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On May 1, 2009, Diane Orenstein and Susan Haber presented the
first of a series of events highlighting the latest releases
of several AHRQ tools. This presentation addressed the Centers
for Disease Control and Prevention (CDC) Chronic Disease Cost
Part 2 of 2 (files split due to size of full-length
Audio File, 40.5 minutes, 19.0 MB)
Return to Transcript,
Amanda Brodt: Great. Thank you for the demonstration,
Susan. We could have used any State as an example State for this analysis. We
purposely picked Kansas to do a walk-through of their data because the greatest
number of participants on today's call are from Kansas. We've
also asked the State's Medicaid Medical Director, Dr. Margaret Smith,
to provide some reactions to the numbers as they were just presented. Margaret,
did any of the prevalence rates or associated costs surprise you? What
did you learn from the analysis?
Margaret Smith: This is Margaret Smith from Kansas. I
thought it was interesting. I didn't expect that the prevalence
rates would be lower in Kansas than they were in the U.S. as a whole. But they
were pretty close. So not really surprised here. I was interested
to see that, with each of the diseases that you looked at, we're pretty
close to the U.S. average on cost per beneficiary. So that was an interesting
thing to note, especially since we have been noticing that our cost overall
for our chronic disease population has increased rapidly over the past few
years. But of course, this data is from 2004 so it wouldn't capture
I did have a couple of questions that I wanted to ask the presenters. First
of all, correct me if I'm wrong, my understanding is that this data includes
both the managed care population as well as the fee-for-service population
in the State in the estimates.
Susan Haber: That's right. Yes. That's
because we were using the MEPS data rather than the Medicaid claims data for
the main source of our cost estimates. So MEPS, they go out and survey
everybody or a sample of the population regardless of whether they are in managed
care or fee-for-service Medicaid. And then they ask people to keep track
of what services they're using and then they also go out and validate
that against medical records and provider offices and things like that. They're
not relying on claims data for getting their estimates. That's
one of the advantages of using the MEPS data rather than Medicaid claims data. More
and more Medicaid beneficiaries are enrolled in managed care, which is a great
thing, but then we lose their claims data, and you can't do these types
of analyses in something like the MAX data or the MSIS data that States report
to CMS. That's the great advantage of using the MEPS data. Obviously,
certain populations are enrolled in managed care rather than fee-for-service
Medicaid. So if you only look for Medicaid at the fee-for-service population,
you get a very biased picture of what Medicaid is spending and what the prevalence
is and things.
That was a long answer to your question. Sorry.
Diane Orenstein: If I could just shortly add to that, Susan…one
of the reasons why we wanted to use the MEPS data is to make it easy for States
that don't have access to the data or don't have clean data or
have the resources, being staff and financial resources, to actually do their
own calculations. This allows every State to have the ability to use
this calculator and use a consistent methodology as well as data source across
Dr. Margaret Smith: The other question I have is, the cost
per beneficiary that you present here, is that the cost that's attributable
just to that disease? That's not going to be our total cost for
that beneficiary, is that correct?
Susan Haber: That's correct. That's one
of the ways that our cost estimates differ sometimes from other estimates that
you may see out there in the world. They may look at who are the people
that have these diseases and what's the total amount that Medicaid is
spending for them. Whereas we're looking at just the amount that's
attributable to that disease. There are reasons for doing each way, there
are pros and cons of each. But obviously even if you control hypertension
or you find less costly ways of strokes--for example, keeping people out of
the nursing home--that's not going to get rid of all of the medical costs
that people have. So that's why we wanted to focus in on specifically
the costs that are attributable to these diseases.
Dr. Margaret Smith: Do we know if those people that have
the chronic diseases have higher costs otherwise--say, for their preventive
care or whatever--beyond the cost that is attributable to the disease?
Susan Haber: Well, we didn't look at that in this. I
couldn't speak to preventive care in particular, but certainly lots of
other people have looked at what are the costs of people with chronic diseases--the
Center for Health Care Strategies has done this, there's some work from
people out of John Hopkins--and all of that shows that overall the costs for
people with chronic diseases are much higher than costs for people without
chronic diseases. But we didn't address that in this calculator.
