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September 2010 Evaluation of Medicare Care Management for High Cost Beneficiaries (CMHCB) Demonstration: VillageHealth’s Key to Better Health (KTBH) Final Report Prepared for David Bott, PhD Centers for Medicare & Medicaid Services Office of Research, Development, and Information 7500 Security Boulevard Baltimore, MD 21244-1850 Prepared by Nancy McCall, ScD Jerry Cromwell, PhD Carol Urato, MA RTI International 3040 Cornwallis Road Research Triangle Park, NC 27709 RTI Project Number 0207964.025.000.001 EVALUATION OF MEDICARE CARE MANAGEMENT FOR HIGH COST BENEFICIARIES (CMHCB) DEMONSTRATION: VILLAGEHEALTH’S KEY TO BETTER HEALTH (KTBH) by Nancy McCall, ScD Jerry Cromwell, PhD Carol Urato, MA Federal Project Officer: David Bott, Ph.D. RTI International* CMS Contract No. 500-00-0024 TO#25 September 2010 This project was funded by the Centers for Medicare & Medicaid Services under contract no 500-00-0024 TO#25. The statements contained in this report are solely those of the authors and do not necessarily reflect the views or policies of the Centers for Medicare & Medicaid Services. RTI assumes responsibility for the accuracy and completeness of the information contained in this report. _________________________________ RTI International is a trade name of Research Triangle Institute. CONTENTS EXECUTIVE SUMMARY .............................................................................................................1 E.1 Scope of Implementation ...............................................................................................1 E.2 Overview of the KTBH CMHCB Demonstration Program ...........................................3 E.3 Key Findings ..................................................................................................................5 E.4 Conclusion .....................................................................................................................9 CHAPTER 1 INTRODUCTION TO THE MEDICARE CARE MANAGEMENT FOR HIGH COST BENEFICIARIES (CMHCB) DEMONSTRATION AND VILLAGEHEALTH’S KEY TO BETTER HEALTH (KTBH) PROGRAM ......................11 1.1 Background on the CMHCB Demonstration and Evaluation ......................................11 1.2 KTBH’s CMHCB Demonstration Program Design Features ......................................14 1.2.1 KTBH Organizational Characteristics ................................................................14 1.2.2 Market Characteristics ........................................................................................15 1.2.3 KTBH Intervention and Comparison Populations ..............................................15 1.2.4 KTBH Operations ...............................................................................................17 1.2.5 Overview of the KTBH CMHCB Demonstration Program ................................17 1.3 Organization of Report ................................................................................................22 CHAPTER 2 EVALUATION DESIGN AND DATA ..................................................................23 2.1 Overview of Evaluation Design ...................................................................................23 2.1.1 Gaps in Quality of Care for Chronically Ill ........................................................23 2.1.2 Emerging Approaches to Chronic Care ..............................................................23 2.1.3 Conceptual Framework and CMHCB Demonstration Approaches ....................25 2.1.4 General Analytic Approach ................................................................................30 2.2 Participation, Clinical Quality and Health Outcomes, and Financial Outcomes Data and Analytic Variables ........................................................................................32 2.2.1 Data .....................................................................................................................32 2.2.2 Analytic Variables ..............................................................................................35 CHAPTER 3 BENEFICIARY AND PHYSICIAN SATISFACTION .........................................42 3.1 Beneficiary Satisfaction ...............................................................................................42 3.1.1 Survey Instrument Design...................................................................................42 3.1.2 Analytic Methods ................................................................................................45 3.1.3 Medicare Health Services Survey Results for the KTBH Program ....................48 3.1.4 Conclusions .........................................................................................................52 3.2 Physician Satisfaction ..................................................................................................52 3.2.1 KTBH Clinical Partnership Relations .................................................................52 3.2.2 KTBH Provider Recommendations ....................................................................53 iii CHAPTER 4 PARTICIPATION RATES IN THE KTBH CMHCB DEMONSTRATION PROGRAM AND LEVEL OF INTERVENTION ...............................................................55 4.1 Introduction ..................................................................................................................55 4.2 Methods........................................................................................................................56 4.2.1 Participation Analysis Methods ..........................................................................56 4.2.2 Level of Intervention Analysis Methods.............................................................58 4.3 Findings........................................................................................................................59 4.3.1 Participation Rates for the KTBH Population ....................................................59 4.3.2 Characteristics of the KTBH Intervention and Comparison Populations ...........65 4.3.3 Characteristics of Participants in the KTBH Original and Refresh Populations ..........................................................................................................67 4.3.4 Level of Intervention...........................................................................................70 4.4 Summary ......................................................................................................................83 CHAPTER 5 CLINICAL QUALITY PERFORMANCE .............................................................84 5.1 Introduction ..................................................................................................................84 5.2 Methodology ................................................................................................................84 5.3 Findings........................................................................................................................87 5.4 Summary of Findings and Conclusion .........................................................................90 CHAPTER 6 HEALTH OUTCOMES ..........................................................................................92 6.1 Introduction ..................................................................................................................92 6.2 Methodology ................................................................................................................92 6.2.1 Rates of Hospitalizations and Emergency Room Visits .....................................92 6.2.2 Rates of 90-Day Readmissions ...........................................................................93 6.2.3 Mortality .............................................................................................................94 6.3 Findings........................................................................................................................94 6.3.1 Rates of Hospitalizations and Emergency Room Visits .....................................94 6.3.2 Rates of 90-Day Readmissions ...........................................................................98 6.3.3 Mortality ...........................................................................................................100 6.4 Conclusions ................................................................................................................102 CHAPTER 7 FINANCIAL OUTCOMES ...................................................................................104 7.1 Introduction ................................................................................................................104 7.2 Data and Key Variables .............................................................................................105 7.2.1 Sample Frame and Data ....................................................................................105 7.2.2 Constructing PBPM costs .................................................................................106 7.2.3 Monthly Fees ....................................................................................................109