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Value of Primary Care Diabetes Management: Long-Term Cost Impacts
Daniel D. Maeng, PhD; Xiaowei Yan, PhD; Thomas R. Graf, MD; and Glenn D. Steele, Jr, MD, PhD
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Value of Primary Care Diabetes Management: Long-Term Cost Impacts

Daniel D. Maeng, PhD; Xiaowei Yan, PhD; Thomas R. Graf, MD; and Glenn D. Steele, Jr, MD, PhD
Geisingerís all-or-none diabetes bundled system of care implemented in routine primary care settings was associated with sustained long-term total cost savings.
ABSTRACT

Objectives: To estimate long-term cost savings associated with patients’ exposure to an all-or-none bundle of measures for primary care management of diabetes.

Study Design: In 2006, Geisinger’s primary care clinics implemented an all-or-none diabetes system of care (DSC). Claims data from Geisinger Health Plan were used to identify those who met Healthcare Effectiveness Data and Information Set criteria for diabetes and had 2 or more diabetes-related encounters on different dates before 2006. A cohort of 1875 members exposed to the DSC was then compared against a propensity score matched non-DSC comparison cohort from January 1, 2006, through December 31, 2013.

Methods: A set of generalized linear models with log link and gamma distribution was estimated. The key explanatory variable was each member’s bundle exposure measured in months. The dependent variables were inpatient and outpatient facility costs, professional cost, and total medical cost excluding prescription drugs measured on a per-member-per-month basis.

Results: Over the study period, the total medical cost saving associated with DSC exposure was approximately 6.9% (P <.05). The main source of the saving was reductions in inpatient facility cost, which showed approximately 28.7% savings (P <.01) over the study period. During the first year of the DSC exposure, however, there were significant increases in outpatient (13%; P <.05) and professional (9.7%; P <.05) costs.

Conclusions: A system of care with an all-or-none bundled measure used in primary care for patients with diabetes may reduce long-term cost of care while improving health outcomes.

Am J Manag Care. 2016;22(3):e88-e94
Take-Away Points
 
Despite the availability of evidence-based clinical guidelines, unwarranted variation in diabetes care remains.
  • Since 2006, Geisinger’s primary care clinics have implemented an all-or-none diabetes bundled system of care. A recent study has shown that the intervention was associated with improved health outcomes. This study examines its impact on cost of care.
  • The first year of the system exposure was associated with higher outpatient and professional costs. Subsequent years of exposure were associated with lower total cost, driven by reductions in inpatient costs. 
  • Standardization of care process may simultaneously improve patient health outcomes while reducing cost.
Despite the existence and availability of effective clinical guidelines for treating diabetes,1-3 wide variability in the treatment patterns of patients with diabetes remains,4-8 resulting in adverse health outcomes and incurring avoidable care and cost.9,10 Reducing unjustified and nonpatient-centered variations in care, therefore, via a comprehensively redesigned system of care tuned to deliver all of the care needed to every patient at every encounter, can lead to both improved patient health outcomes and avoid expensive “downstream” care.

An increased focus on standardization is likely to increase the reliability of care delivery. One such effort to standardize care is Geisinger’s diabetes system of care (DSC). Geisinger has redesigned its care system to allow physicians to focus on “physician work” (ie, complex medical decision making, and patient relationships and leading staff members functioning in a top-of-license team). This physician-directed, team-delivered care is facilitated and enhanced by hard-wired technology accelerators available in primary care clinics.11 The care team is a standard office complement involving physicians, advanced practitioners, and front-office staff. Staffing ratios are approximately 2.25 nonproviders to 1 physician or advanced practitioner. This system of care allows the team to focus on an all-or-none bundle that consists of quantifiable measures of care based on commonly accepted clinical elements and intermediate outcome targets (summarized in Table 1) that can be easily implemented during routine primary care visits and are associated with improved outcomes for the patients.12-14

The DSC is a practice-level intervention that changes how care is delivered to all patients with diabetes treated within a primary care practice site. Thus, in this study, all primary care physicians and healthcare providers are employed by Geisinger, are practicing in one of the primary care sites owned by Geisinger, and are subject to the DSC. Operationally, the DSC specifies delegated accountable responsibilities for each team member, with the goal to develop work flows that are measurable and reliable—not dependent on the diligence of individual providers. To this end, DSC emphasizes automation of routine care processes (eg, a provider decision support system built directly into patients’ electronic health records [EHRs], automatically generated patient report cards [to be shared with patients during office visits], and automatic updates to the patient registry).

The DSC also includes monthly feedback, active physician leadership, and administrative leadership management of performance and incentive payments to the primary care team, based on the proportion of the team’s population of patients with diabetes who achieved all of the process and intermediate outcome measures. Furthermore, these feedback reports are made available to all other physicians/teams within Geisinger to encourage improvements among lower-performing teams. One study12 has shown that during the 3-year period following the first implementation of the DSC in January of 2006, patients with diabetes whose physician-led care teams had implemented the DSC experienced lower rates of myocardial infarction, stroke, and retinopathy. For more detailed descriptions of the DSC program elements and their implementation, refer to previously published studies.12,15,16

In this study, we built upon this previous work and sought to quantify the impact of these improved health outcomes by estimating any cost saving associated with patients’ exposure to the DSC. More specifically, we tested the following 2 hypotheses: 1) during the first year of the DSC exposure, the cost of care will be higher for the DSC-exposed patients than it is for the non–DSC-exposed patients, due to increased adherence to the clinical guidelines (eg, frequent testing, aggressive medication optimization); and 2) in subsequent years, cost of care for the DSC-exposed patients will be lower. In testing these hypotheses, we separately examined the association between the DSC and each of the main cost components—namely, inpatient, outpatient, and professional costs—and sought to determine the main sources of savings.