Dr. Margaret Smith: Okay. The other thing I thought
was interesting is that if you look at our prevalence data and you look at
our cost per beneficiary…if you just look at the cost per beneficiary,
you would tend to focus on, say, congestive heart failure or diabetes. Obviously,
diabetes is one that is very big and it still has one of the higher prevalences
of these diseases. But something like hypertension, which has an attributable
cost that isn't as high as those other things, certainly not as high
as stroke, has the total overall greatest amount of costs because of the high
Susan Haber: Absolutely.
Dr. Margaret Smith: Just a technical question--so how small
a population can I introduce into the calculator before I start getting lots
of insufficient boxes in my estimates?
Diane Orenstein: The insufficient boxes are based on our
analysis of the MEPS data. We were analyzing the MEPS data--the prevalence
of these conditions that was surveyed in MEPS was not large enough. If
you have your own data, if you have some estimates yourself of prevalence conditions
at the county level or something like that that you want to use, you can always
enter those in. You won't get any insufficient. You just
need to use your own judgment that your sources of data are adequate to support
analyses at that level. We're just saying that based on the data
we use to create our default estimates, we couldn't do it any finer than
what we show there.
Dr. Margaret Smith: If I'm trying to develop a care
management program that focuses on diabetes and I've got a pilot and
I only have 200 people in that pilot, I could still get some estimates even
though I only have a small number of people?
Susan Haber: Sure. First of all you've got what
the per-person cost is. You know what the per-person cost is. So
you could just take that number there and say, "Here is the per-person
cost, I have 200 people in this pilot, I think I can reduce per person costs
by 10%" You can use that number and the 200 people you've
got in your pilot, reduce that per-person cost by 10%, multiply by your 200
people and see what your savings are.
Diane Orenstein: This is something that Susan and I have
presented at other meetings when we are there in person. You can look
at this as, if you feel that you have a program that would reduce the prevalences,
what would the costs look like? You can enter it the other way as well--if
you can reduce the cost by X amount, what would that look like?
Once you go in and download the tool and use it, you can play with that and
say, If we have--whether disease management programs or other programs through
our health departments, etc.--and we were able to reduce the prevalence, what
change would we see in those costs? When you mentioned about hypertension,
this is a wonderful way to look at this. If you are going to use this
in aiding you in having discussions about disease management, you can see that
the focus of hypertension is so high, if you can reduce it, then you know that
you probably are going to be able to reduce stroke and heart failure in the
future. Even though this is a burden as well as a cost, it still gives
you some of the information when you are thinking about how to focus your programs
or which programs you would like to create and hopefully reduce those burdens.
Dr. Margaret Smith: That's what I see is the most benefit
from the calculator. It could be used to either help you figure out where
you want to focus your efforts or it could be used to help you decide if you
really have made a difference, sort of if you bent the curve in terms of the
increase in costs for the chronic disease population.
Amanda Brodt: Thank you, Margaret, Susan, and Diane, for
some of your answers. I know we have a lot of people in the queue who
also have some questions to ask. I wanted to open the call up to all
participants. Feel free to either continue to ask questions electronically
from the Q&A panel or we're now going to open lines such that you
can use the raise hands function that is on the participant list. If
you click on that option, our moderator will unmute your line and you'll
be able to ask your question orally. For those who have submitted electronic
questions, if you prefer, please do feel free to ask any of those orally or
we'll continue to go through the list that has been generated as we were
Question: The first question that we're going to address
from that list goes directly to the tool demonstration. We had a request
to show how exactly one goes about saving the outputs in a text and in an MCC
Susan Haber: Gee, I'd have to go back into my desktop
to do that. Actually, if you want to, I can just tell you. It's
quite simple. Let's say you wanted to save it to the text file. Click
on the button that says save and it's going to ask you where
you want to save it to, what folder in your computer you want to save it to. It's
going to ask you to give a name to it. Once you do that, it will save
the information for you. The output is going to be saved in something
called a CSV file. It looks like an Excel spreadsheet. It basically
has that type of format. Same thing, if you want to save the input, again
you just click on the button and it will ask you where you want to save it
to and give the file a name and you're done. It's quite
I hope that answers the question. If necessary, I can go back to the
Moderator: At this time we have a live question request from
Mark Mailer. Mark, your line is unmuted and you can go ahead with your
Question: Thank for that response. I guess my question
along that line had to do with, number one, I'm not aware that I have
an MCC file on my computer. So I just don't know how to make that
connection. I don't have MCC software and so I don't know
how it would go into an MCC file. The second question is, You said to
import it into a text file and you can do manipulations on the data. I
don't know how to do manipulations on text file. I can do manipulations
on an Excel spreadsheet but that would not be a text file. So I was
just kind of curious as to what kind of files these things are going to go
into. Are they in my computer and how can I manipulate the data if it's
in text rather than actual data?
