TheFacesof MedicaidIII

1 The FacesofMedi cai d III :Ref iningthePo rt ra it ofPeople wi th Mul tip leChronicConditi onsOc to ber 2009 Made possible withsupportfromKaiserPer manente. 2009 Centerfor HealthCare Kronick,M. Bella, Faces of MedicaidIII : Refiningthe Portraitof Peoplewith HealthCare Strategies,Inc., tho ,PhDUni ver sit y of Calif ornia ,Sa n DiegoMelanieBellaCent er for He alth Ca reSt ra ,PhDUni ver sit y of Calif ornia ,Sa n DiegoEd it er for He alth Ca reSt ra tegiesWe are in debt ed to th e vision ary le ader ship at Kai ser Permanenteforrec ogn iz in g the nee d to uncov er the fa ces of Medic aid s hig hest-need populati ons . In pa rti cu lar , Ra y Ba xte r has beena critic alsupporte r of our work to de velop more effe cti ve ways to ca re for Medicaid smostcomplex ne ed ben efi ci ar ies.

2 We al so rec ogn ize Da ve Baugh and Wil liamClark at th e Ce nt ers for Medi care and Medicaid Servi ces fo r providing acce ss tothe MA X data for thi s anal ys is . At CHCS,Stephen Som ers and Al lison Ham blinpr ovi ded va lu able fe edback in the des ign of th e ana lysi s and pres entation ofthe findi ngs and Mi ch ael Can on ico helpedwith fi na l pac kagi ng of th e re por la stl y, we applaud the pi one eri ng effortsof Medica id sta keholdersinColora do, New Yor k, Pe nn sy lv ania , and Wa shingtonStatewho are pil oti nginn ovat ive approache s for hi gh-n eed, high-costbeneficiaries th roughCHC S Re th inki ng Ca re Program. It is ou r hopethat the findingshereininspirean dgu ide addi ti on al st ate s in de si gnin g moreac coun ta ble systems of care foradu lt s with chr oni c ph ysi cal an d se ri ous menta l C K N O W L E D G E M E N T S Tab le of Con te nt sFor ew ord.

3 1 Introd ..3 Data and Metho ds ..6 Res ul ts ..7 Concl us ion ..21 Appe ndi ces ..22 Indexof Exhibits ..26Fo rewordThe Ce nte r for Hea lth Car e Str ate gi es (CHCS)is ple asedto publ is h this la test issuein itsFace sofMedicaidser ie s with ongoing su pp ort from KaiserPer ma ne nte and the Rob er t WoodJoh nsonFo und at ion. Eachit erat ion has broughtwar ran ted at te nti on to the com ple xity ofMedicaid s high -n eed,high-cost populations and the challe nge s inhe ren t in desig nin g cost -effective syst ems of carefor the m. TheFacesreportsha ve he lped dri ve CHCS eff or ts to ret hinkcare for these ben efic iar ies throu gh it s policyana lyses,te chni ca l ass is tance, and rigor ous sta te -bas ed rese ar ch and dem onstration the spir it of con tinuousle ar nin g, we ar e excit ed to publishFac es ofMedicaidIII.

4 Wit h theins igh tful an alysis of Ri ck Kr onickand ToddGilmer,our research partn ers at the Universit y ofCaliforn ia , San Diego(UCSD),we now ha ve a clear er an d mor e co mpe ll ing pictur e of the ag ed ,bl ind, and disab led (ABD)populationthat re vealsmaterial ly hig her pr ev alencerate s forbe haviora l healt h and car diovascular disease, as we ll as incre as ed rates of com orb idit y. Theorigi na lFaces IIex ami ned one yea r of diagnostic dat a for adu lt Me di ca id ben efici aries and, inso do ing , be ga n to ident ify pr evalence an d patt ern s of chron ic co nd it io ns wit hin this hig h-n eedpo pulatio n. Th is new ana lys is addstwo sets of data one year of pharmacy cl ai ms an d fou rye ars of diagnost ic data and providestwo se pa rat e ana lyse s of these da ta set s.

5 Wit h th eadditio n of pha rmacydata , the nu mbe r of ben eficiarie s wit h thr ee or mo re ch ron ic condition sincr ease s fro m 35% to 45%in com pa risonto theFacesIIan al ysis. In ex pa nd ing th e origin aldi agn ost ic da ta se t fromone yea r to five year s of data , the pe rce nta ge of individuals wit h thr eeor mo re ch ron ic conditionsrise s evenmoredra mat icall is wel l kn own th at a sm all subsetof Medicaid smoreth an 60 mi llio n bene fic ia ries hasde ma nd in g and costlyheal th car e nee ds. De velopinga clea re r pic tur e of th ese in div id uals is acom plic at ed task for stat es and heal th plansre sponsiblefor ma na ging ca re for mil lion s ofbe nef iciar ie s. We com men d our research partners at UCS D for thei r sk il lf ul examination of th edat a on Med ica id s hig hest -n eed, highest-costbeneficia ries.

6 As a nex t step, CH CS plans to workwith th em to in ve sti ga te re admissionrates for th is population in order to he lp id en tify th erel at io nship bet weenspecific cl usters of comorbi dit y and the lik eli ho od of rea ar eal so plan ning fur ther stu dy to inve stigateopportun itie s for impr ovi ng ca re for adults who haveph ysicalco mo rbid iti es alongwith ser iou s men tal illn tr ust th at ot hers in the fi eld wi ll find this lat est ana lysis,an d, thes e futu re re sea rch dir ect io ns,as excit in g as we do. Mor e important ly, we hope that thesefi ndin gs wi ll help st ate and fe de ralpo licymake rs, and thosewh o ar e rede si gn ing pr ogr ams at th e gro un d lev el, cr eat e bet tersys te ms of ca re fo r theseben efici arie eph en A.

