PEBB: 1/18/05Prepared by Aon Consulting1 Chronic Disease Management 2003 Annual Report-Highlights PEBB Board Meeting 1/18/05 BD attach. 5

PEBB: 1/18/05Prepared by Aon Consulting 1

Chronic Disease Management 2003 Annual Report -Highlights

PEBB Board Meeting1/18/05

BD attach. 5


2003 Highlights - Outline

• Purpose of Annual CDM Report• Review Methodology• Prevalence Updates• Aon Reported Statistical Findings (Cost &

Utilization for Level I & Level II Analysis)• Carrier Program Design• Participation• Carrier Reported Clinical Measures• Summary and Next Steps

BD attach. 5





BD attach. 5


Purpose

To coordinate and measure theeffectiveness of component chronic diseasemanagement programs developed andadministered by PEBB’s medical insuranceCarriers (Kaiser and Regence).

BD attach. 5





BD attach. 5


Methodology

Aon Statistical Report• Examines 4 different chronic diseases: Asthma, Diabetes,

Coronary Artery Disease (CAD), Congestive Heart Failure (CHF)

• Measures changes in disease prevalence, participation, utilization, & cost for PEBB members based on incurred claims data

• Prevalence based on agreed-upon definitions of each chronic disease (ICD, CPT, & NDC Codes)

• Participation based on member list provided by carriers

• Three types of utilization & cost analysisLevel I – with & without diseaseLevel II – participant vs. non-participantsClinical Measures – provided by carriers

BD attach. 5


Methodology

Carrier Reported Clinical Measures• Additional clinical measures reported separately by carriers

from non-claims sources (e.g. chart notes).

• Data reported uses the criteria mutually agreed upon by both carriers as outlined in the 2003 CDM Report

• HEDIS* measures have been added as a benchmark where available

• Regence relies on claims system for reporting on clinical measures from administrative data and does not have access to lab results

* The carrier reported values should not be compared to HEDIS values as the carriers do not have the HEDIS continuous enrollment requirement. This difference in methodology was agreed to by both carriers at the beginning of the reporting process.

BD attach. 5


Methodology

Illustration of Different Criteria Used for the Three Types of Analysis

Level I AnalysisAll Diagnosis

Level IIAnalysis

Disease andRelated

Diagnosis Only

ClinicalMeasures

DiseaseDiagnosis

Only

BD attach. 5





BD attach. 5


Prevalence

• 11,835 (9.5%) PEBB members were identified with one or more of theses four chronic diseases as of 12/31/03, including:– 5.0% with Asthma– 3.6% with Diabetes– 1.75% with CAD– 0.50% with CHF

• 1,179 (0.94%) have more than one chronic disease

• Prevalence rates are generally consistent with industry benchmarks

• Prevalence rates are similar for both carriers for CAD and CHF. Kaiser has a much higher prevalence of Asthma and Diabetes than Regence

BD attach. 5





BD attach. 5


Aon Statistical Findings

Cost Findings• 28% of total 2003 PEBB claims were for members with at

least one of the four chronic disease (includes claims for non-disease related illness/injury)

• Average monthly claims for members (PMPM) with chronic disease was $570 – 4x higher than for those without chronic disease

• PMPM ranged from $493 for asthma to $2,039 for CHF

• Rate of increase in PMPM costs from 2002 to 2003 was 19% for members with chronic disease compared to a 5% increase for members without chronic disease

BD attach. 5


Aon Statistical Findings

Utilization Findings• Overall utilization continues to be higher for members with

chronic disease verses members without chronic disease

• Changes in utilization rates for members with chronic disease are mixed; additional analysis will be conducted to explain the reasons. Increases in utilization may be the result of members receiving appropriate preventive procedures which is positive.

• Still too early to confirm trends due to anomalies during the reporting period– 2002 consolidation of carriers and plan designs– Small numbers for PEBB’s chronic disease populations– Many members have co-morbidities that confound

analysis

BD attach. 5





BD attach. 5


Carrier Program Design

Kaiser• Members are automatically

registered in DM programs – ‘opt-out’ program

• Members are automatically considered participating once entered in the Disease Registry

• DM programs tightly integrated with physicians and case management

• Kaiser data collected through EMR which includes lab results

Regence• DM programs rely on

voluntary member participation – ‘opt-in’ program

• Member must receive 2 interventions to be considered a participant

• DM programs target the member and do not have direct contact with physicians

• Regence data relies on claims system for reporting from administrative data

A detailed description of the disease management programs for each carrier by disease is found in the ‘Carrier Interventions’ section

beginning on page 13 of the 2003 Report .