Susan Haber: Right. So I don't believe you need
any special software to do this because I don't have MCC software on
my computer either. It's just a format it will save the file as. You
don't need anything special to do that when you save it. That's
the format it will be saved as. If you want to manipulate the output
file, it will be saved as a CSV file, but then you can open that up in Excel,
for example. It will go into Excel perfectly and you can manipulate in
Question: We have had a number of questions about whether
you'd be able to select site-specific cancer estimates, e.g., colorectal
Susan Haber: Yeah. We did not do that for this project
because the sample size in MEPS just wasn't large enough to support site-specific
cancer estimates. So we don't have that in this, unfortunately. This
is just an average across all cancers and it reflects the mix of cancers in
your State Medicaid program.
Diane Orenstein: That's actually listed in the technical
user guides, which cancers.
Question: Great. We've had another question come
in that refers to someone mentioning at the beginning of the presentation that
one could download the code for the cost calculations. They would like
some clarification on how that would be done.
Susan Haber: Sure, actually Diane said I would talk about
that and I didn't, so I apologize. The calculations in this are
based on the MEPS data, but we also wrote parallel code where you can do the
same type of calculation using your Medicaid claims data. We've
written sample SAS code that you can use, and we've got instructions
about what you need to do. Basically, we describe what variables you
need to create in your data to do these analyses, what you should call the
variable, how to set up the file to do the analysis. You can run the
data against the SAS code that we provided using your own State Medicaid data. It
means you are going to have to be able to manipulate your Medicaid data. For
example, the basic variable that you need is a variable for what the total
Medicaid expenditures are for a person during the year. You need information
on what diseases the person has. So basically, you need to go through
your claims data for a person to find claims that have different diagnoses
on them. We have written code that will do that calculation for you,
but you have to have the Medicaid data set up in the right way to run through
it in that way. We have provided that sample SAS code. So you've
got to have SAS and you have to have some ability to manipulate your own Medicaid
Diane Orenstein: It's not anywhere in the format where
the tool is, but it has all been for you using the MEPS data. You have
to have that information and manipulate it and do all that yourself. We
just provide how to do it--the codes to do it or the program to do it.
Question: Great. Thanks. We have a quick clarification
to that question and some followup. We're wondering where to go
to download the information and the sample code. Is there a link on the
Web site? How do you access that information?
Susan Haber: It's on the CDC Web site. There's
a link to the code and to some documentation how to use the code. It's
all there on the CDC Web site.
Question: Then we have had a couple of questions come in
that are related to trending and whether there's any way to use the tool
to see changes and cost over time.
Susan Haber: Version 2. Do you agree Diane?
Diane Orenstein: Yes, version 2. That's not something
we could do here.
Susan Haber: I was going to say, the reason we included that
in version two is this question came up many, times when we presented this
and we realized that this is something that people wanted.
Question: Great. We have a couple of questions related
to cost estimates as well. One is asking whether there's any inflation
factor that can be used to project expenditures based on today's costs?
