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.

The Important Look AHEAD Action for Health in Diabetes Study No Benefit from Exercise and Weight Loss in Diabetes

Diabetes? Exercise and then die just as soon.

It makes sense, doesnt it? If persons are overweight and have diabetes, diet and exercise-based "prevention" should translate into fewer heart attacks, strokes and deaths, right?

Wrong.

It turns out that a just-published and high quality research study shows its not so simple.  Whats more, the Disease Management Care Blog brazenly suggests that the disease management/population health vendors discovered this years ago.

The just-published study is here in the prestigious New England Journal of Medicine. The DMCB suspects that, thanks to the mainstream medias fixation on Snowden, SCOTUS, and Shakira possibly hawking Obamacare, this important research may not get the front-page attention it deserves.  Considering that it was ten-year, prospective, randomized multi-center academic study involving over 5000 patients, thatd be a shame.

Heres the DMCBs summary:

Eligibility: Participants had to be between 45 and 75 years of age with adequately controlled (A1c less than 11) "type 2" diabetes, an "overweight" body mass index (BMI) of 25 or more, blood pressure less than 160/100, an ability to exercise and access to a primary care provider. 

Recruitment: This went from August of 2001 through April of 2004. It was also tailored to keep insulin-using participants to less than 30% of the study group.

Interventions That Were Compared: Participants were randomly assigned to an "intensive lifestyle intervention" study arm or a "support and education" study arm.  The intensive group received weekly group and individual counseling for six months that subsequently tapered over the subsequent duration of the study. The counseling included a 1200-1800 calorie diet plus 175 minutes of moderate physical activity per week that was aimed at achieving a weight loss of at least 7% of body weight.  The support group got only three group sessions per year. Medicines and their doses were generally left to the primary care provider.

Outcomes Studied: Participants waist circumference, weight, blood pressure, medications and exercise tolerance were assessed once a year. Hospital and other medical records were reviewed to assess the number of deaths and cardiovascular events, such has heart attack or stroke.

The Study Population: 5,124 persons were enrolled; 2570 were randomly assigned to the intensive group while 2575 were assigned to the support group. The average age was 59 years, 60% were women, the median duration of the diabetes diagnosis was 5 years and the average body mass index was a hefty 36. Only 4% were lost to follow-up.

Outcomes:  After a median of 9.6 years of follow-up......

• patients assigned to the intensive group lost approximately three cm. from their waist and six kg. in weight vs. zero cm. and four kg., respectively, in the support group. This translated to a weight loss of 6% of body weight (vs. the target of 7%) in the intensive group vs. about 3.5% in the support group.

• the A1c, which is a test of overall blood sugar control, was about two tenths of a point (7.4% vs. 7.2%) lower (i.e. better) in the intensive group. LDL cholesterol was also lower. Better control of the diabetes meant that the persons in the intensive group were taking fewer medicines at lower doses.

• But it was all for naught.  During the course of the study, there were 403 cardiovascular deaths, non-fatal heart attacks or heart-related ("angina") hospitalizations in the intensive group, vs. 418 in the support group. The calculated rates of 1.8 vs. 1.9 events per 100 person years was too small to be statistically significant and was more likely the result of chance or randomness.

The Disease Management Care Blogs take?

The early painful lesson of the "disease management" industry was that a broad life-style intervention applied to a large group of diabetics was not going to meaningfully improve outcomes. Critics believed that while the interventions were conceptually sound (diet, exercise, weight loss), the delivery was flawed. 

This just published NEJM study would suggest the intervention itself is futile. If so, that is bad news.

"Not so fast!" says the DMCB.

In addition to renaming itself (now "population health"), the industry responded to the science and the critics by retooling.  It learned to channel tailored interventions at population sub-segments who are most likely to experience a specific benefit. Instead of an "intensive" weight loss intervention for all overweight diabetics, population health can use baseline survey, insurance or clinical data to spot (risk stratify) those diabetics who are most likely to achieve a specific benefit that could range from (for example) a sustained 7% weight loss to reduced readmissions.

This NEJM study tried to benefit all diabetics.  A better approach is to find which diabetics will benefit.

As an aside there were some other issues with the study to bring up when debating the study with colleagues and foes:

The BMI of 36 suggests this was a very obese study population that lost only 6% of their body weight during the course of the study.  Since weight was still a health risk at the end of the study, the DMCB wonders if the intervention would have shown more benefit with a less heavy population.

The support group also lost weight and lowered their A1c, which could have obscured the clinically significant benefit in the intervention group. 

This accompanying editorial points out that lower statin and ACE drug use in the intervention group could have paradoxically increased their risk, since these drugs are known to lower the incidence of stroke and heart attack.

The editorial also points out that spin-off studies have already shown that the intervention group benefitted from higher quality of life.

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Low Calorie Diet Extends No Age

It seemed everyone wanted to live long and stay healthy. So, anything will be done to keep the body young. One way is to implement a low-calorie diet. However, recent studies refute it.

National Institute on Aging (NIA) in the United States conduct long-term studies on rhesus monkeys on the effects of a low calorie diet for longevity possible. As a result, this diet can indeed prevent some diseases, but it does not prolong life.

The belief that a low calorie diet can extend the life originated in a study in 1934. At that time, mice, yeast, fruit flies and roundworms fed with calorie content 10-40% lower can live 30% longer. In fact, in other studies, these animals lived twice as long. Since then, many believe that calorie restriction can create longevity.

To prove the truth, two separate research teams using rhesus monkeys. NIA research began in 1987, while researching Wisconsin National Primate Research Center (WNPRC) beginning two years later. Rhesus monkeys selected as physiology, genetics, and the median lifespan (27 years) is more closely related to humans than mice used in the study first.

Apparently the end result is different. In 2009, research showed that 80% WNPRC free monkeys eat anything dead from diseases like diabetes, cancer, and heart disease. This figure is higher than the monkeys that restricted calorie intake, is 50%. And they concluded that caloric restriction slows aging in primates.

NIA research just mentioned that monkeys do not consume fewer calories live longer than other monkeys. This also applies to the monkey who started this diet from the age of 1-14 years. NIA scientists say that they are likely to live longer than the monkey that is not limited to food less than one tenth of 1%.

In fact, the health of the monkeys who started calorie restriction since young worse than those who start as adults. In addition, animals that reduce calorie intake from childhood more died of disease unrelated to aging than the animals that eat just about anything.

You could say that the animals are restricted calorie intake more healthy. Cholesterol levels, loss of muscle mass, as well as a lower risk of disease, but that does not mean theyll live longer. From this study we can see that health and longevity are not interconnected.