Evaluation of a Program to Improve Diabetes Care Through Intensified Care Management Activities and Diabetes Medication Copayment Reduction

Brian J. Quilliam; Scott Johnson; Stephen J. Kogut; Tara Higgins

摘要

BACKGROUND: Medication copayment reduction can be integrated with disease management programs to incentivize patient engagement in chronic care management. While disease management programs in diabetes have been evaluated across a range of settings and designs, less is known regarding the effectiveness of copayment reduction as a component of disease management. OBJECTIVE: To evaluate the short-term results of a diabetes-focused disease management program that included copayment reduction, care coordination, and patient goal setting, focusing on rates of evidence-based care processes and all-cause pharmacy and health care costs. METHODS: Blue Cross Blue Shield of Rhode Island offered large employer groups the opportunity to participate in a diabetes disease management initiative that featured reduced copayments (from $7/$25/$40 for generic, tier 2, and tier 3 drugs, respectively, to $0 for generic and $0-$2 for brand drugs) for diabetes-related medications. In return for the copayment reduction, participants agreed to the following: (a) participate in care coordination with a case manager, (b) have an annual physical examination, (c) have a hemoglobin A1c blood test at least twice annually, and (d) have a low-density lipoprotein cholesterol (LDL-C) test at least once annually. Patients received personalized support provided by a registered nurse and dietician, disease-related education provided by nurses, and intensified case management services, including working with a health coach to establish healthy behavioral change goals. All study subjects were aged 18 years or older and had at least 1 ICD-9-CM code for diabetes and at least 1 claim for an antidiabetic drug during a 12-month measurement period, which was each subject’s most recent 12-month period of continuous enrollment from January 1, 2008, through May 31, 2010. Administrative claims data were used to determine the percentage of intervention (participating) and nonintervention (nonparticipating) subjects from among all of the plan’s employer groups who received at least once-yearly monitoring of A1c, high-density lipoprotein cholesterol (HDL-C), and LDL-C; medical attention (or drug therapy) for nephropathy; and an eye examination. We conducted multivariate logistic regression analyses to assess the effect of the intervention and other patient characteristics and comorbidities on rates of performance of these care processes, aggregating the 5 processes of care into an “all or none” single composite outcome. We also developed a propensity score-weighted model to attempt to adjust for differences between the intervention and nonintervention groups resulting from the nonrandomized study design. Additionally, we quantified average plan payments to providers less patient copayments (i.e., net plan cost) per patient per year (PPPY) for the 12-month follow-up period and compared these costs for the intervention versus nonintervention groups. RESULTS: The study sample consisted of 9,698 patients with diabetes; 649 (6.7%) of whom participated in the intervention. 9,049 (93.3%) patients were identified by the insurer as patients with diabetes receiving usual care. Patients in the intervention and nonintervention groups were similarly likely to have all 5 recommended processes of care performed (40.1% vs. 38.9%, respectively, P?=?0.543). Younger patients received all 5 recommended care processes less frequently than older patients (30.5%, 38.0%, and 47.0% for ages 18-48 years, 49-59 years, and 60 years or older, respectively, P? less than ?0.001); in adjusted analyses, patients aged 60 years or older were approximately twice as likely to receive all 5 care processes compared with patients aged 18-48 years (odds ratio [OR]?=?1.97, 95% CI?=?1.75-2.21). Users of oral antidiabetic monotherapy were least likely to have these processes of care performed compared with users of multiple oral therapies (OR?=?1.23, 95% CI?=?1.11-1.36) and insulin (OR?=?1.59, 95% CI?=?1.41-1.78). PPPY prescription drug costs incurred by the plan were greater for intervention than comparison patients (means [SDs] of $3,139 [$3,426 ] vs. $2,854 [$3,938], respectively, P? less than ?0.001); and the generic-dispensing ratio was slightly lower (means [SDs] of 62.1% [22.4%] and 65.4% [23.0%], respectively, P? less than ?0.001). There were no significant differences between the intervention and comparison groups in mean [SD] PPPY all-cause medical care costs ($7,475 [$17,601] vs. $8,577 [$22,972], respectively, P?=?0.213) or total all-cause costs ($10,613 [$18,590] vs. $11,431 [$24,060], P?=?0.666). CONCLUSIONS: Patients participating in this incentive program featuring diabetes medication copayment reduction and disease management components did not receive recommended care any more or less frequently than other enrolled members with diabetes. Younger patients and those utilizing oral antidiabetic monotherapy as their drug regimens were less likely to have the recommended processes of care

