Identifying Medicaids Best Buys Dan Crippen Former Director, - PowerPoint PPT Presentation

Identifying Medicaid’s Best Buys Dan Crippen Former Director, Congressional Budget Office for CHCS/Harvard Government Innovators Network “Best Buys” Call February 5, 2007

Federal Budget as a Percent of the Economy

Federal Spending for Retirees

Spending Non-elderly Per Capita Healthcare Per Capita Spending

Per Capita Medicare Spending Percapita Medicare Spending 70,000 $70,000 60,000 $60,000 Percapita Spending Per Capita Spending 50,000 $50,000 $40,000 40,000 $30,000 30,000 $20,000 20,000 Average $5800 Ave.=$5200 $10,000 10,000 $0 0 1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 Percentile Percent of Population

Distribution of Medicare Spending Among Beneficiaries

Profiles of Medicare Beneficiaries by Spending Group Top 5 Percent Top 20 Percent Bottom 40 Percent Spending Group (Mean Spending) ($53,538) ($24,161) ($197) Inpatient PPS Spending / Beneficiary $25,309 $11,119 None Physician Spending / Beneficiary $8,872 $4,934 $165 Chronic Conditions Diabetes 43% 36% 14% CHF 59% 47% 9% Cognitive impairment 30% 24% 5%

Per capita Medicaid Spending Total Per capita Costs Percent of Medicaid Population

What Groups Drive Medicaid Spending? Elderly Elderly Disabled Adults Disabled Children Adults Children

Defining the Population Identification of Targeted Population--Acute Care 20% of Population Drive > 85 % of Costs • The top 1% of members account for 33% of total costs • The annual cost of this 1% is $52,500/member as compared to $1,500 average annual cost • The bottom 50% of members (188,000 members) account for only 1.5% of total costs and have an average cost of $50/member

Defining Utilization Identification of Top 20 Primary Conditions and Comorbidities for the Top 25% of Members Most Prevalent Comorbidity 2nd Most Prevalent Comorbidity 3rd Most Prevalent Comorbidity % of Incidence Incidence Incidence Unique Annual rate w/i rate w/i rate w/i Primary Diagnostic Condition Members Costs Annual cost PMPM Description Prim. Cat. Description Prim. Cat. Description Prim. Cat. Rank 1 Cancer 2,400 11.3% 24,995,265 $ 1,001 Other upper 38% Spondylosis, 28% Abdominal pain 28% respiratory disease intervertebral disc 2 CHF 2,337 10.9% 24,234,874 $ 932 HTN 76% Hyperlipidemia 55% Other upper respiratory 39% disease 3 Asthma 3,634 10.5% 23,265,682 $ 581 Other upper 64% Other lower respiratory 43% Abdominal pain 18% respiratory disease disease 4 Spondylosis, intervertebral disc 3,365 7.7% 17,120,867 $ 494 Other upper 36% Abdominal pain 27% Headache, including 22% respiratory disease migraine disorders, other back problems 5 Diabetes 1,580 6.1% 13,574,852 $ 858 Hyperlipidemia 40% HTN 38% Other upper respiratory 34% disease 6 Abdominal pain 2,449 5.4% 11,976,201 $ 482 Other upper 34% Urinary tract infections 19% Other lower respiratory 15% respiratory disease disease 7 Non-Recurrent Conditions 2,582 4.3% 9,629,659 $ 490 8 Chronic Renal Failure 261 3.6% 7,972,054 $ 3,038 HTN 64% CHF 51% Hyperlipidemia 44% 9 Fetal disorders 412 3.2% 7,028,974 $ 2,448 Other upper 40% Congenital Anamolies 21% Other lower respiratory 20% respiratory disease disease 10 Metastatic Cancer 166 3.1% 6,799,178 $ 4,688 Cancer 61% Other lower respiratory 45% Abdominal pain 35% disease 11 Moderate or Severe Liver Disease 635 3.0% 6,666,521 $ 1,040 Abdominal pain 33% Spondylosis, 32% Substance-related 30% intervertebral disc mental disorders 12 COPD 604 3.0% 6,631,835 $ 1,048 Other upper 49% Other lower respiratory 43% Asthma 43% respiratory disease disease 13 Other upper respiratory disease 1,563 2.3% 5,015,169 $ 324 Other lower respiratory 5% Abdominal pain 3% Urinary tract infections 2% disease 14 Congenital Anamolies 798 2.2% 4,922,061 $ 658 Other upper 49% Other lower respiratory 22% Heart valve disorders 10% respiratory disease disease 15 CAD 435 1.8% 4,055,861 $ 996 Hyperlipidemia 36% HTN 35% Other lower respiratory 33% disease 16 Autism & Preadult Disorders 1,274 1.8% 3,918,294 $ 270 Other upper 45% Other Affective 18% Other lower respiratory 12% respiratory disease Disorders disease 17 Sickle Cell Anemia 185 1.5% 3,273,287 $ 1,638 Other upper 43% Other lower respiratory 39% Abdominal pain 28% respiratory disease disease 18 Major Depression 665 1.5% 3,255,184 $ 496 Other upper 27% Other Affective 19% Substance-related 18% respiratory disease Disorders mental disorders 19 AIDS/HIV 373 1.3% 2,806,488 $ 755 Other upper 33% Other lower respiratory 28% Substance-related 25% respiratory disease disease mental disorders 20 Urinary tract infections 569 1.2% 2,674,983 $ 462 Other upper 30% Other lower respiratory 8% Substance-related 8% respiratory disease disease mental disorders

High-Cost Medicaid Conditions (Top 25% of patients)  Cancer » 47% Inpatient and ER  Chronic Heart Failure » 50% Inpatient and ER  Asthma » 46% Inpatient and ER

High-Cost Medicaid Patients (Top 25%)  Inpatient and ER — 55%  Surgical — 9%  Physician — 12%  Imaging — 4%  Lab — 1%

Hospitalizations  Unnecessary Hospitalizations » “Convenience”  Preventable Hospitalizations » Asthma  Predictable Hospitalizations » Pattern of pharma use » Number and type of physician encounters  Avoidable Hospitalizations » Diabetes » CHF