California Regional Health Care Cost & Quality Atlas · 2019-12-17 · Higher quality, Lower cost...
Transcript of California Regional Health Care Cost & Quality Atlas · 2019-12-17 · Higher quality, Lower cost...
Dolores Yanagihara, MPH
September 23, 2016
IHA Stakeholders Meeting
California Regional Health Care Cost & Quality Atlas
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• Purpose: Illuminate variation in clinical quality, hospital utilization, and cost across geographic regions and payer types
• Collaborators: California Health Care Foundation, California Health and Human Services Agency
• Data Partners: Health plans, Department of Health Care Services, Truven Health Analytics
• Desired Outcomes: Identify “hot spots” for targeted improvement efforts; create baseline to measure progress against
Atlas Overview
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Atlas MeasuresC
linic
al Q
ual
ity
Tota
l Co
st o
f C
are 1. Risk-Adjusted Cost
(average per enrollee per year)
2. Observed (unadjusted) Cost
3. Total Cost Index
Ho
spit
al U
tiliz
atio
n 1. Emergency Department Visits per thousand member years (PTMY)
2. All-Cause Readmissions
3. Inpatient Bed Days PTMY
4. Hospital Utilization Composite
1. Breast Cancer Screening
2. Colorectal Cancer Screening
3. Blood Sugar Screening for People with Diabetes
4. Poorly Controlled Blood Sugar for People with Diabetes
5. Kidney Disease Monitoring for People with Diabetes
6. Medication Management for People with Asthma
7. Clinical Quality Composite
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Region
No
rth
ern
1. Northern Counties
2. North Bay Counties
3. Greater Sacramento
4. San Francisco County
5. Contra Costa County
6. Alameda County
7. Santa Clara County
8. San Mateo County
Cen
tral
9. Central Coast – North
10. Central Valley – North
11. Greater Fresno Area
12. Central Coast – South
13. Eastern Region
14. Kern County
Sou
ther
n 15. Los Angeles – East
16. Los Angeles – West
17. Inland Empire
18. Orange County
19. San Diego County
Atlas Regions
• Results by 19 regions, payer, and product type
• No member, provider, or health plan identification
1
123
19
17
18
1214
13
13
1615
9 10
10
1178
564
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Atlas Coverage
Two-thirds of 2013 California population is included in the Atlas.
California Total Population: 37.2 million
Atlas Total Population: 24.4 million
Payer Product Enrollment by Product
Enrollment by Payer
Total CA Enrollment
CommercialHMO 10.1 M
14.5 M
24.4million
Californians
PPO 4.3 M
Medicare
Advantage 1.6 M
1.6 MFFS
No member-level data
Medi-CalManaged Care 5.7 M
8.3 MFFS 2.6 M
Source: California Regional Health Care Cost & Quality Atlas.
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Atlas Interactive Web Tool:Compare Measures and Products
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Add Map, Download Data, Share Display
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Commercial Insurance:Regional Variation
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• Northern California regions overall outperform Central and Southern on clinical quality measures
• Northern Counties, Region 1, behaves like Central California regions
Northern California Shows Better Clinical Quality
-1.50
-1.00
-0.50
0.00
0.50
1.00Better
Worse
Northern Central Southern
Statewide Average
Regional Clinical Quality Composite for Commercially Insured Californians, 2013
Source: California Regional Health Care Cost & Quality Atlas, commercial HMO and PPO 2013 data.
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• Average commercial cost of care varies widely across the state
• All Northern California regions have higher costs than the statewide average
• All Southern California regions have lower costs
• Central California regions show mixed cost performance
Southern California Has Lower Costs
$3,400
$3,800
$4,200
$4,600
$5,000
$5,400
Ris
k-A
dju
sted
To
tal C
ost
of
Car
e
California State Average: $4,300
Northern Central Southern
Regional Average Annual Per-Enrollee Total Cost of Care for Commercially Insured Californians, 2013
Source: California Regional Health Care Cost & Quality Atlas, commercial HMO and PPO 2013 data.Note: All cost values are risk adjusted and rounded to the nearest $200.
