Outcomes and Lessons Learned From Evaluating TRICARE’s Disease Management Programs

Volume 16: 438-446 June 2010 Number 6

Outcomes and Lessons Learned From Evaluating TRICARE’s Disease Management Programs

Timothy M. Dall, MS; Rachel C. Askarinam Wagner, MS; Yiduo Zhang, PhD; Wenya Yang, MPA; CAPT David R. Arday, MD, MPH; and CAPT Cynthia J. Gantt, NC, USN, FNP-BC, PhD

Objective: To share outcomes and lessons learned from an evaluation of disease management (DM) programs for asthma, congestive heart failure (CHF), and diabetes for TRICARE patients.

Study Design: Multiyear evaluation of participants in voluntary, opt-out DM programs. Patientcentered programs, administered by 3 regional contractors, provide phone-based consultations with a care manager, educational materials, and newsletters. The study sample consisted of 23,793 asthma, 4092 CHF, and 29,604 diabetes patients with at least 6 months' tenure in the program.

Methods: Medical claims were analyzed to quantify program effect on healthcare utilization, medical costs, and clinical outcomes. Multivariate regression analysis with an historical control group was used to predict patient outcomes in the absence of DM. The difference between actual and predicted DM patient outcomes was attributed to the program. A patient survey collected data on program satisfaction and perceived usefulness of program information and services.

Results: Modest improvements in patient outcomes included reduced inpatient days and medical costs, and (with few exceptions) increased percentages of patients receiving appropriate medications and tests. Annual per patient reductions in medical costs were $453, $371, and $783 for asthma, CHF, and diabetes program participants, respectively. The estimated return on investment was $1.26 per $1.00 spent on DM services.

Conclusion: Findings suggest that the DM programs more than pay for themselves, in addition to improving patient health and quality of life. Lessons learned in program design, implementation, effectiveness, and evaluation may benefit employers contemplating DM, DM providers, and evaluators of DM programs.

(Am J Manag Care. 2010;16(6):438-446)

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Providing patients with information to manage their medical conditions and encouraging positive change in health-related behavior can lead to improved health and avoidance of costly medical expenditures. The Disease Management Association of America identified asthma, congestive heart failure (CHF), and diabetes among the chronic diseases with the greatest potential for disease management (DM).¹ There is no consensus, however, on whether DM provides the anticipated benefits. Some studies report positive return on investment (ROI),^2-10 whereas others report negative ROI or inconclusive results.^3,11-14

The Military Health System, through the TRICARE program administered by the TRICARE Management Activity (TMA), provides care to 9.2 million beneficiaries at an annual cost of $44.8 billion (FY 2009 budget).¹⁵ Among current beneficiaries under age 65 years residing in the United States, analysis of administrative records suggests that approximately 80,000 have asthma, 11,000 have CHF, and 225,000 have diabetes.

TRICARE Management Activity contracted with its 3 regional managed care support contractors (MCSCs) to provide DM services to high-utilization patients with asthma and CHF beginning in September 2006, adding diabetes in June 2007. Although this voluntary, opt-out DM program is ongoing, the findings presented here are based on analysis of patients contacted through September 30, 2008, who had at least 6 months’ tenure in the program. The 6-month-tenure criterion was to allow sufficient time for the MCSCs to provide DM services. The September 2008 cutoff was to ensure 100% completeness of medical claims. The analysis sample consisted of 23,793 asthma, 4092 CHF, and 29,604 diabetes patients.

STUDY DESIGN

TRICARE Management Activity identifies candidates for DM based on high utilization of disease-related services (emergency and outpatient visits, hospitalizations) and, for asthma, high use of short-acting rescue prescriptions. Patient names are forwarded to the MCSCs to verify eligibility and provide DM services. Some patients choose to fully participate and receive personalized telephonic counseling and educational mailings (referred to as “engaged” patients), whereas others decline personalized care but receive newsletters. Some patients opt out of the program.

The DM content and services follow industry best practices, including (1) an initial 40- to 50-minute baseline assessment by telephone with a care manager; (2) monthly follow-up telephone calls to set goals, assess progress toward those goals, and educate patients about their conditions and self-management; (3) educational materials specific to the patient’s needs (eg, pamphlets, videos, cookbooks); and (4) newsletters and Internet-based materials. All services are educational and are intended to provide patients with disease-specific knowledge and self-management skills. Two MCSCs consider a patient to have “graduated” 12 months after receiving the baseline assessment, while the third considers a patient to have graduated when goals regarding disease understanding and self-management have been met. After graduation, patients continue to receive newsletters and biannual phone contact.

METHODS

Best practices for DM evaluation suggest measuring program effect along 4 dimensions: utilization, financial, clinical, and humanistic.¹⁶ Using an encrypted patient identifier, we electronically linked patient DM administrative records, medical claims, and a patient survey. Study protocols were approved by an institutional review board.

Outcome Metrics

Patient outcome metrics were selected using recommendations of the 2nd Annual Disease Management Outcomes Summit.¹⁷ Utilization metrics (emergency visits and hospital inpatient days) and financial metrics (medical expenditures) for asthma and CHF are disease specific. Claims are counted only when the disease is listed in the first or second diagnosis code position (first diagnosis position only for asthma-related hospitalization and emergency visits).

Only a small portion of diabetes-related medical costs are directly for treatment of diabetes; the majority are associated with complications of diabetes (eg, neurologic symptoms, peripheral vascular disease, cardiovascular disease, renal complications, endocrine complications, ophthalmic complications) and higher use of medical care for general medical conditions.¹⁸ Therefore, for diabetes we report disease-related utilization and cost but focus on total utilization and cost (with claims for injury, pregnancy, congenital abnormalities, and malignant cancer excluded). All medical costs were adjusted to 2008 dollars using the medical component of the consumer price index.¹⁹

Clinical metrics were limited to those available in electronic records and include the percentage of patients receiving an exam or a pharmaceutical in the past year. Asthma metrics were (1) use of long-term controller medications (measured as the percentage of patients with at least 1 dispensed prescription for inhaled corticosteroids, nedocromil, cromolyn sodium, leukotriene modifiers, or methylxanthines); and (2) the percentage of patients with a documented spirometry test. For CHF we determined the percentage of patients with angiotensin-converting enzyme (ACE) inhibitor and beta-blocker prescription fills. Diabetes metrics were (1) the percentage of patients with at least 1 glycosylated hemoglobin (A1C) test, (2) the percentage of patients with at least 1 dilated retinal examination, and (3) the percentage of patients with at least 1 microalbuminuria or clinical albuminuria test.²⁰

Humanistic metrics included patient self-assessment of change in quality of life, improved understanding of both the disease and self-management, and overall program satisfaction.

Data Collection

Patient characteristics and demographics came from the Defense Enrollment Eligibility Reporting System. Healthcare utilization and expenditures came from TRICARE’s Medical Data Repository. These included care provided through TRICARE’s purchased care program and care provided at military treatment facilities. Information on DM services received and patient DM participation status came from the MCSC patient tracking system.

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