Transcript Medicaid High Cost Patients

HIGH COST MEDICAID PATIENTS
An Analysis of New York City Medicaid
High Cost Patients
March 2004
Robert F. Wagner Graduate School of Public Service
Center for Health and Public Service Research
SUMMARY OF FINDINGS
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High cost patients account for a large share of Medicaid costs
(20% patients => 70-80% of expenditures)
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There appears to be substantial opportunity for improved
management of high costs patients
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Improved management of these patients will present
substantial challenges, with high levels of…
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There are high levels of chronic disease (many with multiple chronic
conditions)
Many have multiple hospitalizations
Many appear to lack a medical home, visiting multiple providers in multiple
“systems”
Substance abuse
Mental Illness
Learning disability
Improved management is likely to require…
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A capacity to identify patients in real time
Improved integration/coordination of health care services
• Primary care and specialty care
• Hospitals and ambulatory care
• Home care services and primary care services
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A capacity to link patients to non-medical services (housing, social
services, etc.)
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ANALYTIC APPROACH
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Limited detailed analysis to patients not eligible for mandatory
enrollment in managed care
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Divided patients into subgroups (buckets) based on
characteristics that are likely to impact intervention design
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Children vs adults vs elderly
Substance abuse
Serious mental illness
HIV/AIDS
Institutional status (SNF/HRF/ICF)
Focused on top 3% of most costly patients with each
subgroup (limiting analysis to subgroups with large numbers of
patients and significant total expenditures)
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Analyzed expenditures
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Examined patterns of utilization
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Profiled diagnostic characteristics
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SUBGROUPS ANALYZED
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Disabled children (non-ICF/HRF/ICF)
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Disabled adults
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Substance abuse
Serious mental illness
Non-HIV/AIDS, substance abuse, or serious mental illness
Elderly
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Dual eligible - non-disabled (non-SNF/HRF/ICF)
Dual eligible - disabled (non-SNF/HRF/ICF)
Medicaid only - non-disabled (non-SNF/HRF/ICF)
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DISTRIBUTION OF PATIENTS
AND EXPENDITURES
CHILDREN - AGE 0-17 - DISABLED
100%
31.3%
80%
60%
15.4%
80.0%
21.7%
40%
68.7%
20%
31.6%
10.0%
0%
7.0%
3.0%
Patients
Expenditures
Disabled
[Non-Institutionalized]
Source: NYU Center for Health and Public Service Research, UHF, NYSDOH - Data for FY 1999.
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DISTRIBUTION OF PATIENTS
AND EXPENDITURES
CHILDREN - AGE 0-17 - DISABLED
Pe rc e nt o f
Pa tie nts
Num b e r o f
Pa tie nts
Disa ble d (No n-SNF/ IC F)
1-3%
1,595
4-10%
3,722
11-20%
5,317
21-100%
42,535
To ta l
53,169
To ta l
C o st
Mea n
C o st
% o f To ta l
C o st
$173,068,289
$118,561,645
$84,466,695
$171,363,681
$108,439
$31,871
$15,886
$4,029
31.6%
21.7%
15.4%
31.3%
$547,460,311
$10,297
100.0%
High cost cases (top 3%) in FY 1999…
• Total expenditures were $173 million
• Averaged $108,439 per patient
• Accounted for 31.6% of all costs for disabled children
Source: NYU Center for Health and Public Service Research, UHF, NYSDOH - Data for FY 1999.
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ANATOMY OF THE
AVERAGE HIGH COST PATIENT
HIGH COST CHILDREN - AGE 0-17 - DISABLED
$120,000
$108,439
All Other ($9,119)
14.1%
DME ($3,052)
Pharmaceuticals ($3,981)
$100,000
Other Outpatient ($14,305)
$80,000
43.8%
Home visit ($25,504)
$60,000
School based ($5,909)
Rehab ($1,502)
Psych Outpatient ($874)
MD/Clinic ($2,718)
$40,000
Other Inpatient ($23,158)
Injury ($2,628)
42.1%
$20,000
Psych ($12,339)
Delivery ($5,877)
ACS ($4,965)
$0
Inpatient
Outpatient
Other Expenditures
Source: NYU Center for Health and Public Service Research, UHF, NYSDOH - Data for FY 1999.
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DIAGNOSTIC CHARACTERISTICS
AND UTILIZATION PATTERNS
HIGH COST CHILDREN - AGE 0-17 - DISABLED
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48.5% with a chronic disease
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36.2% with asthma
16.6% with multiple chronic diseases
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45.5% mental retardation
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45.6% other congenital disability
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31.8% cerebral palsy
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61.0% with psychiatric conditions
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15.0% attention deficit disorder
14.0.% pre-adult adjustment disorder
11.5 % personality disorder
8.1% major depression/bipolar disorder
7.1% schizophrenia
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On average visited 3.1 different provider organizations
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65% had multiple hospitalizations
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DISTRIBUTION OF PATIENTS
AND EXPENDITURES
ADULTS - AGE 18-64 - DISABLED
100%
22.7%
80%
17.1%
60%
80.0%
28.5%
40%
77.3%
20%
31.7%
10.0%
0%
7.0%
3.0%
Patients
Expenditures
Disabled
[Non-HIV/Alc/Drug/Schiz/SNF/ICF]
Source: NYU Center for Health and Public Service Research, UHF, NYSDOH - Data for FY 1999.