BD attach. 5





BD attach. 5


Participation

• Kaiser participation is 100% for all diseases

• Regence participation rates vary by disease:– Asthma: 56%– Diabetes: 74%– CAD: 27%– CHF: 34%

• Regence participation increased significantly for CAD and CHF as a result of substantial changes in the administration of its disease management programs. Participation in 2002 was 5% for each disease prior to the changes.

Note: Regence only contacts members considered ‘suitable’ for enrollment in disease

management. For participation based on Regence suitability refer to page 20 of the

2003 Report.

BD attach. 5





BD attach. 5


72.0%

71.2%

Carrier Reported Clinical Measures: Asthma

79.3%

79.0%Use of Appropriate Medications for Patients with Persistent Asthma

Kaiser Regence HEDIS 75th

•Good care for asthmatics includes preventing flares of wheezing and shortness of breath which interfere with the patient’s functioning.

•Two types of medication are used to treat patients with asthma; one to prevent acute flares, and one to treat acute flares when they occur

•Clinical Goal: increase in the percentage of patients regularly using medications to prevent acute flares

Note: HEDIS percentiles have been included for benchmarking only and should not be used as a comparator with the carrier reported values as the carriers do not have a continuous enrollment requirement.

Compliance with Appropriate Labs & Exams

2002

2003

Data for Regence is Not Available

BD attach. 5


47.7

52.1

Carrier Reported Clinical Measures: Asthma

59.5

60.6ER Visits per 1,000


•Preventive treatment should reduce acute flares which cause the patient to seek emergency care

•Clinical Goal: a decrease in the number of ER visits by patients with asthma

Utilization Results

2002

2003

There is no HEDIS Equivalent

BD attach. 5


Carrier Reported Clinical Measures: Diabetes

50.9%

73.7%

49.8%

88.0%

51.7%

44.3%

52.9%

87.2%Mbrs (18-75 yrs old) who had HbA1c Test

Mbrs who had Eye Exam

Mbrs (18-75 yrs old) who had LDL-C Screening

Mbrs Monitored for Diabetic Nephropathy


•Excellent care of diabetes includes good control of the blood sugar levels and of cardiac risk factors (coronary artery disease is the leading killer of diabetics)

•Early detection of eye or kidney disease can lead to interventions to prevent or delay the onset of blindness or kidney failure

•Clinical Goal: increase in percentage of members receiving appropriate screenings

49.2%

86.9%

40.7%

88.1%

35.0%

78.4%

33.2%

81.4%

58.7%

89.8%

60.4%

88.3%

52.8%

85.9%

61.3%

86.9%

Note: HEDIS percentiles have been included for benchmarking only and should not be used as a comparator with the carrier reported values as the carriers do not have a continuous enrollment

requirement.


2002

2003

BD attach. 5


61.0%

39.6%

55.5%

42.3%


60.0%

23.9%

55.1%

26.0%Of the Mbrs Tested for HbA1c, the % of those tested with Poor HbA1c Control

Of the Mbrs Screened for LDL-C, the % of those screened with LDL-C Controlled


•Proper care should result in controlled blood sugar level and controlled cardiac risk factors

•Clinical Goal:-Decrease in the percent of members with poor HbA1c control-Increase in the percent of members with LDL-C controlled


requirement.

Clinical Results

2002

2003

Regence does not have Access to Lab Results

BD attach. 5



154.5

137.3

35.8

90.9

25.1

8.4

ER visits per 1,000

Hospitalization for Diabetes or Comorbidity as Any Diagnosis


•Proper care should result in a reduction in the number of hospital admissions and ER visits for members with diabetes

•Clinical Goal: decrease in the number of hospitalizations per 1,000 and ER visits per 1,000 for diabetics

130.9

136.4

34.9

67.6

11.0

9.1

Utilization Results

2002

2003

Hospitalization for Diabetes or Comorbidity as Primary Diagnosis

There are no HEDIS Equivalents

BD attach. 5


83.5%

97.9%

82.2%

97.0%

69.4%

86.2%

72.8%

79.6%

Carrier Reported Clinical Measures: CAD

57.6%

84.9%

87.0%

57.1%

81.0%

75.8%Mbrs Receiving Beta Blocker following a Heart Attack (AMI)