7 Some rs, PhDPr esidentandCEO,Centerfo r HealthCareStrategiesTH E FACES OF MED ICAIDIII: REF ININGTHE PORTRAIT OF PEOPLEWIT H MUL TIP LE CH RONICCONDITIONS1 FacesIII: Ke y FindingsPhar ma cy Da ta Anal ysi sAddingpharmac y data to th e diagnosticdata use d in th e earlie rFac es IIanalysisco ns ider ably enhance s th e pict ur e of complex comorbidities amongMedicaidbeneficiar ies with disabilities. Follo wing ar e key fin dings: The addition of pharmacy data inc re ases the proportionof Medicaidbeneficiarieswit h dis abilit ies diagnosed wit h th ree or mor e chr on ic condit io ns fr om 35% to 45%ov er diagnostic data alon e. Addingpharmac y data to diagnostic data sign ificantlyincr easesth e fr equencyofps yc hiat ric illnessam ong Med icaid beneficiaries with disabilities fr om 29% to 49%ve rs us sole ly lo okin g at diagnostic ilarly,the pre vale nce of car di ovasculardis eas e inc re as es from 32% to 44%.

8 Wit h the addit ion of pharmacy dat a, costs for Medicaid-only beneficiaries withthr ee or mo re chro nic conditions incre ase fr om 66% to 75% of total spendingforbeneficiar ies with disabilities. Wit h the addit ion of pharmacy dat a, psychiatric illnessis repr esen ted in thr ee ofthe to p fiv e most prev alen t pa irs of diseases,or dyads,amongthe highest-cost5% of Me dicaid-only ben ef iciarieswit h disabilities;in lookingat diagnosticdataalo ne, ps yc hiat ric illn ess was not amongthe top five pairs. A few pair s of diagnoses de mo nstrate str ong corre lations,whichwer estre ngthened by th e addition of example,82% of Me dicaid-on ly be nefic iarie s wit h disabilitiesdiagnose d with diabetes also haveca rdio vas cular disease, repr ese ntinga nearly25 % increasein pr evalencewhenpharmacy dat a ar e used in ad ditio n to diagnosticdat ve -Year Di ag nostic Data AnalysisEx am iningfiv e year s of diagnos tic data resultsin evenlargerincre ases in thepro por tio n of ben ef iciar ies who are identified with mu ltiplecomorbidities,inpart icu lar.

9 Wit h fiv e year s of diagnostic data, two-t hirds(67%)of Me dicaid-onlybeneficiarieswit h dis abilit ies hav e th ree or mo re ch ronicconditions,mor e th an twicethe 29%ident ified when on ly on e ye ar of data ar e use d.** The five -y ea r ana lys is is limited to Medicaid- only beneficiarieswi th dis abi li tie s who we re enr oll ed con tin uousl y for fi veyea rs . As a re su lt, on e- ye ar fin din gs from the five-yearanal ysis vary from one-yearfin di ng s among all di sabl edbe ne fici ar ies .2 Int roducti onIn Med ica id , the elderlyan d ad ults wit h disa bilitiesmakeup only25 pe rc ent of ben eficiaries,but ac co unt for a majority of pro gra m sp ending. Withinthis population,fe we r than5% ofbenefi ciar ie s acco unt for mo re th an 50% of ove rall Medicaid of thes e high-costbe nefi ci ar ies man y of who m havemultiple chr on ic physical and behavioralhealthco ndi tion s receivecare wit hin an unmanagedfee -for- servicedeliverysystem, and themaj ori ty of th em wo uld ben efit greatly frommoreinte grated systemsof betterund ers tand ing th e spe cific hea lth condit ionsof th ese be neficiaries,states can makemoreinf orm ed de cis io ns about how to best managecare , the rebyimpr ovinghealthoutcomes,inc re asi ng qualityof life, and co ntro llingprogram s thi rd ed it ion of theFacesofMedicaid(FacesofMedicaidIII)

10 Was commissionedby CHCSto prov ide a mo re co mprehensiveviewof be neficiarieswit h multiplechr onicco nditions,particul ar ly tho se withser iousmen tal buildson the earlierFacesofMedicaidIIan al ys is pub lis hed in 2007 , whichsou ght to an swe r two key que st io ns: (1) whatis th epr eval en ce of ch ron ic co nditions with in the Med icaidpopulation;and (2) are ther e patterns orcl uster in gs of the se conditions that couldin for m the development of moreapp rop riategu ide li ne s, car e models,per for manceme asu rement systems, and reim bursementme th odo logies?2 Thi s ne w ed itionexamines two po werfulnew datasources one yearofph arm ac y claims and five ye ars of diagnosticdata to fu rtherrefinethe portraitof Medicaidbe nefi ci ar ie ea rl ierFacesIIana lysisrevealedtha t many Med icaidbeneficiarieswithdisabilitieshavemu lti pl e ch ron ic co ndit ion s and th at Med icaid shigh est-costbeneficiaries havenumero usco mo rb iditie s an d account fo r a majorityof initialanalysisal so fou nd th at whilether e wer e so me diag nost ic pairs ,diabetesand cardiovasculardi se as e, car diovascularan d pulmonar y disease,etc.