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Trends in Military Health System Costs for Colorectal Cancers, FY07-FY14 Michelle Kloc, PhD, MSN, RN Diana D. Jeffery, Ph.D. Joe Dorris, M.A. Harry Burke, M.D., Ph.D. Presentation for APHA Session 3300.1: “Best Practices and Innovations in Cancer Care Delivery Models” Altarum Institute integrates independent research and client-centered consulting to deliver comprehensive, systems-based solutions that improve health and health care. A nonprofit, Altarum serves clients in both the public and private sectors. For more information, visit www.altarum.org Research Team Altarum Institute Michelle Kloc, Ph.D., MSN, RN [[email protected]] Joe Dorris, MA Department of Defense Office of the Assistant Secretary of Defense (Health Affairs), Defense Health Agency, Clinical Division • Diana Jeffery, Ph.D. Uniformed Services University of the Health Sciences • Harry Burke, MD, Ph.D. 2 Presenter Disclosures Michelle Kloc Diana D. Jeffery, Ph.D. Joe Dorris, M.A. Harry Burke, M.D., Ph.D. The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: “No relationships to disclose” 3 Disclaimer The opinions expressed herein are those of the authors, and are not necessarily representative of the opinions or policies of the Department of Defense (DOD); or the United States Army, Navy, Marine Corps, Air Force, or Coast Guard 4 Overview of Colorectal Cancers What are Colorectal Cancers? A cancer of the colon or rectum, located at the digestive tract's lower end Most colorectal cancers start as a non-cancerous polyp – a growth that starts in the inner lining of the colon or rectum and grows toward the center. Only certain types of polyps (called adenomas) can become cancer. Over 95% of colon and rectal cancers are adenocarcinomas. These are cancers that start in gland cells, like the cells that line the inside of the colon and rectum. Risk Factors for Colorectal Cancers Age History of ulcerative colitis or Crohn’s disease Family history of colorectal cancer Cooking meats at very high heat Eating diets high in red or processed meats 5 Colorectal Cancer Statistics Prevalence Colorectal cancer is the second most common cancer found in men and women in this country1 Colorectal cancer is the #2 cancer killer in the US among cancers that affect both men and women2 Approximately 132,700 new colorectal cancers diagnosed each year3 Direct Costs The mean total colon cancer cost per Medicare patient 1 year after diagnosis was $29,196.4 Average 1-year costs for veterans who predominately used Medicare was $39,136; for veterans who predominately use VA was $36,146; and for dual users was $44,264. All were statistically significantly different.5 6 Objective To examine the trends in costs for colorectal cancer patients receiving care in the Military Health System (MHS), by age group and gender from fiscal years (FY) 2007 – 2014 7 Study Design Study Population Study Population MHS beneficiaries ages 18 to 64, residing within the United States, were included only if they had accessed the healthcare system within the FY. Included individuals were assigned to one of three groups based upon the system of care in which their healthcare occurred: • Direct Care (DC) – if all healthcare for a FY occurred in military treatment facilities • Purchased Care (PC) – if all healthcare for a FY occurred in a civilian network facility • Both Systems (Both) – if healthcare for a FY occurred in both military and civilian facilities 8 Study Design Data and Analysis Data Principle ICD-9 codes for claims paid by TRICARE in FY07-14 were obtained from the MHS Master Data Repository Cancer diagnoses were identified using the Agency of Healthcare Research and Quality (AHRQ) Clinical Classification Software algorithm HEDIS-based measures • A beneficiary was considered to have a cancer if they had a minimum of: – a) 2 outpatient visits within a FY with the same ICD-9, and/or – b) 1 inpatient admission for a given ICD-9. Costs were standardized to 2014 dollars Analysis Descriptive statistics and time-series linear regression models were used to analyze the data. Regression models controlled