California Regional Health Care Cost & Quality Atlas Briefing

© 2016 Integrated Healthcare Association. All rights reserved.

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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


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


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



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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


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



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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


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.


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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


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

California Regional Health Care Cost & Quality Atlas Briefing

Documents

Transcript of California Regional Health Care Cost & Quality Atlas Briefing