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DISTRIBUTION OF PATIENTS
AND EXPENDITURES
ADULTS - AGE 18-64 - DISABLED
Pe rc e nt o f
Pa tie nts
Num b e r o f
Pa tie nts
To ta l
C o st
Mea n
C o st
Sc hizophre nia (No n-SNF/ IC F - No n-HIV/ AIDS)
1-3%
1,177
$142,063,458
$120,700
4-10%
2,746
$167,272,118
$60,937
11-20%
3,923
$141,055,993
$35,956
21-100%
31,382
$253,035,749
$8,063
To ta l
39,227
% o f To ta l
C o st
20.2%
23.8%
20.1%
36.0%
$703,427,317
$17,932
100.0%
No n-HIV/ AIDS)
$105,819,317
$100,432,411
$68,212,728
$108,171,518
$137,249
$55,796
$26,532
$5,260
27.7%
26.2%
17.8%
28.3%
$382,635,975
$14,884
100.0%
All Othe rs (No n-SNF/ IC F - No n-HIV/ AIDS)
1-3%
4,738
$497,506,805
4-10%
11,056
$447,360,737
11-20%
15,794
$267,979,960
21-100%
126,350
$355,219,154
$104,981
$40,467
$16,968
$2,811
31.7%
28.5%
17.1%
22.7%
$9,928
100.0%
Alc ohol/ Drug (No n-SNF/ IC F 1-3%
771
4-10%
1,800
11-20%
2,571
21-100%
20,566
To ta l
To ta l
25,708
157,938
$1,568,066,656
Source: NYU Center for Health and Public Service Research, UHF, NYSDOH - Data for FY 1999.
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ANATOMY OF THE
AVERAGE HIGH COST PATIENT
HIGH COST ADULT- AGE 18-64 - DISABLED
[Non-HIV/AIDS, Non-SNF/ICF, Non-Alc/Drug/Schiz]
$120,000
$104,981
All Other ($8,248)
DME ($1,252)
Pharmaceuticals ($5,292)
13.5%
$100,000
Other Outpatient ($26,490)
[Including outpatient LTC]
$80,000
50.3%
$60,000
Home visit ($23,798)
$40,000
Dialysis ($2,203)
Rehab ($1,929)
Psych Outpatient ($424)
MD/Clinic ($2,100)
Other Inpatient ($22,733)
$20,000
36.2%
Cancer ($5,556)
Injury ($4,118)
Psych ($1,120)
ACS ($7,370)
$0
Inpatient
Outpatient
Other Expenditures
Source: NYU Center for Health and Public Service Research, UHF, NYSDOH - Data for FY 1999.
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DIAGNOSTIC CHARACTERISTICS
AND UTILIZATION PATTERNS
HIGH COST ADULT- AGE 18-64 - DISABLED
[Non-HIV/AIDS, Non-SNF/ICF, Non-Alc/Drug/Schiz]
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69.3% with a chronic disease
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48.7% with multiple chronic diseases
30.8% diabetes
53.5% coronary artery disease/hypertension
23.4% congestive heart disease
17.5 COPD or other lung disease
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27.9% mental retardation
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15.5% deaf/blind
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10.4% cerebral palsy
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5.3% multiple sclerosis
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47.8% with psychiatric conditions
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12.3% major depression/bipolar disorder
12.8%adjustment reactions
10.5% senility/organic syndrome
20.6% anxiety/other depression
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75% visited multiple provider systems, on average visiting
3.2 different provider organizations
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86% had multiple hospitalizations
Source: NYU Center for Health and Public Service Research, UHF, NYSDOH - Data for FY 1999.
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DIAGNOSTIC CHARACTERISTICS
AND UTILIZATION PATTERNS
HIGH COST ADULT- AGE 18-64 - DISABLED
[Alcohol/Drug and Schizophrenia Patients]
Alcohol/Drug Patients [Non-HIV/AIDS, Non-SNF/ICF]
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89.5% with a chronic disease
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76.4% with multiple chronic diseases
21.3% of hospital admissions are for chronic disease
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17.8% of hospital admissions are for preventable/avoidable
(ACS) conditions
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More than 60% have a alcohol/drug related psychiatric
disorder
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20% have no primary care visits and less than 1% of total
expenditures are for primary care
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Averaged 4 emergency department visits per year (not
resulting in a hospital admission)
Schizophrenia Patients [Non-HIV/AIDS, Non-SNF/ICF]
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63.8% with a chronic disease
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43.1% with multiple chronic diseases
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Average 2.5 psychiatric hospital admissions per year
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Average 2 non-psych hospital admissions per year
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27.5% are retarded/developmentally disabled
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51.4% have alcohol/drug related diagnoses
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Averaged 3.3 emergency department visits per year (not
resulting in a hospital admission)
Source: NYU Center for Health and Public Service Research, UHF, NYSDOH - Data for FY 1999.
