Chronic obstructive pulmonary disease (COPD) is currently the fourth-leading cause of death worldwide.1 In the United States, during 2014 and 2015, 5.9% of adults (more than 15.9 million) had COPD.1 The economic costs within the United States were estimated to be $32.1 billion in 2010 and were projected to increase to $49.0 billion by 2020.2 COPD is typically a progressive disease marked by a gradual decline in lung function and, in many cases, repeated exacerbations lead to severe disease. Due to its progressive and debilitating nature, COPD can interfere with a person's ability to work, leading to productivity losses and lost wages for workers and their employers.
Numerous studies have indicated that COPD severity, as measured by spirometry, is a key element influencing a person's capacity to engage in strenuous activities.2,3 Therefore, disease severity is likely to be a critical determinant of work capacity with established COPD. Although the direct costs of COPD are well documented, the cost impact of different levels of COPD severity is not well known. Understanding the prevalence of COPD in a population or risk pool and the severity of the disease in individuals is important to plan, implement, and monitor population management programs. Studies have shown that even a basic chronic condition management program can reduce inpatient and emergency room (ER) admissions for COPD and potentially reduce healthcare costs.3
The severity of COPD is primarily assessed by physicians using the results of investigative tests, and this information is not available in claims data. Methodologies that allow for severity-based segmentation of COPD using claims data alone will help payers and employers develop insights into disease severity and utilization and cost implications. This poses the question of which criteria can be applied to identify COPD severity in patients from claims without results for investigative tests available in the claims data.
To solve the above concern, Medinsight® Chronic Conditions Hierarchical Groups (CCHGs) has a feature that identifies individuals with severe and less severe COPD based on Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, as well as other published evidence.4,5 To identify COPD severity the tool uses an algorithm based on recognizing specific patterns of service utilization, including multiple inpatient or ER visits, oxygen support, and spirometry services. MedInsight’s Chronic Conditions Hierarchical Groups is one such product that enables patient-focused analyses, including COPD severity.
To identify the severity of members with COPD, we analyzed a large data set containing commercial insurance claims from major health plans in the United States. We used MedInsight’s CCHGs to identify individuals with severe and less severe COPD and conducted further analysis of utilization patterns and costs for 2017. CCHG assigns one primary and up to five additional CCHG chronic conditions for a member in a month. The primary CCHG is the highest-ranking active condition category for a member that is the most significant driver for trend and expenditure. For this blog, the COPD population refers to those with a primary CCHG of COPD.
Note: Not all members with COPD will be included in this population—only members with a primary CCHG of COPD will be included. For example, members with COPD and a higher-ranking active CCHG condition category are excluded, as they will be in the CCHG of the higher-ranking active CCHG condition.
Overall, the results highlighted that 20% of members with chronic disease accounted for 60% of total spending. Figure 1 compares healthy and chronic disease populations. As we can see from Figure 1, a relatively small number of members with chronic disease has a significant impact on total costs.
Figure 1: Chronic disease profile
For the COPD analysis, CCHG identified 1% of the COPD population, from the entire population, that accounted for 0.2% of the total cost. We conducted further analysis to determine cost drivers and understand utilization for different services and settings (Figure 2). As we can see, it is apparent that office-based care was utilized by a high percentage of the COPD population, which can be considered a good sign. Based on clinical consensus, it can be hypothesized that regular office visits can be helpful for the timely assessment of disease and to prevent its exacerbation.
Figure 2: Utilization and cost patterns of members with COPD
Our review of the COPD population using CCHGs showed that approximately 40% had severe COPD and were responsible for approximately 58% of the total cost attributed to the COPD population (Figure 3). Results from this figure can be used to identify the severity mix of the COPD population, which can be important information for planning.
Figure 3: Profile of members with COPD by severity
We wanted to understand the pattern of cost and utilization for members with severe COPD. Figure 4 shows that ER visits and inpatient admission services were the major factors driving the cost and utilization for these members. Identifying members with severe COPD cases will support opportunities for disease management programs focusing on avoiding the exacerbation of disease and preventing admissions.
Figure 4: Utilization and cost for members with severe COPD
Using CCHGs, as evident from the results above, could prove valuable as a tool to identify members with severe COPD and to refer them for potential outreach by disease management services.
COPD is typically a progressive disease marked by a gradual decline in lung function and, in many cases, repeated exacerbations. Optimal chronic disease management should focus resources and educational activities on patients’ individual needs to enhance outcomes and encourage patients to actively participate in managing their condition.6 Therefore, management must be reviewed regularly and tailored to the changing needs of patients. Population-based severity stratification can be used to optimize pharmacotherapy and timely referral to pulmonary rehabilitation to reduce the risk of exacerbations.6
The CCHGs enable clients to make smarter and more informed decisions on financial trend drivers. They can help medical management departments by allocating disease, severity, and care management resources more effectively.
For more information on healthcare services utilization of chronic conditions, visit the MedInsight CCHG web page at https://www.medinsight.milliman.com/-/media/medinsight/pdfs/medinsight-chronic-conditions-cchgs.ashx.
1 Sullivan, J., Pravosud, V., Mannino, D.M., Siegel, K., et al. (2018). National and State Estimates of COPD Morbidity and Mortality – United States, 2014-2015. Journal of COPD Foundation;5(4):324-333.
2 Centers for Disease Control and Prevention. COPD Costs. Retrieved March 29, 2023, from https://www.cdc.gov/copd/infographics/copd-costs.html.
3 Rice, K.L., Dewan, N., Bloomfield, H.E., Grill, J. et al. (2010). Disease Management Program for Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial. American Journal of Respiratory and Critical Care Medicine Vol 182. pp 890–896.
4 GOLD (2020). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Retrieved March 29, 2023, from https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf.
5 Stanford, R.H. et al. (March 16, 2016). Validation of a New Risk Measure for Chronic Obstructive Pulmonary Disease Exacerbation Using Health Insurance Claims Data. Ann Am Thorac Soc Vol 13, No 7, pp 1067–1075. Retrieved March 29, 2023, from http://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.201508-493OC.
6 Lung Foundation Australia (May 21, 2020). COPD-X Concise Guide a crucial resource in delivering best-practice care for COPD.– Retrieved March 29, 2023, from https://lungfoundation.com.au/news/updated-copd-x-concise-guide-a-crucial-resource-in-delivering-best-practice-care-for-people-with-copd/.