The Impact ct of a Multisite Care Management Pr Program on Spend - PowerPoint PPT Presentation

The Impact ct of a Multisite Care Management Pr Program on Spend and Utilization in Children with Me Medi dical Compl plexity ty David Bergman, MD, Stanford University School of Medicine, David Keller, MD, Children's Hospital Colorado, Dennis Kuo, MD, MHS, Jacobs School of Medicine University at Buffalo, Carlos Lerner, MD MPhil, UCLA, Mona Mansour MD, University of Cincinnati, Christopher Stille, MD, MPH, University of Colorado School of Medicine, Troy Richardson, PhD, Children's Hospital Association, Jonathan Rodean, MPP, Children’s Hospital Association, and Mark Hudak, MD, University of Florida College of Medicine

Supported by award Number 1C1CMS331335-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Background and Objectives Children with medical complexity (CMC) comprise < 1% of Children but account for: • 30% of pediatric health care costs E. Cohen; Pediatrics 2012 • 55% of pediatric inpatient costs J. Berry; JAMA Pediatrics 2012 • 85% of pediatric readmission costs J. Berry; CMS Readmissions Summit 2011

Background and Objectives • For families of children with medical complexity: • 14% spend 11 hours per week on care coordination • 57% experience financial problems • 54% had a family member stop working to care for their child DZ Kuo Archiv Pediatr Adol Med 2011

Background and Objectives • To assess the impact of a multi-center care management program on spend and utilization in CMC. • 10 children’s hospital complex care programs and 42 pediatric primary care practices

Methods • Design: a prospective cohort study of CMC whose claims data was analyzed between 05/01/2014 and 04/30/2017. o The claims data from this group was compared to a propensity matched group of eligible but not enrolled subjects • Intervention: A national learning collaborative of 10 children’s hospitals and 42 practices to implement: • A patient registry • Dynamic care teams • Individualized access action plans • Care plan with shared goals

Methods • Population: CMC ages 0-19 who clinical diagnoses were compatible with Clinical Risk Group Categories 5b – 9 CRG Example Conditions 5b Significant lifelong chronic condition Epilepsy, diabetes 6 Significant chronic diseases in multiple organ Behavior problems+diabetes, epilepsy+obesity systems 7 Dominant chronic diseases in 3 or more Polycystic kidney disease+cerebral organ systems malformations+autism 8 Dominant metastatic malignancy Leukemia, lymphomas, solid organ malignancies 9 Catastrophic Spina bifida, progressive muscular dystrophy, congenital quadriplegia, organ transplant

Methods • Outcome Measures • Total per-member-per-year (PMPY) standardized expenditures. • Service-line specific PMPY spending (e.g. inpatient, outpatient, ED, pharmacy) • Annualized utilization for inpatient admissions, ED visits, office visits, pharmacy claims, and home health days

Methods • Statistical Analysis • Association for categorical variables was evaluated using a Chi Square test • Comparison of demographic and clinical characteristics between enrolled and eligible patients was evaluated using the Wilcoxon rank-sum test • Statistical process control methods were used to assess changes in PMPY and annualized utilization over time in CMC enrolled in the study

Methods • Propensity Matching • We used a greedy 1:1 propensity-matched difference-in-differences sub- analysis of enrolled CMC and eligible CMC. Matching occurred on: Patient demographics CRG group and severity level PMPY spend Pre-study ED visits and hospital admissions • Percent savings attributed to the study interventions were estimated using post-enrollment slope estimates from the eligible population applied to the post-enrollment period in the enrolled population.

Results • Patient population 197,372 subjects who met eligibility 186,655 subjects eligible but not enrolled 8096 subjects /10 hospitals enrolled in the 5849 subjects study Incomplete claims or failure to report both eligible and enrolled Claims data available on enrollees 4063 enrollees, 8 hospitals and 7 claims providers 178 excluded from propensity match 3885 enrollees, 8 hospitals and 7 claims providers available for propensity match

