Health Services Research:

Helps Us Get Our Money’s Worth

What works?

For whom?

Under what circumstances?

At what cost?

Research-Driven Solutions for

Innovative State Policy

Joseph W. Thompson, MD, MPH

Surgeon General, State of Arkansas September 27, 2012

Health Care’s Iron Triangle

Access Cost

Quality

4

Arkansas Health System Improvement

Agency Organizational Structure

State Leadership

State Leadership

Implementation

& Coordination

Implementation

Workgroup

Participation

Steering Group: DHS, ADH, BCBS,

QualChoice, United, ACHI

AID (Exchange)

DHS (Mcd

eligibility &

expansion) EBD

UAMS ADH & ACHI

Higher Ed (2- & 4 yr)

AFMC UAMS

DIS Medicaid

Governor Mike Beebe

Payment & Quality Improvement Mr. John Selig

Insurance Exchange

Commissioner Jay Bradford

Workforce Chancellor Dan Rahn & Dr. Paul Halverson

Health Information

Technology Mr. Ray Scott

Governor’s Policy Staff & Dr. Joe Thompson

ACHI

National and Arkansas Childhood Obesity Trends

NHANES data sources: Ogden et al. Prevalence of Obesity Among Children and Adolescents: United States,

Trends 19631965 Through 20072008. NCHS Health E-Stat, June 2010. Available at

http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.htm. Accessed 04/18/11.

Arkansas data source: Arkansas Center for Health Improvement, Little Rock, AR, September 2010.

0

5

10

15

20

25

Pe

rce

nt O

be

se

US 6–11 yr

US 12–19 yr

AR grades K, 2, 4, 6

AR grades 8 & 10

1963-65 1971-74 1988-94 01-02

1966-70 1976-80 99-00 03-04 05-06

07-08

20

21

22

23

2004 2005 2006 2007 2008 2009 2010

Per

cen

t O

bes

e

Arkansas Assessments

Grades 8 & 10Grades K, 2, 4, 6

Preliminary working draft; subject to change

6

Our vision to improve care for Arkansas is a comprehensive, patient-

centered delivery system…

Episode-based care

▪ Acute, procedures or

defined conditions

How care is

delivered

Population-based care

▪ Medical homes

▪ Health homes

Objectives

▪ Improve the health of the population

▪ Enhance the patient experience of care

▪ Enable patients to take an active role in their care

Four aspects

of broader

program

▪ Results-based payment and reporting

▪ Health care workforce development

▪ Health information technology (HIT) adoption

▪ Expanded access for health care services

For

patients

For

providers

▪ Reward providers for high quality, efficient care

▪ Reduce or control the cost of care

Preliminary working draft; subject to change

7

Payers recognize the value of working together to improve our system, with

close involvement from other stakeholders…

Coordinated multi-payer leadership…

▪ Creates consistent incentives and standardized reporting rules and tools

▪ Enables change in practice patterns as program applies to many patients

▪ Generates enough scale to justify investments in new infrastructure and operational models

▪ Helps motivate patients to play a larger role in their health and health care

1 Center for Medicare and Medicaid Services

Spending Breakdown for CHF 30-day Episodes with and without a Readmission

8

Number ofEpisodes

$5,936

$0

$2,510

$288 $337 $368

Index Readmits PAC OPD Physician Other

$6,305

$10,569

$3,975

$379 $1,453 $832

Index Readmits PAC OPD Physician Other

% Total Costs

63% 0% 27% 3% 4% 4%

% Total Costs

27% 45% 17% 2% 6% 4%

24%

76%

N=4,992 CHF

episodes

Source: Medicare FFS claims data, 2010

Avg Total Episode Cost = $23,511

Avg Total Episode Cost = $9,440

Preliminary working draft; subject to change

9 9

$12,000

10,000

8,000

6,000

4,000

2,000

0

$120

100

80

60

40

20

0

Case for change: variation in costs by episode are substantial even after

adjusting for risk

Total average cost per episode post-risk adjustment by Principal Accountable Provider, 2008-2010

Total hip replacement

Pregnancy2

ADHD3

Simple upper respiratory infection1

Total episodes

Median cost

10% percentile

90% percentile

~30,000

$3,608

$3,208

$4,071

Total episodes

Median cost

10% percentile

90% percentile

~20,000

$1,641

$1,073

$7,046

Total episodes

Median cost

10% percentile

90% percentile

~80,000

$57

$44

$76 4,000

500

3,000

$5,000

2,500

0

Total episodes

Median cost

10% percentile

90% percentile

1 Episode costs for children less than 10 risk-adjusted by a historically-derived multiplier.

2 Individual episode costs risk-adjusted for clinical drivers of severity based upon historically-derived multipliers.

3 Eligible defined as ADHD without comorbidities between ages 6 and 17.

SOURCE: Arkansas Medicaid claims data; Team analysis

0

$20,000

15,000

10,000

5,000

Total episodes

Median cost

10% percentile

90% percentile

140

$7,953

$5,867

$12,814

Preliminary working draft; subject to change

10.5

▪ Surgical procedure plus all

related claims from 30 days

prior to procedure to 90 days

after

▪ Pregnancy-related claims for

mother from 40 weeks before

to 60 days after delivery

▪ Excludes neonatal care

▪ 21-day window beginning with

initial consultation

▪ Excludes inpatient costs and

surgical procedures

▪ Hospital admission

▪ Care within 30 days of discharge

▪ 12-month episode

▪ Includes all ADHD services +

pharmacy costs (with exception of

initial assessment)

Principle Accountable Provider

Wave 1 episodes

Orthopedic surgeon

Delivering provider

First provider to diagnose

patient in-person

Admitting hospital

Depends care pathway

• Physician

• Licensed clinical

psychologist, and/or

• RSPMI provider

Total Hip/ Knee

replacement

ADHD

Acute/post-

acute heart

failure

Ambulatory URI

Perinatal

(non-NICU1)

Preliminary working draft; subject to change

What’s next

• Stents

• Pacemakers

Hip/ knee

replacements

Perinatal • Include NICU

Ambulatory URI • Urinary tract infections

• Ear infections

Acute / post-acute

CHF

• Pneumonia

• Myocardial infarction

ADHD • Depression

Developmental

disabilities

• Long-term care

• Severe and persistent mental

illness

Examples