospital for a mental health condition in the year after discharge from a mental health hospitalization. Background, index hospitalization and preindex inpatient, emergency room, and outpatient utilization information were collected for 766 adult members discharged from a mental health hospitalization during a 1-year period. A regression model was developed to predict hospitalized days for a mental health condition in the year after discharge. A regression model was created containing five statistically significant predictors: Medicare insurance coverage, preindex mental health inpatient days, index length of stay, depression diagnosis, and number of mental health outpatient visits with a professional provider. It is possible to predict future mental health inpatient utilization at the time of discharge from a mental health hospitalization using administrative data, thus allowing disease managers to better identify members in greatest need of additional services and interventions.

Patterns of healthcare utilization and costs for vascular dementia in a community-dwelling population.

BACKGROUND: While vascular dementia (VaD) is the second most prevalent dementia diagnosis, little is known about healthcare use and costs for VaD. PURPOSE: This study compares the healthcare use and costs of community-dwelling patients with VaD to patients with Alzheimer's disease (AD), other dementias (OD), cerebrovascular disease without dementia (CVD), and patients without dementia or cerebrovascular disease (controls). METHODS: Using diagnoses codes from medical claims and encounter records, 678 VaD, 1,722 AD, 957 OD, 2,718 CVD, and 14,023 controls were identified from patients enrolled in a 100,000-member group practice Medicare HMO during 1999-2002. Annual healthcare use and costs of the study groups were compared, using regression analysis to control for patient characteristics. RESULTS: VaD patients had the highest annual costs, dollars 14,387, followed by dollars 10,716 for OD, dollars 8,254 for CVD, and dollars 7,839 for AD, and dollars 5,494 for controls (p<0.0001 for all comparisons to VaD). Despite higher total direct costs, VaD patients had lower costs for physician visits and prescription drugs compared with all study groups except OD. In contrast, CVD patients had the highest costs for these services. Moreover, hospital admissions for VaD were nearly twice those for CVD, and hospital days for VaD nearly three times those for CVD, despite the high prevalence of cardiovascular conditions for both VaD and CVD. CONCLUSIONS: VaD patients had higher healthcare costs compared to all other patient groups. The substantially higher costs for VaD compared to CVD and the differences in use of healthcare services by VaD compared to CVD suggest that dementia, not cerebrovascular disease, is a major source of the cost differences. Lower costs for physician visits and prescription drugs for VaD suggest possible opportunities for improving ambulatory care and preventing high-cost hospitalizations.

Health care utilization and costs of Alzheimer's disease: the role of co-morbid conditions, disease stage, and pharmacotherapy.

BACKGROUND AND OBJECTIVES: Studies on the relationship between Alzheimer's disease (AD) and health care costs have yielded conflicting results. This study analyzed the relationship between co-morbid conditions and health care utilization and costs for patients with AD and estimated costs by stage of disease and receipt of pharmacotherapy. METHODS: We conducted a retrospective analysis of administrative data for 1,366 patients with AD and 13,660 age-gender matched controls enrolled in a large Medicare managed care organization (MCO). Co-morbid conditions were based on the diagnostic classifications from the Charlson co-morbidity index. Health care costs and utilization for MCO-covered services for cases were compared to controls. We used presence of complications of AD associated with later-stage disease to classify patients as having earlier- or later-stage AD. RESULTS: After controlling for co-morbid conditions, age, and gender, annual costs were $3,805 higher for AD patients, resulting in excess costs of $5 million to the MCO. For seven of the 10 most prevalent co-morbidities for AD patients, adjusted costs were higher for AD patients compared with controls with the same condition. Higher costs were attributable to higher inpatient and skilled nursing facility costs. Costs for patients classified as earlier-stage AD were 44% higher than controls and significantly higher for eight of 10 co-morbid conditions when compared with controls with the same conditions. Costs for AD patients receiving treatment by a cholinesterase inhibitor were $2,408 lower than AD patients not receiving therapy. CONCLUSIONS: Utilization and costs for patients with AD were higher compared to controls and were substantially higher for patients with both AD and co-morbid diseases commonly targeted for disease management. Earlier-stage AD and receipt of pharmacotherapy were associated with lower costs. These findings indicate that better treatment and care management of AD could reduce the costs of co-morbid illnesses commonly suffered by AD patients.

The effect of donepezil therapy on health costs in a Medicare managed care plan.

The objective of this study was to estimate the ramifications of donepezil use on the health care costs of a large Medicare managed care plan. Patients with a diagnosis of Alzheimer's disease or related dementia were identified from the claims-and-encounter records of the plan. Costs for 204 patients identified as having Alzheimer's disease and who were receiving donepezil were compared with a control group of 204 patients with Alzheimer's disease who had matching characteristics, but who were not receiving therapy. After controlling for age, gender, pharmacy benefits, comorbid conditions, and complications of dementia, annual costs for medical services and prescription drugs were found to be $3,891 lower for the study group. Costs were $4,192 lower for patients receiving longer-term therapy (> or = 270 day supply of donepezil) and $3,579 lower for patients receiving shorter-term therapy when compared with controls. By improving cognitive and daily functioning, donepezil may lower costs by improving medical management.