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The American Journal of Managed Care August 2014
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Personalized Preventive Care Reduces Healthcare Expenditures Among Medicare Advantage Beneficiaries
Shirley Musich, PhD; Andrea Klemes, DO, FACE; Michael A. Kubica, MBA, MS; Sara Wang, PhD; and Kevin Hawkins, PhD
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Andrew M. Goldsweig, MD; Kimberly J. Reid, MS; Kensey Gosch, MS; Fengming Tang, MS; Margaret C. Fang, MD, MPH; Thomas M. Maddox, MD, MSc; Paul S. Chan, MD, MSc; David J. Cohen, MD, MSc; and Jersey Che
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Personalized Preventive Care Reduces Healthcare Expenditures Among Medicare Advantage Beneficiaries

Shirley Musich, PhD; Andrea Klemes, DO, FACE; Michael A. Kubica, MBA, MS; Sara Wang, PhD; and Kevin Hawkins, PhD
This study investigated the impact of an enhanced preventive care delivery system on healthcare expenditure and utilization trends among Medicare Advantage beneficiaries.
Objectives
To investigate the impact on healthcare expenditure and utilization trends of a personalized preventive care program designed to deliver individualized care focused on disease prevention among Medicare Advantage beneficiaries.

Study Design
MD-Value in Prevention (MDVIP) consists of a network of affiliated primary care physicians who utilize a model of healthcare delivery based on an augmented physician-patient relationship and focused on personalized preventive healthcare. The cost-effectiveness of the program was estimated using medical and pharmacy claims data relative to nonmembers.

Methods
Multivariate modeling was used to control for demographic, socioeconomic, supply of healthcare services, and health status differences between members and nonmembers. Healthcare expenditure and utilization trends for members and nonmembers were tracked from the pre-period prior to member enrollment for a period of 2 years post enrollment.

Results
MDVIP members experienced significantly reduced utilization rates for emergency department visits and inpatient admissions. Reduced medical utilization resulted in program savings of $86.68 per member per month (PMPM) in year 1 and $47.03 PMPM in year 2 compared with nonmembers.

Conclusions
A primary care model based on an augmented physician-patient relationship and focused on personalized preventive medicine can reduce Medicare Advantage healthcare spending.

Am J Manag Care. 2014;20(8):613-620
Personalized medicine is a relatively new healthcare delivery model designed to provide more individualized care focused on disease prevention while delivering high-quality, coordinated care with easy access. The MDVIP program is based on an augmented physician-patient relationship and focused on personalized preventive care. This study investigated the impact of an enhanced preventive care delivery system on healthcare expenditure and utilization trends among Medicare Advantage beneficiaries.
  • Healthcare savings were realized from significantly reduced emergency department and inpatient admission utilization rates.
  • A primary care model focused on personalized preventive medicine can reduce Medicare Advantage spending.
Slowing the rise in Medicare healthcare spending is among the nation’s top health policy priorities. The Congressional Budget Office (CBO) estimates that Medicare spending will grow at an average of 7 percent each year from 2010 to 2018, compared with overall United States inflation rates of about 2 percent from 2010 to 2013.1,2 The pattern of healthcare spending growth, however, has changed dramatically over the past 2 decades. From 1987 to 1997, most spending growth was linked to intensive inpatient services, primarily associated with heart disease.3 In more recent years, much of the growth in spending among Medicare beneficiaries is attributable to rising spending on the management of chronic disease—especially diabetes, arthritis, hyperlipidemia, hypertension, kidney disease, and mental disorders. In addition, the channels of medical spending have changed such that, common chronic conditions are typically treated in outpatient settings and/or with prescription drugs rather than through hospitalizations and inpatient care.3

Among community-dwelling Medicare beneficiaries, more than half are treated annually for 5 or more medical conditions.4 Nearly 7 in 10 Americans aged 65 years or older are living with 2 or more common chronic health conditions. 5 Each year, the typical Medicare beneficiary sees 2 primary care physicians and 5 specialists working in 4 different practices.6 An average of 33% of beneficiaries change their assigned primary care physician from one year to the next. This dispersion of medical care delivery means that chronically ill patients managing multiple conditions receive episodic care from multiple providers who rarely coordinate the care they deliver.4,6

Over the past decade, chronic disease management and care coordination programs proliferated in an attempt to fill this gap. Most of the programs were telephone-based interventions staffed by nurses who develop and update care plans to meet patients’ needs, educate patients about self-care and medication adherence, and monitor patients’ care. In most programs, the disease/care managers are not integrated into physicians’ practices and maintain contact with patients remotely.7 Generally, disease/care management programs use various criteria to target high-cost or high-risk patients.7,8 CMS has tested several demonstrations of disease management and care coordination programs; most have been unsuccessful in reducing medical expenditures (specifically hospitalizations), increasing medication adherence, or improving quality-of-care indicators.8-11

Successful programs tended to supplement telephone calls with in-person meetings, promote direct interactions with physicians, deliver evidence-based education to patients, include strong medication management (often delivered by a pharmacist), and provide comprehensive transitional care after hospitalization.8-13 CMS concluded that programs that reduced hospitalizations tended to target a subset of high-risk beneficiaries based on a combination of diagnoses and severity levels. Diagnoses included congestive heart failure, chronic obstructive pulmonary disease, or coronary artery disease, and severity included the criterion of 1 or more hospitalizations in the year before enrollment.8