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• All Northern regions fall into the higher-quality, higher-cost quadrant except Region 1, Northern Counties
• All Southern regions fall into the higher-quality, lower-cost quadrant
• All Central regions fall into lower-quality quadrants but with mixed costs
The Value Equation
-1.50
-1.00
-0.50
0.00
0.50
1.00
1.50
$3,000 $3,500 $4,000 $4,500 $5,000 $5,500
WO
RSE
<--
--C
linic
al Q
ual
ity
Co
mp
osi
te -
----
> B
ETTE
R
LOWER <----- Risk-Adjusted Total Cost of Care ($PMPY)------> HIGHER
Northern Central Southern
Higher quality,Lower cost
Lower quality,Lower cost
Lower quality, higher cost
Higher quality,Higher cost
Bringing Together California Commercial Cost-Quality Performance, by Region, 2013
Source: California Regional Health Care Cost & Quality Atlas, commercial HMO and PPO 2013 data.
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• Wide variation in utilization across California, but no geographic patterns
• ED visits measure has the widest range, with the maximum being more than double the minimum
Hospital Utilization Varies; No Geographic Pattern
Hospital Utilization Ranges for Commercially Insured Californians, 2013
Source: California Regional Health Care Cost & Quality Atlas, commercial HMO and PPO 2013 data.Note: PTMY = per thousand member years.
Utilization MeasureMinimum
Region RateStatewide
Average RateMaximum
Region Rate
Emergency Department Visits (PTMY) 114 148 256
All-Cause Readmissions (% of admissions) 6.6% 8.1% 8.4%
Inpatient Bed Days (PTMY) 109 133 157
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Commercial Insurance:HMO vs. PPO Performance
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• We’ve had Commercial HMO clinical results via P4P, but not the broader context for assessing level of performance
Commercial HMO Clinical Quality
-1
-0.5
0
0.5
1
1.5
Clin
ical
Qu
alit
y C
om
po
site
HMO
Better
Worse
Northern Central Southern
California Regional Clinical Quality Composite for HMOs, 2013
Source: California Regional Health Care Cost & Quality Atlas, commercial HMO and PPO 2013 data.
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• The Atlas provides that context—and HMO performs above the Commercial statewide average in all but one rural region
HMO Clinical Quality Above Statewide Average
-1
-0.5
0
0.5
1
1.5
Clin
ical
Qu
alit
y C
om
po
site
HMO Commercial statewide average
Better
Worse
California Regional Clinical Quality Composite for HMOs, 2013
Northern Central Southern
Source: California Regional Health Care Cost & Quality Atlas, commercial HMO and PPO 2013 data.
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HMO Clinical Quality Superior to PPO
California Regional Clinical Quality Composite for HMOs and PPOs, 2013
-1.0
-0.5
0.0
0.5
1.0
1.5
Clin
ical
Qu
alit
y C
om
po
site
Northern Central Southern
HMO PPO Commercial statewide average
Better
Worse
• Across California, HMOs far outperform PPOs
• All but one rural HMO region are above commercial statewide average
• All PPO regions are below commercial statewide average
• California HMOs perform better than their national counterparts; California PPOs lag national performance
Source: California Regional Health Care Cost & Quality Atlas, commercial HMO and PPO 2013 data.
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• Northern California more costly than Southern California for HMO
• Northern California above Commercial statewide average
• Southern California below Commercial statewide average
HMO Total Cost of Care
$3,000
$3,500
$4,000
$4,500
$5,000
$5,500
$6,000
$6,500
Ris
k A
dju
sted
To
tal C
ost
of
Car
e ($
PM
PY
)
HMO Commercial statewide average
Source: California Regional Health Care Cost & Quality Atlas, commercial HMO and PPO 2013 data.
California Regional Total Cost of Care for HMOs, 2013
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• Northern California also more costly than Southern California for PPO
• Northern California above Commercial statewide average
• Southern California below Commercial statewide average
PPO Total Cost of Care
$3,000
$3,500
$4,000
$4,500
$5,000
$5,500
$6,000
$6,500
Ris
k A
dju
sted
To
tal C
ost
of
Car
e ($
PM
PY
)
PPO Commercial statewide average
Source: California Regional Health Care Cost & Quality Atlas, commercial HMO and PPO 2013 data.