METHODS
Data

Claims data from Geisinger Health Plan (GHP) covering the period from January 1, 2005, through December 31, 2013, were obtained. We used claims data rather than encounter-based EHR data because claims data provide the comprehensive summary of all types of care used by patients during the coverage period, whereas the EHR data may omit certain types of care (eg, emergency department visits, inpatient visits) if they occurred outside of the Geisinger Health System. Moreover, claims data provided “allowed” amounts (ie, health plan payments to providers plus member out-of-pocket expenses via co-payments, coinsurance, and deductibles). For the purposes of this study, we defined "cost of care" as the allowed amounts incurred by each member in each month of the study period. To the extent that the allowed amounts represent the “price” of the care rendered by the provider for the member, we believe the allowed amounts serve as a reasonable proxy for the true cost of care.

The date of the first full implementation of the DSC across all Geisinger primary care clinics was January 1, 2006. The study population was, therefore, confined to those who had GHP coverage for at least 6 months before and after January 1, 2006, to ensure that care experiences both before and after the DSC implementation were captured. To define the diabetes patient population, the Healthcare Effectiveness Data and Information Set criteria were used.17 The study population was then further restricted to those 18 years or older between 2006 and 2013 and who had at least 2 claims with an International Classification of Diseases, Ninth Revision, Clinical Modification code for diabetes (250.x) on different dates before 2006 to ensure that the study sample consisted only of those who were eligible for the DSC intervention. Within the study population, GHP members were grouped into either the intervention group (defined as those who received primary care from a physician office that used the DSC as of January 2006) or the comparison group (defined as those whose physician office did not).

Over the study period, some members moved in and out of the sample depending on their GHP enrollment in each year. Also, some members switched between the intervention group and the comparison group. In cases where a member had switched from a primary care practice using the DSC to one not using it, such members were excluded from the analysis because they were assumed to have been contaminated by the DSC intervention. In other cases where a member had switched from a practice not using the DSC to one using it, the month that switching occurred was considered as the first month that he or she was exposed to the DSC intervention.

A logistic regression model was developed to estimate a propensity score for each member, in which member age, gender, and Charlson comorbidity index score18 (as of December 2005) were included as covariates. These pre-DSC period data were obtained from the members’ GHP claims data for calendar year 2005. We then used the nearest-neighbor propensity score–matching method with a caliper of 0.2 (± 0.2 of the standard deviation of the propensity score) to find 1-to-1 matched cohorts. The final sample included 1875 members in the DSC intervention cohort and the same number of members in the comparison cohort. Also, there were 454 members who could not be matched to the intervention cohort and, therefore, were not included in the analysis. These members tended to be younger, have fewer chronic conditions, and were more likely to be male than the matched cohorts. See the eAppendix (available at www.ajmc.com) for a comparison across these 3 groups using the available pre-DSC data (2005). Moreover, there were 59 primary care practices that had adopted the DSC and 564 that were never represented in the final sample. The latter number was higher than the former because the comparison cohort was drawn mostly from smaller independent practices not owned by Geisinger.

Statistical Analysis

A set of generalized linear models with log link and gamma distribution was estimated. In all models, the key explanatory variable was each member’s length of exposure to the DSC at a given month during the study period, measured in terms of the number of months during which the member had received care from any of the primary care practices using the DSC since January 2006. Other covariates included in the model were member age, gender, case management status, plan types (Medicare health maintenance organization [HMO]/preferred provider organization [PPO], commercial HMO/PPO), comorbidities (chronic kidney disease, end-stage renal disease, asthma, congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, hypertension, cancer, and depression), GHP prescription drug coverage status (ie, whether the member has drug coverage through GHP or not), and year and month indicator variables.

Case management in this context refers to GHP’s nurse-based management of a high-risk patient population, which may confound the DSC effect because some of the members in the sample were also enrolled in the case management program. The drug coverage status variable accounts for the fact that not all members in the sample obtained drug coverage through GHP. To the extent that access and utilization of prescription drugs affect utilization of other medical care, the DSC effect may also be confounded by the drug coverage status. Additionally, another potential confounder is the impact of Geisinger’s advanced medical home model known as ProvenHealth Navigator (PHN), which has been shown to be associated with lower cost of care.19 To capture this confounding medical home effect, the regression model also includes a PHN exposure variable, as previously defined and used in the analysis by Maeng and colleagues.19

The dependent variables were inpatient and outpatient facility costs, professional cost, and total medical cost (excluding prescription drugs), measured on a per-member-per-month (PMPM) basis. Cost of care in this case was defined as the “allowed” amount (ie, the sum of GHP’s payment to providers plus member out-of-pocket cost sharing). Prescription drug costs were not separately considered because, as noted above, not all members in the sample obtained drug coverage through the GHP; therefore, drug cost data were incomplete. A small positive value (0.0001) was added to all the dependent variables to ensure that the 0 values were not dropped from the analysis due to the log-link function.

 
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