机译：背景：减少药物共付额可以与疾病管理计划相结合，以激励患者参与长期护理管理。尽管已经在各种环境和设计中对糖尿病的疾病管理计划进行了评估，但对于减少共付额作为疾病管理组成部分的有效性知之甚少。目的：评估以糖尿病为中心的疾病管理计划的短期结果，包括减少共付额，护理协调和患者目标设定，重点是循证护理过程的费用以及全因药房和医疗费用。方法：罗得岛州的蓝十字蓝盾为大型雇主团体提供了参加糖尿病疾病管理计划的机会，该计划的共付额减少了（从仿制药，第2层和第3层药物分别从$ 7 / $ 25 / $ 40减少到$ 0，非专利药和$ 0- $ 2的品牌药）用于糖尿病相关药物。作为减少共付额的回报，参与者同意以下各项：（a）与病例管理员一起参加护理协调，（b）进行年度体检，（c）至少每年两次进行血红蛋白A1c血液检查，以及（ d）至少每年进行一次低密度脂蛋白胆固醇（LDL-C）测试。患者获得注册护士和营养师的个性化支持，护士提供的疾病相关教育，以及强化的病例管理服务，包括与健康教练一起制定健康的行为改变目标。所有研究对象均年龄在18岁以上，并且在12个月的测量期间内至少具有1个ICD-9-CM糖尿病代码，并且至少有1项抗糖尿病药物声明，这是每个受试者最近的12个月测量期。从2008年1月1日到2010年5月31日连续招生。使用行政索赔数据来确定该计划的所有接受至少每年一次监测的雇主组中干预（参与）和非干预（非参与）受试者的百分比A1c，高密度脂蛋白胆固醇（HDL-C）和LDL-C的含量;肾病的医疗护理（或药物治疗）;和眼睛检查我们进行了多元逻辑回归分析，以评估干预措施以及其他患者特征和合并症对这些护理过程的执行率的影响，将5个护理过程汇总为“全部或全部”的单一复合结果。我们还开发了一个倾向得分加权模型，以尝试针对非随机研究设计导致的干预组和非干预组之间的差异进行调整。此外，我们量化了在12个月的随访期内向提供者提供的平均计划付款减去每位患者每年的患者共付额（即计划净费用），并比较了干预组和非干预组的这些费用。结果：该研究样本包括9,698例糖尿病患者; 649名（6.7％）参加了干预。保险公司将9049名（93.3％）患者确定为接受常规护理的糖尿病患者。干预组和非干预组的患者同样有可能执行所有推荐的5种护理过程（分别为40.1％和38.9％，P = 0.543）。年轻患者接受所有5种推荐护理程序的频率低于老年患者（18-48岁，49-59岁和60岁或60岁以上的年龄分别为30.5％，38.0％和47.0％，P <小于0.001）。 ;在调整后的分析中，年龄在60岁以上的患者接受全部5次护理的可能性是18-48岁患者的两倍（优势比[OR]？=？1.97，95％CI？=？1.75-2.21）。与使用多种口服疗法（OR？=？1.23，95％CI？=？1.11-1.36）和胰岛素（OR？=？1.59，95％）的使用者相比，口服抗糖尿病单药疗法的使用者执行这些护理过程的可能性最小。 CI≥1.41-1.78）。该计划产生的PPPY处方药费用比干预患者要高（分别为[SD]分别为$ 3,139 [$ 3,426]与$ 2,854 [$ 3,938]，P <小于0.001）;通用分配比率略低（分别为[SD]分别为62.1％[22.4％]和65.4％[23.0％]，P <小于0.001）。干预组和比较组之间在[SD] PPPY全因平均医疗费用（分别为$ 7,475 [$ 17,601]与$ 8,577 [22,972]之间，P？=？0.213）或总全因费用（无显着差异）上。 $ 10,613 [$ 18,590]对$ 11,431 [$ 24,060]，P？=？0.666）。结论：参与该奖励计划的患者具有减少糖尿病药物共付额和疾病管理的功能，因此与其他已注册的糖尿病患者相比，没有得到或多或少的推荐治疗。年轻的患者和以口服抗糖尿病单药治疗为药物疗法的患者不太可能接受推荐的护理程序

Evaluation of a Program to Improve Diabetes Care Through Intensified Care Management Activities and Diabetes Medication Copayment Reduction

摘要

著录项

相似文献

相关主题

期刊订阅