California Regional Total Cost of Care for PPOs, 2013
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• PPOs are more costly than HMOs in 12 regions
• HMOs are more costly than PPOs in some Central California regions and in Northern Counties
• The largest cost gap between HMOs and PPOs is $1,200 in San Mateo
• Los Angeles-East and Orange County have the same cost for HMOs and PPOs
PPOs Often Costlier than HMOs, Including Patient Cost Sharing
California Commercial HMO and PPO Average Annual Per-Enrollee Total Cost of Care Differences by Region, 2013
Central Coast - South (12), -$600
San Mateo County (8), $1,200
-$1,000 -$500 $0 $500 $1,000 $1,500
1. Northern Counties
2. North Bay Counties
3. Greater Sacramento
4. San Francisco County
5. Contra Costa County
6. Alameda County
7. Santa Clara County
8. San Mateo County
9. Central Coast - North
10. Central Valley - North
11. Greater Fresno Area
12. Central Coast - South
14. Kern County
15. Los Angeles - East
16. Los Angeles - West
17. Inland Empire
18. Orange County
19. San Diego County
HMO Costlier PPO Costlier
Los Angeles - East (15) and Orange (18), same cost for HMO and PPO
Source: California Regional Health Care Cost & Quality Atlas, commercial HMO and PPO 2013 data. Note: All cost values are risk adjusted and rounded to the nearest $200.
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• Only HMOs fall into the higher-quality, lower-cost quadrant
• Only PPOs fall into the lower-quality, higher-cost quadrant
Only HMOs in Higher-Quality, Lower-Cost Quadrant
Linking California Commercial HMO and PPO Quality and Cost Performance, 2013
Source: California Regional Health Care Cost & Quality Atlas, commercial HMO and PPO 2013 data. Notes: Region 13, Eastern Counties, is excluded because of insufficient data. When data points overlap on the chart, the number of regions represented is labeled as “n=” on the chart. All cost values are risk adjusted and rounded to the nearest $200.
-1.5
-1.0
-0.5
0.0
0.5
1.0
1.5
$3,000 $3,500 $4,000 $4,500 $5,000 $5,500 $6,000
WO
RSE
<--
-C
linic
al Q
ual
ity
Co
mp
osi
te -
-->
BET
TER
LOWER <--- Risk-Adjusted Total Cost of Care ($PMPY) ---> HIGHER
HMO PPO Commercial statewide average
Higher quality, Higher cost
Higher quality, Lower cost
Lower quality, Lower cost Lower quality,
Higher cost
n=2 n=3
n=2
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• Commercial HMO and PPO utilization rates statewide are similar for readmissions and inpatient bed days
• Commercial HMOs had higher ED utilization rates than PPOs
• Hospital utilization not driving higher PPO costs
PPO Hospital Utilization Slightly Lower than HMO
Comparison of California Commercial HMO and PPO Hospital Utilization Rates, 2013
Measure Name Commercial Insurance
HMO PPO
Emergency Department Visits (PTMY) 159 107
All-Cause Readmissions (% of admissions) 8.1% 8.1%
Inpatient Bed Days (PTMY) 134 131
Source: California Regional Health Care Cost & Quality Atlas, commercial HMO and PPO 2013 data. Note: PTMY = per thousand member years.
© 2016 Integrated Healthcare Association. All rights reserved. 22
• Cost is a function of unit price and utilization
• Overall moderate negative correlation between cost and hospital utilization
• Higher-cost regions have lower utilization
• Lower-cost regions have higher utilization
• Results point toward unit price driving cost, but inconclusive due to limited utilization measures
Unit Price Driving Cost?
Linking Hospital Utilization and Total Cost of Care for Commercially Insured Californians, by Product Type, 2013
Source: California Regional Health Care Cost & Quality Atlas, commercial HMO and PPO 2013 data. Notes: Region 13, Eastern Counties, is excluded because of insufficient data. When data points overlap on the chart, the number of regions represented is labeled as “n=”. All cost values are risk adjusted and rounded to the nearest $200.