Diane Orenstein: Actually, Susan, you may want to speak to
this more. These costs are inflated to 2007 dollars. Even though
the data are from 2001 to 2005, they have been inflated. So what you're
seeing is the costs inflated to 2007 dollars, and version two will be inflated
to 2008 dollars. There's because when the MEPS data become available,
there's a lag time. So version two will be 2006. That's
the latest, so we will inflate that to 2008 dollars.
Susan Haber: The reason data are only inflated to 2007 is
that basically we were using estimates of the Medical Care Consumer Price Index
[CPI] to inflate the data from 2001 to 2005 up to 2007. 2007 was the
most current Medical CPI estimate that was available at the time. If
you've got some estimates of how costs in your Medicaid program have
been increasing between 2007 and currently and you wanted to apply that inflator,
you certainly could, although I caution you to make sure it's being used
appropriately. That's the only reason we go up to 2007.
Diane Orenstein: One thing--I didn't know if it would
be useful to address--is if there are any questions about the cost, how you
looked at the regional costs to get the costs for services.
Susan Haber: Right. Well what we did is--basically,
the costs are adjusted for many States, and the adjustment represents differences
in medical costs between your State and other States in the country, or between
that and the national average. There are some States where the sample
isn't large enough in the MEPS data to actually get a good State-level
estimate. So for some States, we're using regional estimates of
what that region's costs are to adjust the medical spending. But basically,
these are all being adjusted to reflect variation and costs within the States
or within regions of the country. Is that what you were referring to
Diane Orenstein: Yes. You don't want to use the
cost for New York to represent all the States or the cost for South Carolina
to represent all the States.
Susan Haber: Yes. Absolutely.
Question: Another quick question about version two…will
that allow grouping by year of data?
Susan Haber: The way version two will work is there will
be a base estimate, which will be, maybe, 2008, and then we're going
to show for the next 10 years. I believe it will be year by year. I
won't swear to that. I don't know if it's going to
be year by year or if it's just going to be 10 years out, what the costs
will be. That's how that's going to work. It's
going to drive off of changes in population demographics and the prevalence
of these different conditions within different population groups. I
don't know if that answered the question. I don't remember
right now or I don't know if we've decided right now if we're
going to show each of the 10 years or just 10 years out.
Diane Orenstein: I think we're working on that. Trying
to figure that one out.
Susan Haber: Version two is still in process.
Diane Orenstein: It's a lot more complicated because,
instead of just Medicaid, we have Medicare and other payers. So that
makes it even more complicated for our development. Hopefully not for
Question: Speaking to demographics, we had a question raised. Will
calculations be available by race and ethnicity in version 2?
Susan Haber: Unfortunately, that's a MEPS sample size
limitation and the sample wasn't large enough to support estimates by
Question: There is a question about the
per-person costs included in the direct costs. So we're
including outpatient, inpatient, medication, long-term care, etc., but we're
not including indirect costs in the calculator, right?
Diane Orenstein: In the current calculator, we are not. In
version two, we are doing indirect costs but only by defining them by data
on absenteeism. Indirect costs can include so many different costs, and
after looking at the literature, we believe this is the best way to capture
indirect costs for lost productivity. So we'll also, in the user
guide, be very clear to explain what absenteeism is, what that represents,
and what the data source is.
Queston/Comment: Great. As a break in questions, we've
received a comment, a request for version two to please include the total costs
per member rather than disease-attributable costs in future versions of the
Susan Haber: I think what this person is asking is, What's
the average cost per person with diabetes or with hypertension, and not parsing
it out to the costs attributable specifically to those diseases.
Question: There was also another question raised about costs
in terms of the next version. Are you looking to break down the costs
by buckets, including pharmacy costs or inpatient costs associated with a given
disease? That would be a powerful feature if you could.
Moderator: At this time, we do have an open line request
from Lisa. Your line is open. Go ahead with your question.
Question: Hi. Actually I have two questions. One
is whether the cost estimates that you are providing are annual estimates. That's
pretty simple. And the second question is, since you are going to be
including cost estimates for children with asthma in version two, what are
you going to be using for absenteeism if that's going be included?