As the targeting of “successful” disease- and care-management programs has narrowed, the concept of population health management among older adults has been less effectively addressed by the stakeholders of interest. Issues include development and scalability of appropriate programs, marketing to a geographically dispersed group of older adults, and financing of broader population-based programs. The importance of health management among those seniors with fewer or no chronic conditions has been demonstrated in actuarial models developed to test the impact of population health and wellness interventions on healthcare expenditures.14 Beneficiaries were categorized using a claims-based risk score assessing the burden of chronic disease (CMS-Hierarchical Condition Category Score) as a proxy for health risks.14,15 The distribution of risks within the population predicted that as individuals age, they shift into progressively higher risk categories. Lessons learned from employer health management programs serving employees could be applied to senior populations. Successful population risk management depends on health strategies that include not only the management of high-risk, high cost individuals, but preventive health programs to maintain low-risk health status in other individuals and keep them functioning well for as many years as possible.16,17 Research has demonstrated that those who manage their health well as they age are able to delay the onset of chronic disease and disability by several years.17-20 Each additional year spent at low-risk health status results in higher quality of life for the individual and lower spending for the medical system.14

Individualized medicine, a relatively new approach to healthcare delivery, seeks to address the issues of coordinating care and providing preventive care to senior populations. 21-23 The model integrates personalized preventive medicine and wellness management while delivering high levels of coordination within the treatment milieu. The delivery system includes greater focus on evidence-based preventive services, increased physician availability to improve management of patient health, and increased access to other healthcare resources.22 As CMS continues to consider medical service delivery models that have the potential to mitigate Medicare spending, the effectiveness of an enhanced preventive health delivery model will be of considerable interest. 

The purpose of this study was to investigate the impact of a model of preventive healthcare delivery designed to provide more personalized care focused on disease prevention within a Medicare Advantage population. Primary outcomes compared 1) utilization of healthcare services tracked from baseline over the next 2 years, and 2) healthcare expenditure trends over the same time period for members and nonmembers.

METHODS

MDVIP Practice Model

MD-Value in Prevention (MDVIP) consists of a network of affiliated primary care physicians who utilize a model of comprehensive healthcare management based on an augmented physician-patient relationship and focused on personalized preventive healthcare. The MDVIP model delivers health screenings (eg, depression, anxiety, sleep, nutrition, sexual function, vision, and hearing) and diagnostics (eg, testing for diabetes, bone disease, and cardiovascular disease) for a membership fee (paid by the member) of $125 to $183 per month.21,22 Practices are limited to no more than 600 patients per physician to allow for the added time and resources for the physician to deliver the additional services and to provide the personalized attention required for management of each patient’s relevant health issues. With smaller practice sizes, members receive same-day or nextday appointments for urgent and non-urgent care and the ability to reach their primary care physician 24 hours a day. The network currently includes over 600 doctors and over 200,000 patients nationally. Affiliated physicians have an average age of 58 years; 70% are internists and 30% are family practitioners. The average age of members is 66 years; 40% to 45% are enrolled in Medicare plans. 

The model is not a third-party payer (ie, health insurance does not cover the monthly fee) and the fees cover only the extended prevention and wellness services provided by the primary care physician (PCP). Members, therefore, still pay via conventional mechanisms (eg, health insurance) for inpatient and outpatient visits, services provided by specialists, and other medical services (eg, radiological and laboratory tests). Members benefit from an annual wellness program visit, 60 to 90 minutes long, that is modeled after the comprehensive physical typically included in an executive healthcare package. This annual wellness program includes proprietary blood panels, diagnostic tests, screens, and hands-on evaluation.

The model’s underlying premise is that the focus on prevention and wellness, and the additional attention from and access to physicians (ie, higher quality of care delivery), will lead to better health status, lower emergency department (ED) and hospital utilization, and ultimately lower healthcare expenditures. Table 1 summarizes key distinguishing characteristics of MDVIP practices compared with traditional practices as experienced by Medicare Advantage beneficiaries.

Study Population

MDVIP Members. Members were identified from UnitedHealthcare Medicare Advantage databases using 2007- 2012 enrollment files provided by MDVIP. Eligibility for this study was defined as 65 years and older (Medicareeligible), or 64 years or younger and on Medicare medical disability and having continuous health plan membership with a minimum of 3 months prior to MDVIP enrollment during 2009 and a minimum of 18 months post enrollment 2009-2012.

MDVIP Nonmembers. Nonmembers were identified from UnitedHealthcare Medicare Advantage databases. To control for physician selection bias, nonmembers were identified from patient lists of affiliated physicians prior to their becoming MDVIP network physicians. MDVIP maintains an exclusive contract with their affiliated physicians; thus, former patients who did not become members when their physicians transitioned to the MDVIP model of care qualified as controls. Eligibility for nonmembers was similar to members and distribution and continuous health plan membership with a minimum of 3 months prior to a matched range of enrollment dates (2009) with a minimum of 18 months̕ followup (2009-2012).

Control Variables. Control variables included member demographic (including age, gender, plan type, region of the United States, and residing, or not, in a Metropolitan Service Area [MSA]), socioeconomic (eg, income, and local concentration of health services, including number of acute care hospital beds, specialists, and primary care physicians), and health status (eg, Charlson Comorbidity Index [CCI] score, Psychiatric Diagnostic Group [PDG] score, and number of inpatient admissions in the pre period. Non-MDVIP Medicare Advantage plan types included exclusive provider organization (EPO), health maintenance organization (HMO), indemnity, point of service (POS), preferred provider organization (PPO), and others. Region of the United States was based on zip code and assigned as Northeast, Midwest, South, or West. Annual income was inferred as high (>$45,809), medium-high (≥$36,250 and <$45,809), medium (≥$29,875 and <$36,250), or low (<$29,875), based on whether the median income in the individual’s zip code area was in the highest, second-highest, third-highest, or lowest quartile in 2010, according to US Census records. MSA was defined as living in a metropolitan area population (≥50,000), or other. Supply of healthcare services was defined based on the number of PCPs and specialists (per 100,000) and hospital beds (per 1000) in the member/ nonmember zip codes of residence.24 

 
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