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2019 HSR&D/QUERI National Conference Abstract

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1058 — How Patient Targeting Affects the Cost of Care for Veterans Receiving Primary Care in Patient Aligned Care Teams (PACT) vs. Geriatric PACT (GeriPACT)

Lead/Presenter: Ciaran Phibbs,  Resource Center - HERC
All Authors: Phibbs CS (GECDAC, VA Palo Alto Health Care System and Stanford University School of Medicine), Intrator O, GECDAC, Canandaigua VA Medical Center and University of Rochester Kinosian B, GECDAC Philadelphia VA Medical Center and University of Pennsylvania Hong, J, GECDAC, VA Palo Alto Health Care System Scott W, GECDAC, VA Palo Alto Health Care System Dally S, GECDAC, VA Palo Alto Health Care System Edes T, VA Geriatrics & Extended Care, Washington, DC

Objectives:
GeriPACTs are geriatric-focused primary care teams with lower caseloads (2/3 of PACT) and additional team members (e.g., pharmacy) to address the complex needs of patients with potentially higher need for geriatric and extended care (GEC) services, especially those at high-risk for institutional placement or who have high costs due to multiple chronic conditions and/or cognitive or functional decline. We examined the effect of GeriPACT on total VA and Medicare healthcare expenditures.

Methods:
Veterans in PACT or GeriPACT in FY2013 at 84 VA Medical Centers or Community Based Outpatient Clinics with verified GeriPACT. JEN Frailty Index, a measure assessing the need for long-term institutionalization (score between 0-12), over 2 identified Veterans with frailty potentially needing GEC services. NOSOS, VA's refinement of the Medicare HCC model to include adjustments for service-connected and psychiatric conditions and medication use, was used to create expected expenditures. Regressions estimated the effect of GeriPACT on log expenditures comparing GeriPACT Veterans to different cohorts of regular care (PACT) patients by propensity score matching and weighting. Additionally restricting to patients meeting Independence-at-Home eligibility criteria (IAH-Q).

Results:
GeriPACT patients were older (82 vs. 64), with higher NOSOS and JFI scores. Across all comparisons, the point estimates for GeriPACT were always negative (cost saving), but not always significant. Estimated savings ranged from < 1% to 16%. Estimated savings tended to be larger for VA-only expenditures, compared to VA plus Medicare, and much larger for the IAH-Q cohort. Savings were consistently larger for patients with a JFI 3-5, compared to patients with a JFI < 3 or 6+.

Implications:
The robustness of the estimates that GeriPACT reduced both VA costs and combined VA-Medicare costs, especially when targeted at patients with JFI 3-5, implies that GeriPACT probably reduces costs, and certainly doesn't increase costs. The effectiveness of GeriPACT is sensitive to which patients receive this more intensive care mode, so care needs to be taken to target patients who are appropriate candidates for GeriPACT.

Impacts:
GeriPACT can be better targeted to Veterans to achieve better cost control with Veterans having JFI < 3 managed in PACT and Veterans with JFI > 6 probably requiring more intensive management such as Home-Based Primary Care.