Susan Haber: The answer to the first question is yes. These
are annual costs. And the answer to the second one, in terms of absenteeism
for children with asthma, it's going be based on children missing time
from school and then it's assuming a parent has to miss time from work
when a child is absent from school. So the absenteeism will be the parent's
lost time from work due to the child's illness.
Question: Thank you. We'd like to return now
to the question that we had just asked prior to your question. Looking
specifically at the breakdown of costs, in the next version can there be a
breakdown of pharmacy costs, inpatient costs, etc., that are specific to the
disease? If they had the ability to break down the costs, it would be
a powerful feature for the tool.
Susan Haber: You know, well, I guess I partly defer to Diane
on this. The current plans for version two do not include that. I
believe that, in theory, it's possible. It's just not in
our current plans for it.
Diane Orenstein: I think that when we hear these questions,
just as we said, they have certainly had input in how we have been designing
version two. If we have a summary of these questions, it's something
that we do go back as a team and work on, and discuss. Even though it's
not in there now--I can't say it will be--but it's certainly a
question that will be up for discussion. That doesn't mean we can
do it. It means we can debate it, look at whether it's something
that can or cannot be done in this version, and what it would entail to do
that. I'm not trying to be difficult about this, but every change
is a cost to us. We really do appreciate this type of input so we can
make sure we create a tool that addresses the issues for our audience, which
is you all.
Question: Diane, you may not want another suggestion, but
there has been a comment about version two possibly allowing estimates by type
of facility--acute care hospital versus critical care hospital, etc. Also
when you are considering version two, you may want to break down some of the
Diane Orenstein: That may depend on whether the MEPS data
has that information.
Susan Haber: Yeah. My guess is that it's not
in the MEPS data. That's sort of the broader type of categorization,
that inpatient versus prescription drugs versus office. That I think
we can get to, but that finer breakdown by type of institutional facility,
I think, is not in the MEPS data.
Question: We have another question about the current tool. This
person wants to know, When seniors can't access health care due to a
lack of providers who accept Medicare, how will their health costs be calculated? Would
they be included in the tool?
Diane Orenstein: In version one, I think the answer is no.
Susan, please correct me. In version two, I don't know if that goes under "other
Susan Haber: I'm assuming that the person means that
they've actually paid out of pocket for the services, so they've
actually accessed the services, they are just not being paid through Medicare/Medicaid. Version
two, the way it's broken down is we have Medicare estimates, Medicaid,
private insurance, and then we have total, which would include everything,
other types of insurers as well as individual out-of-pocket payments.
Diane Orenstein: Again, I'd hate to say we're limited
by what MEPS provides because it provides so much for us, but we're using
the MEPS data so we do have some types of restrictions of what we can and cannot
Question: A question was raised asking if there was dialog
between people that developed this calculator and those who developed the ROI
[return on investment] calculator at the Center for Health Care Strategies. Probably
a general question is, How does this calculator tool vary from others that
are out on the market?
Susan Haber: Certainly, when we started this project, no,
there wasn't dialog. But probably about a year or so ago, we were
contacted by the people from the Center for Health Care Strategies. I
did make a presentation to a group of people through them. Basically,
they serve kind of different purposes. Ours is not an ROI calculator,
but when I spoke with the people there, they viewed this as something that
could feed into their ROI calculator. For their calculator, you need
to know what a disease is costing you. Then it goes from that to estimate
what the potential savings are from a particular intervention. So I guess,
in our discussions, it seemed like it could potentially provide an input that
someone might use in their ROI calculator.
We were not in communication to start with for sure.
Diane Orenstein: I think these complement. They're
for two different purposes but our data can be used in theirs.
Question: Thanks. We have a quick question about whether
risk adjustment has been incorporated in the estimates and whether or not that
Susan Haber: No. There's no risk adjustment here. I
guess I don't think that's applicable in this case because we're
just reflecting what is the cost for this population in your Medicaid program. I'm
not sure how risk adjustment would apply here. We're not trying
to make people with hypertension more comparable to somebody else. We're
trying to reflect what the people with hypertension cost. There's
no risk adjustment here.