for beneficiary category, sponsor Service branch, age group, gender, comorbids, and TRICARE plan. Costs were standardized to 2014 dollars 9 Demographic Descriptive Statistics of Colorectal Cancer Diagnosed Individuals Min Min FY Max Max FY Average N Average % Male Female 3,489 3,772 FY14 FY07 3,771 4,499 FY09 FY10 3,673 4,208 48.38% 55.43% 18 to 30 31 to 44 45 to 64 129 721 6,485 FY07 FY08 FY14 760 823 6,850 FY09 FY09 FY10 397 769 6,714 5.23% 10.13% 88.45% Active Duty Active Duty Family Members Retirees/Retiree Family Members Other Service Air Force Army Coast Guard Marines Navy Total 426 398 6,005 176 FY08 FY07 FY14 FY07 736 778 6,414 222 FY09 FY09 FY10 FY11 574 561 6,250 205 7.56% 7.40% 82.34% 2.70% 2,255 2,725 147 422 1,733 7,197 FY13 FY07 FY07 FY07 FY08 FY07 2,441 3,278 180 529 1,949 8,122 FY09 FY09 FY14 FY09 FY09 FY09 2,369 3,021 167 462 1,825 7,591 31.21% 39.79% 2.20% 6.09% 24.04% 100.00% Gender Age Group Beneficiary Category 10 Results Trends in Colorectal Cancer Non-Pharmacy Costs Per Person Non-Pharmacy Costs for Colorectal Cancer, by Gender and Age Group, Over Time $50,000 $40,000 $30,000 $20,000 $10,000 $0 FY08 FY09 FY10 FY11 FY12 FY13 FY14 Government Paid Amounts Government Paid Amounts Per Person Non-Pharmacy Costs for Colorectal Cancer, by Age Group, Over Time $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 $0 FY07 FY08 31 to 44 45 to 64 FY10 FY11 FY12 FY13 FY14 Fiscal Year Fiscal Year 18 to 30 FY09 Female 18 to 30 Female 31 to 44 Female 45 to 64 Male 18 to 30 Male 31 to 44 Male 45 to 64 • By FY14, non-pharmacy costs highest for ages 18-30 • Non-pharmacy costs experienced a dramatic decrease in FY09 for several age groups • Males ages 18 to 30 have had consistently higher non-pharmacy costs than other gender-age groups 11 Results Trends in Colorectal Cancer Pharmacy Costs Per Person Pharmacy Costs for Colorectal Cancer, by Gender and Age Group, Over Time $4,000 $3,000 $2,000 $1,000 $0 FY07 FY08 FY09 FY10 FY11 FY12 Fiscal Year FY13 FY14 Government Paid Amounts Government Paid Amounts Per Person Pharmacy Costs for Colorectal Cancer, by Age Group, Over Time $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 Fiscal Year 18 to 30 31 to 44 45 to 64 Female 18 to 30 Female 31 to 44 Female 45 to 64 Male 18 to 30 Male 31 to 44 Male 45 to 64 • By FY14, Pharmacy costs highest for ages 45-64, closely followed by ages 31 to 44 • Pharmacy costs have been consistently higher for males ages 18-44 than other gender-age groups • Pharmacy costs for males ages 18-44 have generally consistently increased over time 12 Results Time-Series Regression: Non-Pharmacy Costs Model DC-Only Coef. P>|t| Age 31 to 44 Age 45 to 64 Comorbid Heart DX Diabetes COPD Asthma Arthritis Back DX Mood DX Other Mental DX Female time_female time_31to44 time_45to64 time _cons 1484.18 0.607 2760.96 0.273 390.58 0.702 13599.38 <0.001 283.96 0.866 -245.31 0.915 -3563.60 0.222 -2586.60 0.272 1843.86 0.241 6519.59 0.002 -329.77 -3102.64 29.56 510.87 756.18 -1199.16 22801.51 PC-Only Coef. P>|t| -4364.14 -9968.64 3935.92 1956.76 -3011.21 3532.93 -5616.72 -5830.35 44.15 674.31 0.369 0.029 0.000 0.036 <0.001 <0.001 <0.001 <0.001 0.952 0.498 Both Systems Coef. P>|t| Per person non- pharmacy costs for 20163.61 <0.001 Colorectal Cancer 10340.23 0.003 statistically 220.63 0.797 11396.42 0.000 significantly -1115.47 0.412 decreased over time 9135.50 <0.001 for DC-Only users. 1615.47 0.494 -3250.20 0.047 Presence of 1077.32 0.390 comorbid 3339.23 0.033 diagnoses significantly impacts 0.897 10111.67 <0.001 3730.76 0.092 costs in PC-Only and 0.081 -2108.00 0.092 -9694.92 <0.001 Both Systems. 0.926 0.374 0.118 0.021 0.000 -190.73 722.31 756.40 -960.02 26219.75 0.289 261.31 0.432 -1747.69 0.372 -884.89 0.266 -124.16 0.000 18970.62 0.400 0.021 FEMALES COSTS 0.189 0.861 WERE LOWER 0.000 THAN MALES…. 