Identifying Medicaids Best Buys Dan Crippen Former Director, - - PowerPoint PPT Presentation

SLIDE 1

Identifying Medicaid’s Best Buys

Dan Crippen Former Director, Congressional Budget Office for CHCS/Harvard Government Innovators Network “Best Buys” Call February 5, 2007

SLIDE 2

Federal Budget as a Percent of the Economy

SLIDE 3

Federal Spending for Retirees

SLIDE 4

Spending Non-elderly Per Capita Healthcare

Per Capita Spending

SLIDE 5

Per Capita Medicare Spending

Percapita Medicare Spending

10,000 20,000 30,000 40,000 50,000 60,000 70,000 1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 Percentile Percapita Spending

Ave.=$5200

$70,000 $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 $0

Average $5800

Percent of Population

Per Capita Spending

SLIDE 6

Distribution of Medicare Spending Among Beneficiaries

SLIDE 7

Profiles of Medicare Beneficiaries by Spending Group

Spending Group (Mean Spending) Top 5 Percent ($53,538) Top 20 Percent ($24,161) Bottom 40 Percent ($197) Inpatient PPS Spending / Beneficiary $25,309 $11,119 None Physician Spending / Beneficiary $8,872 $4,934 $165 Chronic Conditions Diabetes 43% 36% 14% CHF 59% 47% 9% Cognitive impairment 30% 24% 5%

SLIDE 8

Per capita Medicaid Spending

Total Per capita Costs Percent of Medicaid Population

SLIDE 9

What Groups Drive Medicaid Spending?

Elderly Disabled Adults Children Elderly Disabled Adults Children

SLIDE 10

Defining the Population Identification of Targeted Population--Acute Care

20% of Population Drive > 85 % of Costs

• The top 1% of members account for 33% of total costs
• The annual cost of this 1% is $52,500/member as compared to $1,500 average annual cost
• The bottom 50% of members (188,000 members) account for only 1.5% of total costs and have an average cost of

$50/member

SLIDE 11

Defining Utilization Identification of Top 20 Primary Conditions and Comorbidities for the Top 25% of Members

Most Prevalent Comorbidity 2nd Most Prevalent Comorbidity 3rd Most Prevalent Comorbidity

Rank

Primary Diagnostic Condition Unique Members % of Annual Costs Annual cost PMPM Description

Incidence rate w/i

• Prim. Cat.

Description

Incidence rate w/i

• Prim. Cat.

Description

Incidence rate w/i

• Prim. Cat.

1 Cancer

2,400 11.3% 24,995,265 $ 1,001

Other upper respiratory disease

38%

Spondylosis, intervertebral disc

28%

Abdominal pain

28%

2 CHF

2,337 10.9% 24,234,874 $ 932

HTN

76%

Hyperlipidemia

55%

Other upper respiratory disease

39%

3 Asthma

3,634 10.5% 23,265,682 $ 581

Other upper respiratory disease

64%

Other lower respiratory disease

43%

Abdominal pain

18%

4 Spondylosis, intervertebral disc

disorders, other back problems 3,365 7.7% 17,120,867 $ 494

Other upper respiratory disease

36%

Abdominal pain

27%

Headache, including migraine

22%

5 Diabetes

1,580 6.1% 13,574,852 $ 858

Hyperlipidemia

40%

HTN

38%

Other upper respiratory disease

34%

6 Abdominal pain

2,449 5.4% 11,976,201 $ 482

Other upper respiratory disease

34%

Urinary tract infections

19%

Other lower respiratory disease

15%

7 Non-Recurrent Conditions

2,582 4.3% 9,629,659 $ 490

8 Chronic Renal Failure

261 3.6% 7,972,054 $ 3,038

HTN

64%

CHF

51%

Hyperlipidemia

44%

9 Fetal disorders

412 3.2% 7,028,974 $ 2,448

Other upper respiratory disease

40%

Congenital Anamolies

21%

Other lower respiratory disease

20%

10 Metastatic Cancer

166 3.1% 6,799,178 $ 4,688

Cancer

61%

Other lower respiratory disease

45%

Abdominal pain

35%

11 Moderate or Severe Liver Disease

635 3.0% 6,666,521 $ 1,040

Abdominal pain

33%

Spondylosis, intervertebral disc

32%

Substance-related mental disorders

30%

12 COPD

604 3.0% 6,631,835 $ 1,048

Other upper respiratory disease

49%

Other lower respiratory disease

43%

Asthma

43%

13 Other upper respiratory disease

1,563 2.3% 5,015,169 $ 324

Other lower respiratory disease

5%

Abdominal pain

3%

Urinary tract infections

2%

14 Congenital Anamolies

798 2.2% 4,922,061 $ 658

Other upper respiratory disease

49%

Other lower respiratory disease

22%

Heart valve disorders

10%

15 CAD

435 1.8% 4,055,861 $ 996

Hyperlipidemia

36%

HTN

35%

Other lower respiratory disease

33%

16 Autism & Preadult Disorders

1,274 1.8% 3,918,294 $ 270

Other upper respiratory disease

45%

Other Affective Disorders

18%

Other lower respiratory disease

12%

17 Sickle Cell Anemia

185 1.5% 3,273,287 $ 1,638

Other upper respiratory disease

43%

Other lower respiratory disease

39%

Abdominal pain

28%

18 Major Depression

665 1.5% 3,255,184 $ 496

Other upper respiratory disease

27%

Other Affective Disorders

19%

Substance-related mental disorders

18%

19 AIDS/HIV

373 1.3% 2,806,488 $ 755

Other upper respiratory disease

33%

Other lower respiratory disease

28%

Substance-related mental disorders

25%

20 Urinary tract infections

569 1.2% 2,674,983 $ 462

Other upper respiratory disease

30%

Other lower respiratory disease

8%

Substance-related mental disorders

8%

SLIDE 12

High-Cost Medicaid Conditions (Top 25% of patients)

• Cancer

» 47% Inpatient and ER

• Chronic Heart Failure

» 50% Inpatient and ER

• Asthma

» 46% Inpatient and ER

SLIDE 13

High-Cost Medicaid Patients (Top 25%)

• Inpatient and ER — 55%
• Surgical — 9%
• Physician — 12%
• Imaging — 4%
• Lab — 1%

SLIDE 14

Hospitalizations

• Unnecessary Hospitalizations

» “Convenience”

• Preventable Hospitalizations

» Asthma

• Predictable Hospitalizations

» Pattern of pharma use » Number and type of physician encounters

• Avoidable Hospitalizations

» Diabetes » CHF