-1.5
-1.0
-0.5
0.0
0.5
1.0
1.5
2.0
$3,000 $3,500 $4,000 $4,500 $5,000 $5,500 $6,000
HIG
HER
<--
--H
osp
ital
Uti
lizat
ion
Co
mp
osi
te -
--->
LOW
ER
LOWER <------ Risk-Adjusted Total Cost of Care ($PMPY) -----> HIGHER
HMO PPO Commercial statewide average
Higher cost,Lower utilization
Lower cost,Lower utilization
Higher cost, Higher utilization
Lower cost, Higher utilization
n=2
n=2
n=2
n=2
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Performance of Other Insurance Types
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Measure Best Performer CA Average Worst Performer
Breast Cancer Screening66.4%
Orange County50.7%
44.2% Greater Fresno Area
Colorectal Cancer Screening
35.2%San Mateo County
23.6%18.3%
Los Angeles – West
Emergency Department Visits (PTMY)
357 visitsOrange County
450 visits736 visits
Eastern Region
All-Cause Readmissions12.3%
Central Coast – North16.4%
20.8%Northern Counties
Inpatient Bed Days (PTMY)
66 days
Contra Costa County236 days
326 daysGreater Sacramento
Observed Total Cost of Care (PMPY)
$2768Eastern Region
$4431$7985
San Francisco
Medi-Cal Managed Care Performance Variable; No Geographic Patterns
PTMY= Per Thousand Member Years; PMPY = Per Member Per Year
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• Managed Care shows better clinical quality and fewer inpatient bed days, but higher ED visits and costs
MeasureManaged Care
AverageFFS Average
Breast Cancer Screening 50.7% 44.8%
Colorectal Cancer Screening 23.6% 21.3%
Emergency Department Visits (PTMY) 450 visits 321 visits
All-Cause Readmissions 16.4% 16.4%
Inpatient Bed Days (PTMY) 236 days 457 days
Observed Total Cost of Care (PMPY) $4431 $3221
Medi-Cal Managed Care vs. Medi-Cal FFS Results Mixed
PTMY = Per Thousand Member Years; PMPY = Per Member Per Year#### = better performance
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MeasureMedicare
AdvantageMedicare
Fee For Service
Clinical Quality Best in state ?
Emergency Department Visits (PTMY) 373 visits 567 visits
All-Cause Readmissions 11.2% 18.4%
Inpatient Bed Days (PTMY) 789 days 1,363 days
Total Cost of Care (PMPY) $12,783 $13,111
Medicare FFS Hospital Utilization Higher than Medicare Advantage; Total Cost Similar
• Hospital utilization is not driving total cost
PTMY= Per Thousand Member Years; PMPY= Per Member Per Year#### = better performance
Note: Measurement methodology may vary slightly between Medicare FFS and Medicare Advantage, so are not directly comparable.
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Coming Next: Atlas 2
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Planned Expansion for Atlas 2
Atlas Edition 1 (available online)
Atlas Edition 2 (coming in 2017)
2013 data 2015 data
6 clinical measures + composite 10-15 clinical measures + composite
3 hospital utilization measures + composite
10-15+ hospital utilization measures + composite
2 cost measures + index 9 cost measures + index
24 million Californians 30 million Californians• More PPO, including more self-insured• ACA Coverage expansion• Medicare FFS
Potentially split out results for:• ACOs• Market segments (lg/sm group, individual)• Chronic conditions
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Spring/ Summer 2016:
Update health plan
agreements; explore new data sources
Fall 2016:
Data collection
from participating
plans
Winter 2016/2017:
Calculate measure results
Spring/ Summer 2017:
Analyze results; write issue brief;
update Atlas tool
Summer/Fall 2017:
Publicly release Atlas 2
Atlas 2 Timeline
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Moderator:
• Maribeth Shannon, California Health Care Foundation
Panel:
• Lance Lang, MD, Covered California
• Melissa Welch, MD, Blue Shield of California
Panel
© 2016 Integrated Healthcare Association. All rights reserved. 31
• Interactive Web Mapping Tool
• Issue Brief
• Fact Sheet
Atlas Resource Links