Medicaid Disease Management No Impact on Emergency Room Utilization or Inpatient Costs for Enrollees with Diabetes

Regular readers of the Disease Management Care Blog know that Medicaid is coming. While many of the nations Governors have declined President Obamas invitation to run Medicaid the Affordable Care Act way, others have agreed to use the ACAs generous funding to enroll millions of their indigent citizens into this vastly expanded public insurance program.

"No problem!" says the disease management vendors.  For years, theyve been offering their services to state Medicaid programs and would be happy to expand their contracts.

Unfortunately, an article by Matthew Conti that was just published in the journal Health Services Research suggests that that may not be a good idea.  The articles title is Effect of Medicaid Disease Management Programs on Emergency Admissions and Inpatient Costs.  The only thing thats missing are the words "The Lack of Any" at the front of that sentence.
   
The article studied the impact of diabetes "opt-out" disease management on diabetic patients emergency room utilization and admissions in three states Medicaid programs: Washington (started in 2002), Texas (started in 2004), and Georgia (started in 2005).

These states with were compared to states without diabetes disease management.  These control states were selected on the basis of baseline Medicaid enrollment trends that were similar to the three study states. These control states were Hawaii, Kentucky, Massachusetts, Maryland, Maine, North Carolina, Nebraska, South Carolina and Tennessee.

To perform the comparison, Dr. Conti used the Agency for Health Care Research and Qualitys (AHRQ) National InPatient Sample (NIS) from the Health Care Cost and Utilization Project ("HCUP"). These databases contain patient-level and longitudinal hospital information on inpatient stays, including cost, payer, admission type (e.g., emergency, urgent and elective), age, gender, primary payer, and total charges. The span of data that was used went from 2000 through 2008.

A complicated pre-post "difference in differences" model was used to compare baseline vs. follow-up:

1) total inpatient charges/Medicaid enrollment (which averaged $430 per diabetic enrollee, with a 95% confidence interval of $265 to $700) and

2) emergency admissions/inpatient admissions (a ratio of 0.37 per admission with a standard deviation of plus or minus 0.12)  All Medicaid enrollees with diabetes were included in the analysis, whether or not they had been enrolled or opted out.  The author used this approach figuring that if a statewide disease management program enrolled up to a third of eligible persons with diabetes (that was the case in Texas), there should have been an observable impact on the entire population. Thats the approach favored by the Disease Management Purchasing Consortium.
 
The results?  No state with disease management had lower emergency room utilization or inpatient costs for their Medicaid enrollees with diabetes. The DMCB couldnt find a table with numbers, but the figures (which cant be reproduced without permission) show little impact over time.

What can readers conclude?  Assuming that, during the period of study, the three states Medicaid programs suffered from the programs endemic issues of underpayment to providers with a relative lack of access to primary care:

1. "Blanket" call-everyone telephonic disease management cannot make up for fee-for-service Medicaids shortfalls.  It remains to be seen if the ACAs revitalization of Medicaid will make up for this and increase the parallel impact of disease management. 

2) This also means that Medicaids experience with disease management cant be generalized to other types of insurance with better provider payment rates and patient access to care.

That being said, the DMCB has two concerns:

1. If the DMCB is reading this right, it appears all persons of any age with diabetes were included in the study, including Type 1 diabetics.  If thats correct, that could have also blunted the impact of any disease management program, since children are over-represented in Medicaid and the impact of remote telephonic coaching in Type 1 is widely viewed (even among the disease management vendors) to be ineffective.  Insulin-requiring kids need lots of face-to-face hands-on care.

2. The DMCB is unfamiliar with the three study states disease management programs, but if they were set up the "old fashioned way" to contact all persons with diabetes without the modern regard to future risk and "impactibility," then its little wonder that the programs failed.  State-of-the-art population health management tailors its programs by focusing on subsets of persons with chronic conditions that are most likely to benefit.  Any impact on emergency room use or inpatient charges for these patients would be lost in the data "noise" of everyone elses utilization.

Should Medicaid programs that are facing huge jumps in enrollment abandon Medicaid as a result of this study?  Based on this study, the DMCB doesnt think so.  The findings are interesting, but more research is needed.

Diet may not impact certain health outcomes in older persons

Eating diets high in sugar and fat may not affect the health outcomes of older adults ages 75 and up, suggesting that placing people of such advanced age on overly restrictive diets to treat their excess weight or other conditions may have little benefit, according to researchers at Penn State and Geisinger Healthcare System.

"Historically people thought of older persons as tiny and frail," said Gordon Jensen, head of the Department of Nutritional Sciences at Penn State, "but that paradigm has changed for many older persons. Currently, 30 percent or more may be overweight, and by 2030, almost 30 percent are projected to be obese, not just overweight. Recent reports even suggest that there may be survival benefits associated with overweight and mild obesity status among the elderly."

"We all know that adverse dietary patterns, such as a Western diet containing high amounts of fat or a diet containing high amounts of ined sugar, both of which may contribute to obesity, are associated with adverse medical conditions and health outcomes for many people, but until now, the health effects of these types of poor diets have not been characterized for people who live to 75 years of age and older," said Pao Ying Hsao, postdoctoral fellow at Penn State.

The teams research is part of a decades-long collaborative study between Penn State and the Geisinger Healthcare System on the effects of nutritional status and diet on the health of more than 20,000 older people living in Pennsylvania. In the current study, the team followed 449 individuals for five years who were on average 76.5 years old at the beginning of the study.

"This is one of the first studies to examine obesity-related health outcomes and dietary patterns in such aged persons," Jensen said.

At study baseline, the team assessed the participants dietary patterns by calling each of them by telephone four or five times during a 10-month period and asking them about their diets over the previous 24 hours. The participants were categorized as adhering to one of three different dietary patterns. The "sweets and dairy" pattern was characterized by the largest proportions of energy from baked goods, milk, sweetened coffee and tea and dairy-based desserts, and the lowest intakes of poultry. The "health-conscious" pattern was characterized by relatively higher intakes of pasta, noodles, rice, whole fruit, poultry, nuts, fish and vegetables, and lower intakes of fried vegetables, processed meats and soft drinks. The "Western" pattern was characterized by higher intakes of bread, eggs, fats, fried vegetables, alcohol and soft drinks, and the lowest intakes of milk and whole fruit.

Using outpatient electronic medical records, the researchers identified whether the participants developed cardiovascular disease, diabetes mellitus, hypertension (high blood pressure) and metabolic syndrome during the five-year period. They found no relationship between dietary pattern and prevalence of cardiovascular disease, diabetes, metabolic syndrome or mortality in the participants; however, they did find an increased risk of hypertension in people who followed the "sweets and dairy" pattern.

The results appeared in this months issue of the Journal of Nutrition Health and Aging.

"We dont know if the participants had been following these dietary patterns their entire adult lives, but we suspect they had been because people dont usually change dietary practices all that much," Jensen said. "The results suggest that if you live to be this old, then there may be little to support the use of overly restrictive dietary prescriptions, especially where food intake may already be inadequate. However, people who live on prudent diets all their lives are likely to have better health outcomes."