Amanda Brodt: Are there other questions that people have
not had a chance to ask? Please feel free to use the Q&A panel or,
if you would like to raise your hand and ask a question orally, our moderator
will unmute your line.
Susan Haber: I would like to go back to the risk adjustment
briefly, as I'm sitting here contemplating it. I guess in a sense,
our numbers reflect the different risk associated with these populations, or
at least a piece of the risk. So, this is how much more a person with
hypertension costs than a person without hypertension. So in that sense,
it's reflecting the different risks. Sorry about that.
Hilary Kennedy: We are coming to the end of our time. We
have a couple of people with their hands raised. If the moderator could
address those, that would be fantastic.
Question: If the data that you are calling costs--I'm
assuming it's Medicare expenditure data--what data would you have from
private payers that would provide that expenditure data to include them in
this cost estimator?
Susan Haber: The MEPS dataset includes everybody, not just
people in Medicaid. It includes privately insured people, people in Medicare;
it's everyone. What the MEPS people do is ask everyone: What's
your source of insurance? So we use that to identify whether a person
is a Medicaid beneficiary versus a Medicare recipient versus someone who's
Question: How do you know the expenditures that go along
with that coverage? It's what they reported paid on their behalf
by the payer?
Susan Haber: Well, exactly, but then MEPS is a very impressive
dataset. They start out by asking people that question, but then they
go out and they do a lot of validation of the information that's reported
by the respondents to the survey. I am not a MEPS expert. There
are other people in our group here at RTI who are much greater experts than
I am, and I'm sure there are people at AHRQ who could speak to this. There
are people being asked to keep track of this information and report it in the
survey. AHRQ goes out and validates that, for example, by going out to
their insurer and their physician's office to make sure they check the
accuracy of what people are reporting.
Question: I was just wondering…you've mentioned
the sample size being a factor. I'm assuming that also applies
to county-specific information, that it's not projected to be available
in version two?
Susan Haber: That's right. Yeah.
Question: Thanks. We have one quick clarification question: this
is cost data and not charges?
Susan Haber: Right. This is cost. This is what
Diane Orenstein: This is what Medicaid pays out.
I actually want to go back to the question about counties because we've
been asked this before. Again, if you can put in--and Susan, you may
need to help me out on this one--if you have some of your own data about the
prevalence within your county, I wouldn't say this is an accurate estimate,
but it can be probably a better guesstimate for you.
Susan Haber: Absolutely. I would agree with that. If
you've got some information on county-level prevalence, for example,
you could use that and get an estimate. You would be assuming that the
per-person costs aren't different at the county level. But at least
you could reflect differences in the prevalence across different counties.
Diane Orenstein: And that's where we were saying in
some earlier questions that you can manipulate your output based on what you
put in for your county, or for any dataset that you would like to use for the
prevalence. You don't have to use our defaults. So maybe
the answer to your question is "somewhat."
Susan Haber: If you can provide the information.
Diane Orenstein: Right. It will do the calculations.
Hilary Kennedy: Thank you so much. These are some wonderful
questions offered electronically and by raising your hand. We appreciate
all of them. We're now going to pass this call to Margie Shofer
for some concluding remarks.
Margie Shofer : I want to thank everyone for the great questions. You
asked a lot of really good questions. I want to thank you for participating
in today's call. We hope this discussion was helpful to you. If
you have any more questions either now or after you've had a chance to
explore the calculator, please don't hesitate to submit them to the Quality
Tools e-mail address. We gave that address to you in the slides. We are
also very interested in hearing how you use the calculator. Please let
us know about that. Be on the look-out for followup e-mail from us inquiring
whether you have used this or have used any of our other tool offerings.
I also want you to know there will be upcoming Web conferences this summer featuring
the online version of the Asthma ROI Calculator and the latest version of the
State Snapshots. Neither of these tools have been released yet, but we
are hopeful that they will be released in the next few months. I'd
like you to fill out the evaluation that will show up after we end the Web conference. We
really value your feedback and want to get a better idea of how you might use
this tool. So thanks again. This concludes the Web conference and
we look forward to hearing from you. Bye-bye.
Current as of May 2009
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