Post on 13-Jan-2017
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California Regional Health Care
Cost & Quality Atlas
Dolores Yanagihara, MPH July 27, 2016 Sacramento Briefing
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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 Measures C
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
1 2 3
19
17
18
12 14
13
13
16 15
9 10
10
11 7 8
5 6 4
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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
Commercial HMO 10.1 M
14.5 M
24.4 million
Californians
PPO 4.3 M
Medicare
Advantage 1.6 M
1.6 M FFS
No member-level data
Medi-Cal Managed Care 5.7 M
8.3 M FFS 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
1.00 Better
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 Measure Minimum
Region Rate
Statewide Average Rate
Maximum 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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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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• 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.
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• 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 Screening 66.4%
Orange County 50.7%
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 visits Orange County
450 visits 736 visits
Eastern Region
All-Cause Readmissions 12.3%
Central Coast – North 16.4%
20.8% Northern Counties
Inpatient Bed Days (PTMY)
66 days
Contra Costa County 236 days
326 days Greater Sacramento
Observed Total Cost of Care (PMPY)
$2768 Eastern 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
Measure Managed Care
Average FFS 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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Measure Medicare
Advantage Medicare
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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Expansion of Atlas
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
• Medicare FFS
• Medi-Cal expansion
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Moderator:
• Jeffrey Rideout, MD, Integrated Healthcare Association
Panel:
• Health Plan/Insurer Perspective: Kristen Miranda, Blue
Shield of California
• Provider Perspective: Don Crane, CAPG
• Purchaser Perspective: Sara Flocks, California Labor
Federation
• Consumer Perspective: Beth Capell, Health Access
Panel