Results: Propensity Match Overall* Eligible Enrolled p-value N, Total Enrollees 7,770 3,885 3,885 N, Months Enrollment-Pre, Median (IQR) 12 (12,12) 12 (12,12) 12 (12,12) 0.241 N, Months Enrollment-Ramp, Median (IQR) 12 (12,12) 12 (12,12) 12 (12,12) 0.665 N, Months Enrollment-Post, Median (IQR) 12 (12,12) 12 (12,12) 12 (12,12) 0.183 Age (years) in 2015, Median [IQR] 7 (3,11) 7 (3,11) 7 (3,11) 0.065 Age Group in 2015, N (%) 0.244 a. 0-1 y 863 (11.1) 424 (10.9) 439 (11.3) b. 2-5 y 2,406 (31.0) 1,177 (30.3) 1,229 (31.6) c. 6-11 y 2,739 (35.3) 1,368 (35.2) 1,371 (35.3) d. 12-18 y 1,762 (22.7) 916 (23.6) 846 (21.8) Gender, N(%) 0.234 Male 3,352 (43.1) 1,650 (42.5) 1,702 (43.8) Female 4,418 (56.9) 2,235 (57.5) 2,183 (56.2) CRG 1.000 5 1,258 (16.2) 629 (16.2) 629 (16.2) 6 4,220 (54.3) 2,110 (54.3) 2,110 (54.3) 7 322 (4.1) 161 (4.1) 161 (4.1) 8 64 (0.8) 32 (0.8) 32 (0.8) 9 1,906 (24.5) 953 (24.5) 953 (24.5) CRG Group 1.000 CRG 5b-6b 4,646 (59.8) 2,323 (59.8) 2,323 (59.8) CRG 6c-9 3,124 (40.2) 1,562 (40.2) 1,562 (40.2) Inpatient Hospitalization Pre Award, N (%) 2,136 (27.5) 1,068 (27.5) 1,068 (27.5) 1.000 ED Visits Pre Award, N (%) 4,440 (57.1) 2,208 (56.8) 2,232 (57.5) 0.582

Results: Propensity Match on Spend Service Eligible (Non-Matched) Eligible (Matched) Enrolled Inpatient $2,474 $9,082 $13,766 Outpatient $5,236 $23,337 $28,230 ED $361 $619 $789 Office $630 $2,233 $2,582 Home Health $899 $9,199 $11,065 MHSA $1,052 $2,018 $2,297 DME $140 $1,031 $1,400 PT/OT $239 $1,123 $1,172 Procs $293 $889 $1,185 Radiology $70 $146 $152 Lab $128 $236 $280 OP Facility $4 $13 $19 Injections $36 $69 $98 Misc $1,384 $5,762 $7,190 Rx $2,700 $4,667 $6,691 Total $10,410 $37,086 $48,687

$4567 (4.6%); p=0.018

$1434 (7.2%); p=.042

$74 (11.6%); p=.044

Limitations • The study patient population may not be representative of the greater population of CMC. • The propensity matched comparison group while comparable to the enrolled group across demographic and disease variables had greater spend and utilization. • The study intervention period was only 12 months and it was not possible to assess the sustainability of our intervention over time

Conclusions • First study able to demonstrate a reduction in total spend for a large population of CMC cared for in both hospital-based complex care clinics and pediatric primary care practices. • The program appeared to have the greatest impact on inpatient and ED spend. • The intervention utilized a learning collaborative which allowed for continuous improvement over the course of the study • Further work is needed to achieve a better understanding which components of the intervention most contributed to change and if these changes are sustainable over time

Acknowledgements Project Site Directors CHA Staff Children’s Hospital Colorado (Aurora, CO): • • Sue Dull RN, David Keller, MD; Heidi Baskfield; Jen Thompson Director, Collaborative Learning and Improvement, CARE Children’s Mercy Kansas City (Kansas City, MO): • Lorne Morelli RN • Amber Hoffman, MD, Chad Moore, Ingrid Larson, Monica Jessick Manager, Collaborative Care Children’s National Medical Center (Washington, DC): • Lowrie Ward MPH • Mark Weissman, MD; Mary Daymont Manager Practice Transformation, CARE Cincinnati Children’s Hospital Medical Center (Cincinnati, OH): • Kate Conrad FACHE • Tracy Huentelman Vice President, Delivery System Transformation Cook Children’s Health Care System (Fort Worth, TX): • • Jacqueline Kueser Jose Gonzalez, MD CHA Leader, Transformation Informatics • Lucile Packard Children’s Hospital Stanford (Palo Alto, CA): • Christy Sandborg, MD; John Mark, MD Mattel Children’s Hospital (Los Angeles, CA): • Lerner, MD; Thomas Klitzner, MD St. Joseph’s Children’s Hospital (Tampa, FL): • Daniel Plasencia, MD; James Baumgartner The Children’s Hospital of Philadelphia (Philadelphia, PA): • David Rubin, MD Wolfson Children’s Hospital (Jacksonville, FL): • Jeffrey Goldhagen, MD