Michelle Kloc, Ph.D., MSN, RN November 4, 2013

1. Age-Focused Evaluation of Prevalence, Healthcare Costs, and Utilization, by CCS Condition, in the Military Health System Michelle Kloc, Ph.D., MSN, RN November 4, 2013 American Public Health Association 141st APHA Annual Meeting

2. Research Team • Altarum Institute • Michelle Kloc, Ph.D., MSN, RN [michelle.kloc@altarum.org] • Joe Dorris, MA • Charles Roehrig, Ph.D. • Department of Defense • Office of the Assistant Secretary of Defense (Health Affairs), Defense Health Agency, Defense Health Cost Assessment and Program Evaluation • Diana Jeffery, Ph.D.

3. Presenter Disclosures Michelle Kloc “No relationships to disclose” The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

4. 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, Air Force, or Coast Guard

5. Introduction Study builds on interest in determining health care condition prevalence, costs and utilization by various demographics (e.g. enrollment, age, gender, beneficiary category, etc.) and assessing trends over time. A driving research interest related to identification of the ‘chronic’ population and its characteristics in order to appropriately determine Patient Centered Medical Home (PCMH) design, policy and resource allocation.

6. Methods • Population: • All unique MHS beneficiaries alive and eligible within the study period, within the U.S. • Beneficiaries with death during the study period were flagged • All MHS eligibles which represented approximately 10 million people each year, with a focus on those age 18 – 64 • Excluded beneficiaries overseas for the full year • Time Frame: • FY06 through FY11, inclusive • Data: • Obtained from SADR, SIDR, TED-I/N, PDTS, Ancillary (Laboratory/Radiology), DEERS VM6 PITE representing directly provided and purchased inpatient, ambulatory, pharmacy, and ancillary care linked to enrollment and eligibility records. ** Results present data from 2 studies of the same population conducted from FY06-10 (excludes Alaska) and FY07-11 (includes Alaska and Hawaii).

7. Methods • Classification of Diseases • HEDIS-based measures • A beneficiary was considered to have a given chronic condition 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. Chronic conditions by ICD-9 were defined using AHRQ chronic condition definition set. • Individual ICD-9s were grouped into higher level conditions using the Agency for Healthcare Research and Quality's (AHRQ) Clinical Classification Software (CCS) • Over 14,000 ICD-9s were grouped into approximately 264 CCS conditions • CCS Classification based upon primary ICD-9 DX only • To provide greater operational relevance, Clinical Classification Software (CCS) condition categories were further grouped into higher level Medical Conditions based upon the method used by Dr. Charlie Roehrig (Altarum Institute) • The approximately 264 CCS were aggregated into approximately 43 Medical Conditions

8. Population demographics

9. Top 5 CCS Conditions, based on Cost, by Age Group, FY2006-2010

10. Top 5 CCS Conditions, based on Cost, by Age Group, FY2006-2010

11. Utilization for Top 5 CCS Conditions, based on Cost, by Age Group, FY2006-2010

12. Top 5 Conditions, based on Cost, for Females by Age Group, FY2007-2011

13. Top 5 Conditions, based on Cost, for Males by Age Group, FY2007-2011

14. Top 5 Medical Conditions, by Unique Diagnosis, Females Ages 18-44

15. Top 5 Medical Conditions, by Unique Diagnosis, Males Ages 18-44

16. Top 5 Medical Conditions, by Unique Diagnosis, Females Ages 45-64

17. Top 5 Medical Conditions, by Unique Diagnosis, Males Ages 45-64

18. Summary Back Problems is the highest cost and utilization CCS condition for the 35-44 and 45-64 age groups. This condition is the 2nd highest cost condition for ages 25-34. Other Musculoskeletal-related CCS conditions also rank in the top 5 CCS conditions across age groups (Other Connective Tissue condition, Other Joint diagnosis, Sprain, Osteoarthritis). Cost for Back Problems, in terms of Government Paid amounts, increase with age almost doubling in cost from age 35-44 to 45-64. Costs increase, within age groups, over the 5 year period. Back Problems, Musculoskeletal, GI, Maternal, Reproductive and Cancers are within the top 5 most costly Medical Conditions for females. Back Problems, Musculoskeletal, GI, Trauma/Injury, Mental Disorders and Cancers are within the top 5 most costly Medical Conditions for males. Musculoskeletal is consistently the 2nd-4th most diagnosed condition for males and females, Active Duty and Retired. It is the most costly condition for Retirees (males and females) and within the top 5 for other age groups. Results suggest that musculoskeletal conditions acquired while on Active Duty persist into retirement.

19. Back-Up Slides

20. CCS Assignments, Example Tuberculosis ICD-9: 010.0-018.9 There are 9 3-digit ICD-9’s and an additional 18 ‘sub-diagnoses’ (4-digit ICD-9s) for Tuberculosis-related conditions. (010) Primary tuberculous infection (010.0) Primary tuberculous infection (010.1) Tuberculous pleurisy in primary progressive tuberculosis (010.8) Other primary progressive tuberculosis (010.9) Primary Tuberculous infection, Unspecifed (011) Pulmonary tuberculosis (011.0) Tuberculosis of lung, Infiltrative ……. CCS: Tuberculosis CCS groups all relevant ICD-9s into specific conditions or condition groups. Ex.: Cancer of head and neck Septicemia (except in labor) HIV infection Hepatitis Viral infection

21. Medical Condition, Example Roll-up to 14,900+ ICD-9 Codes 264 CCS Condition Groups 024 : Cancer of breast 167 : Nonmalignant breast conditions 019 : Cancer of bronchus; lung 125 : Acute bronchitis 240 : Burns (140-149) Malignant neoplasm of lip, oral cavity, and pharynx (150-159) Malignant neoplasm of digestive organs and peritoneum (160-169) Malignant neoplasm of respiratory and intrathoracic organs (170-175) Malignant neoplasm of bone, connective tissue, skin, and breast (176) Kaposi's sarcoma Roll-up to 43 Medical Condition Groups Medical Condition groups were based on ICD-9 chapters (e.g. Neoplasms, Respiratory, Musculoskeletal), but allowed for separation of specific diseases (e.g. ADD, Asthma, ‘Birth’)

22. Methods • Cost Calculation • Laboratory/Radiology costs based upon primary diagnosis associated with the claim for purchased care. Lab/Rad costs taken directly from SIDR/SADR for direct care. • Focus on total government paid amounts/government costs. • People with OHI identified to allow for OHI cost impact analysis. • Costs in constant year dollars (standardized to FY10 based on DoD Green Book). • Utilization • Based upon primary diagnosis associated with the visit/stay • Prevalence • Person-level data de-duplicated to provide a count of unique patients per condition within each fiscal years data

23. Top 5 Medical Conditions, by Total Government Paid, Females Ages 18-44

24. Top 5 Medical Conditions, by Total Government Paid, Males Ages 18-44