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DISTRIBUTION OF PATIENTS
AND EXPENDITURES
ELDERLY - AGE 65+ - DUAL ELIGIBLE
100%
24.4%
80%
60%
24.8%
80.0%
40%
28.8%
74.5%
20%
10.0%
21.9%
0%
7.0%
3.0%
Patients
Expenditures
Non-Disabled
[Non-SNF/HRF/ICF]
Source: NYU Center for Health and Public Service Research, UHF, NYSDOH - Data for FY 1999.
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DISTRIBUTION OF PATIENTS
AND EXPENDITURES
ELDERLY - AGE 65+
Pe rc e nt o f
Pa tie nts
Num b e r o f
Pa tie nts
Dua l Eligible - Non- Disa ble d
1-3%
4,464
4-10%
10,415
11-20%
14,879
21-100%
119,031
To ta l
Mea n
C o st
(No n-SNF/ HRF/ IC F)
$414,047,358
$92,753
$545,810,180
$52,406
$470,297,024
$31,610
$463,614,385
$3,895
% o f To ta l
C o st
21.9%
28.8%
24.8%
24.5%
$1,893,768,946
$12,728
100.0%
Dua l Eligible - Disa ble d (No n-SNF/ HRF/ IC F)
1-3%
1,217
$107,485,653
4-10%
2,840
$123,540,961
11-20%
4,057
$94,937,612
21-100%
32,459
$118,525,814
$88,320
$43,500
$23,395
$3,652
24.2%
27.8%
21.4%
26.7%
$10,955
100.0%
M e dic a id Only - Non- Disa ble d (No n-SNF/ HRF/ IC F)
1-3%
1,477
$122,181,525
$82,723
4-10%
3,445
$121,140,289
$35,154
11-20%
4,922
$70,281,181
$14,282
21-100%
39,377
$48,885,052
$1,241
33.7%
33.4%
19.4%
13.5%
To ta l
To ta l
148,789
To ta l
C o st
40,574
49,221
$444,490,040
$362,488,047
Source: NYU Center for Health and Public Service Research, UHF, NYSDOH - Data for FY 1999.
$7,364
100.0%
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ANATOMY OF THE
AVERAGE HIGH COST PATIENT
HIGH COST ELDERLY- AGE 65+ - NON-DISABLED
[Non-SNF/HRF/ICF] – DUAL ELIGIBLE
$100,000
$92,753
All Other ($3,438)
DME ($866)
Pharmaceuticals ($3,438)
6.0%
$80,000
Other Outpatient ($24,858)
$60,000
70. 6%
Home visit ($40,658)
$40,000
$20,000
Inpatient ($20,756)
22.4%
$0
Inpatient
Outpatient
Other Expenditures
Source: NYU Center for Health and Public Service Research, UHF, NYSDOH - Data for FY 1999.
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DIAGNOSTIC CHARACTERISTICS
AND UTILIZATION PATTERNS
HIGH COST ELDERLY- AGE 65+
Dual Eligible - Non-Disabled [Non-SNF/HRf/SNF]
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84.4% with a chronic disease
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49% have psychiatric disorder
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66.5% with multiple chronic diseases
$11,000 in ACS/chronic hospital admissions per year
36.3% senility/organic mental disorder
$41,895 in home visit expenditures per year
Dual Eligible - Disabled [Non-SNF/HRf/SNF]
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93.1% with a chronic disease
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57% have psychiatric disorder
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80.2% with multiple chronic diseases
$20,000 in ACS/chronic hospital admissions per year
21.5% senility/organic mental disorder
25% depression
$34,756 in home visit expenditures per year
Medicaid Only - Non-Disabled [Non-SNF/HRf/SNF]
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90.7% with a chronic disease
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73.7% with multiple chronic diseases
$26,000 in ACS/chronic hospital admissions per year
$21,000 in home visit expenditures per year
Source: NYU Center for Health and Public Service Research, UHF, NYSDOH - Data for FY 1999.
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ON-GOING ANALYSES
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Detailed analysis for expenditure and utilization patterns for
specific disease subgroups
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Linkage of patients to “predominant provider” (where they
get most of their care), and…
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Analysis of “episodes of illness”
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Comparison of utilization/expenditure patterns among providers and
provider types
Analysis of “shopping” by patients
Analysis of “dumping” by providers
“Serial” high cost patients versus “single” episode patients
Identification of intervention opportunities
Predictive modeling…
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Identification of factors/characteristics that predict high cost utilization
Development of model to predict high cost patients prospectively
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CLINICAL EXPERTS’ OBSERVATIONS
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Ability to identify and engage patients in real time is critical
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Same intervention models may work for several patient
groups
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May require restrictive systems; tough to intervene with
shoppers
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Will require investment in integrative infrastructure and
skilled personnel
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LIKELY INTERVENTION MODELS
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Strengthen links to community resources before discharge
and follow up to ensure effective connections
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Integrate community resources for substance
abuse/psych/primary care
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Strengthen links between home care and physicians/nurse
practitioners
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