Mbrs who had LDL-C Screening following an Acute Coronary Event (AMI, CABG, PTCA)Mbrs Using Aspirin following an Acute Coronary Event (AMI, CABG, PTCA)


•The goal of managing CAD is to prevent further events (angina/chest pain or repeat heart attacks) by controlling all risk factors (high blood pressure, cholesterol, inactivity, tobacco use)

•Beta Blocker medications are the best drug treatment for preventing recurrent heart attacks

•Aspirin has the ability to reduce clot formation in the narrowed coronary arteries

•Clinical Goal: increase in percentage of members receiving beta blocker treatment, cholesterol screening, and aspirin use


requirement.


2002

2003 There is no HEDIS Equivalent

Regence does not have Access to Chart Notes

BD attach. 5


68.6%

67.2%


89.3%

Of the Mbrs Screened for LDL-C, the % of those screened with LDL-C Controlled


•LDL cholesterol is the form of cholesterol circulating in the blood that can attach to the blood vessel wall and cause further damage/narrowing

•Good care will result in management of all cardiac risk factors including cholesterol levels

•Clinical Goal: an increase in the percent of members with LDL-C controlled


requirement.

Clinical Results

2002

2003

Regence does not have Access to Lab Results

Kaiser Data not Available in 2002

BD attach. 5


226.0

91.8


153.9

127.0Hospital Admits for Members Having a Coronary Event (AMI, CABG, PTCA)


•Preventive treatment should reduce the number of hospital admissions for members with CAD

•Clinical Goal: a decrease in the number of hospital admits per 1,000 for members with CAD

Utilization Results

2002

2003

There is no HEDIS Equivalent

BD attach. 5


65.8

1,315.8

18.2

1,389.1

Carrier Reported Clinical Measures: CHF

0.0

423.4

68.5

14.6

Hospital Days for CHF (per 1,000)

Re-admissions within 90 days (per 1,000)


•There are two goals of treatment for CHF-Minimize patient care-After hospitalization, discharge in a stable condition so that patient is able to self-manage

•Appropriate diagnosis and care during hospitalization and appropriate management as an outpatient will reduce both the number of hospital admissions as well as the number of re-admissions

•Clinical Goal: decrease in both the number of hospital days and the number of re-admissions

Utilization Results

2002

2003

There are no HEDIS Equivalents

BD attach. 5


Carrier Reported Measures

Clinical Measures - Findings• Performance on appropriate screenings and exams

generally improved in 2003

• Utilization results are mixed; additional analysis will be conducted to explain the causes. For example, the increase in CAD hospitalizations may be due to increased use of PCTA’s which is positive.

• Both carriers scored below HEDIS 75th percentile on some measures, however, comparisons with HEDIS are difficult to interpret given the small size of PEBB’s chronic disease populations and differences in methodology

*HEDIS benchmark measures not directly comparable due to HEDIS continuous enrollment requirement

BD attach. 5





BD attach. 5


Summary

• There is clear evidence members with chronic disease experience higher cost and utilization than the population without chronic disease

• Performance on clinical measures generally improved in 2003

• Still too early to evaluate the effectiveness of PEBB’s Chronic Disease Management Program on controlling costs - consistent with current industry knowledge as outlined in the recent Congressional Budget Office findings

• In the early stages of evaluation, performance on clinical measures is a better short-term indicator of the overall effectiveness

• Additional experience is needed to isolate the long-term effect of chronic disease management due to:– Anomalies in 2002 reporting year (consolidation of carriers/plan

design)– Random variations possibly due to the small population being

measured

BD attach. 5


Recommendations for Future Program Direction

• Continue to track prevalence, utilization, cost, and clinical measures over time

• Encourage carriers to demonstrate continuous improvement in program design, participation, and outcomes

• Align current programs with 2007 Vision

• Develop intervention strategies for other conditions prevalent in the PEBB population e.g., obesity and smoking cessation

• Develop metrics and opportunities for collaboration to address depression

BD attach. 5

Documents

PEBB: 1/18/05Prepared by Aon Consulting1 Chronic Disease Management 2003 Annual Report-Highlights PEBB Board Meeting 1/18/05 BD attach. 5