13 Results Time-Series Regression: Pharmacy Costs Model Age 31 to 44 Age 45 to 64 Comorbid Heart DX Diabetes COPD Asthma Arthritis Back DX Mood DX Other Mental DX Female time_female time_31to44 time_45to64 time _cons DC-Only Coef. P>|t| 2876.94 0.02 1908.07 0.116 -1418.56 <0.001 3116.94 0.018 2767.70 0.000 1448.21 0.140 1153.47 0.353 1176.94 0.240 1508.52 0.024 2745.39 0.002 798.69 0.462 396.40 0.687 -434.79 0.023 -402.00 0.105 -139.91 0.564 68.23 0.773 6848.33 0.000 PC-Only Both Systems Coef. P>|t| Coef. P>|t| 1430.86 0.088 2265.69 <0.001 1166.64 0.150 1610.01 0.014 553.23 <0.001 321.23 0.029 354.61 0.026 1134.45 <0.001 861.66 <0.001 934.14 <0.001 899.77 0.000 773.99 0.011 418.86 0.063 324.44 0.423 104.53 0.498 -5.08 0.986 990.58 <0.001 391.51 0.068 1464.25 <0.001 1320.95 <0.001 1392.07 <0.001 -225.87 0.552 116.03 0.760 -532.35 0.251 -122.65 0.083 0.97 0.991 -194.20 0.222 -146.01 0.263 -225.98 0.138 -82.75 0.524 392.80 0.016 5.69 0.965 -36.29 0.967 2252.00 0.002 Per person pharmacy costs for Colorectal Cancer statistically significantly increased over time for PC-Only users. Presence of comorbid diagnoses significantly impacts pharmacy costs in all systems of care. 14 Results Time-Series Regression: Total Costs Model Age 31 to 44 Age 45 to 64 Comorbid Heart DX Diabetes COPD Asthma Arthritis Back DX Mood DX Other Mental DX Female time_female time_31to44 time_45to64 time _cons DC-Only Coef. P>|t| 4078.70 0.231 4387.51 0.140 -1023.12 0.396 16719.54 <0.001 3060.27 0.125 1177.25 0.666 -2509.91 0.466 -1463.06 0.599 3332.14 0.073 9189.28 <0.001 437.50 -4041.20 -118.05 162.28 682.18 -1132.38 29732.76 PC-Only Coef. P>|t| -2769.48 0.586 -8484.83 0.075 4488.08 <0.001 2312.97 0.018 -2149.05 0.006 4434.80 <0.001 -5197.24 <0.001 -5724.73 <0.001 1036.42 0.175 2140.08 0.040 Both Systems Coef. P>|t| 22344.11 <0.001 11657.45 <0.001 540.88 0.547 12530.88 <0.001 -177.27 0.901 9909.02 <0.001 1941.17 0.432 -3254.68 0.058 1469.76 0.263 4659.00 0.005 0.885 11505.58 <0.001 3507.42 0.130 0.054 -2241.78 0.087 -10432.80 <0.001 0.755 -263.20 0.162 307.47 0.344 0.811 494.65 0.607 -1874.92 0.018 0.232 462.15 0.602 -902.83 0.201 0.065 -591.21 0.512 -156.18 0.833 0.000 26304.06 0.000 21393.37 0.000 Per person total costs for Colorectal Cancer marginally statistically significantly decreased over time for DC-Only users. Presence of comorbid diagnoses significantly impacts PC-Only and Both Systems. 15 Summary Non-pharmacy costs for colorectal cancer patients decreased non-significantly by 1% between FY07-14. decreased significantly for users of DC-Only care. statistically significantly decreased over time for ages 31-64 compared to ages 18-30. Total pharmacy costs (all scripts) increased non-significantly Per person costs increased significantly for PC-only users. Total costs Non-significantly increased over time Significantly decreased for ages 31-64 compared to ages 18-30 Presence of comorbid conditions significantly impacts costs across systems of care, in both positive and negative directions. 16 Conclusions Changes in per person costs likely relate to updates in clinical guidelines, reimbursement criteria and pharmaceutical treatment options for treatment of Colorectal Cancer Updates in clinical guidelines and pharmaceutical treatment options may have important cost implications, which may be seen mostly clearly by age group. Younger age groups less likely to have CRCa screening, as the recommended age for screening is 50 years of age. Advanced stage at diagnosis or more aggressive cancer may explain differences in costs. Results reflect overall trends to increase CRCa screening. 17 References 1. 2. 3. 4. 5. SEER Cancer Statistics Factsheets: Colon and Rectum Cancer. National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/statfacts/html/colorect.html U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2012 Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2015. SEER Cancer Statistics Factsheets: Colon and Rectum Cancer. National Cancer Institute. Luo Z, Bradley CJ, Dahman BA, et al. (2009). Colon Cancer Treatment Costs for Medicare and Dually Eligible Beneficiaries. Health Care Financing Review. 31(1): 35-50. Hynes DM, Tarlov E, Lee TA, et al. (2007). VA Colon Cancer Quality and Costs Study: Estimating Healthcare Costs for Colon Cancer. Work done for VA. Last accessed: September 29, 2015. Obtained from: http://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archi ves/hmcs-101712.pdf 18