Findings from CCS Administrative Datahealthpolicy.ucla.edu/Documents/Spotlight/Stanford... ·...
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Findings from CCS Administrative Data Lee M. Sanders, MD, MPH Lisa J. Chamberlain, MD, MPH Stanford Center for Policy, Outcomes and Prevention (CPOP) CCS Redesign Stakeholder Advisory Board
Transcript of Findings from CCS Administrative Datahealthpolicy.ucla.edu/Documents/Spotlight/Stanford... ·...
Findings from CCS Administrative Data
Lee M. Sanders, MD, MPH
Lisa J. Chamberlain, MD, MPH
Stanford Center for Policy, Outcomes and Prevention (CPOP)
CCS Redesign Stakeholder Advisory Board
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Analytic Guidance for CCS Program Reform
To use data to help protect the health of children with serious chronic illness.
1. To provide CCS and its stakeholders with data-driven analytic guidance to improve the quality and efficiency of care for children served by the CCS program.
2. To implement a coordinated strategy that bridges the gap between analytic activities and innovative care strategies in CCS subspecialty care centers.
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Essential Questions
How do we protect the health and well-being of a large population of children with serious chronic illness?
1. How do these children use health care services?
2. What is the quality (or appropriateness) of care received by this population?
3. What is the distribution of costs for that care?
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Analytic Design
Retrospective, population-based analysis of all paid claims for the CCS Program (2007-2012)
Total capture of all care episodesInpatient bed days
Outpatient visits (primary, subspecialty, non-MD)
ED visits
Home health and Durable Medical Equipment (DME)
Residential care
Pharmacy
Total capture of all CCS-related costs
Partial capture of non-CCS-related costs (FFS)
N = 323,922 children
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Stanford CPOPCCS Analytics Advisory Board
Out-Patient
Care Systems
CCS
Families
Foundations
Research
Policy
Hospitals
Advocacy
Advisory
Board
Bernardette Arrellano CCHA
Rich Cordova CHLA
Dr. Fran Kaufman CHLA
Dr. Bert Lubin CHORI
Richard Pan CA Assembly
Christy Bethell PhD OHSU
Neal Halfon PhD UCLA
Moira Inkelas PhD UCLA
Dylan Roby PhD UCLA
Meg Okumura, MD, UCSF
Dr. Robert Dimand State
Dr. Louis Girling Alameda
County
Dr. Mark Pian San Diego
Dr. Mary Doyle LA County
Maya Altman Health Plan
San Mateo
Dr. Melissa Aguirre Fresno
John Barry, OTR Shasta
County
Ted Lempert Children Now
Laurie Soman CRISSDr. Tom Klitzner UCLA Complex Care
Dr. David Bergman Stanford Complex Care
Chris Perrone CHCF
Dr. Ed Schor LPFCH
Teresa Jurado CCS, Health Plan San Mateo
Eileen Crumm PhD Family Voices
CCS Redesign Stakeholder Advisory Board
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CCS-enrolled Children: Social and Clinical Characteristics
%
Age – mean (SD) 7.3 (6.5) yearsSex - Female 43.0Race/EthnicityWhite 16.6Black 8.7Hispanic 56.4InsuranceMedicaid Managed care 47.6
Medicaid Fee for Service 19.6CHIP 7.5Mixed / Other 25.3Medical complexityComplex Chronic 51.4Non-complex Chronic 25.3Non-Chronic 23.3Diagnostic categoryNeurology 14.6Cardiology 12.6ENT / Hearing Loss 11.6Trauma / Injury 10.8Endocrine 6.8
CCS Redesign Stakeholder Advisory Board
> 2 organ systems, or progressive
* Simons TD, et al. Pediatric Medical Complexity Algorithm (PMCA), Pediatrics 2014
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Patterns of Care Visits per child per year
Children with > 1 visit
per year
Visits per child per year Mean (SD)
Outpatient Visits (MD) 94% 7.6 (8.6)
Outpatient Pharmacy Visits 87% 18.7 (28.7)
ED Visits 49% 1.6 (1.8)
Hospitalizations (Bed Days) 31% 14.8 (30.5)
Outpatient visits (Non-MD) 29% 10.2 (13.7)
Home health visits 16% 5.8 (13.3)
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Patterns of Care by Age
0
10
20
30
40
50
60
70
80
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Ageatfirstvisit
Medianencounterrateperyear
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
100000
Numberofchildren
HospitalBedDays EmergencyDepartmentVisitsEarlyPeriodicScreening,Diagnosis&Treatment DentalVisitsHomeHealthVisits OutpatientclinicvisitsOtheroutpatientvisits PharmacyprescriptionsfilledNumberofchildren
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Patterns of Care by Medical Complexity
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0
5
10
15
20
25
30
35
40
45
50
Complex Chronic Non-Chronic
Outpatient pharmacy fills
Other outpatient visits
Home health visits
ED visits
Outpatient physician visits
Bed days
Mean e
ncounte
r ra
te p
er
year
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Patterns of Care by Diagnostic Category
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0
10
20
30
40
50
60
70
80
90
100
Neurolo
gy
Hemato
logy
Oncolo
gy
Cardio
logy
Otolary
ngology
Gastro
entero
logy
Pulmonary
Inju
ry
CCS eligible diagnosis
Perc
ent
of t
otal
exp
endi
ture
Inpatient Home health PharmacyOutpatient clinic Other outpatient DME% total expenditures % children
% o
f to
tal vis
its
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Outpatient: Inpatient Patternsby Diagnostic Category
CCS Redesign Stakeholder Advisory Board
CARD
ENT
ENDO
INJ
GASTRO
DEVT
HEME
NEONATAL
NEUR
ONC
OPTH
ORTH
URO
0 5 10 15 20
Mean bed day rate
6
8
10
12
Mea
n ou
tpat
ient
vis
it ra
te
Scatter plot by diagnosis group, Outpatient versus total LOS
Bubble sized based on number of children in each diagnosis group
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Patterns of Care Regional Variability
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Quality of Care:Potentially Preventable Hospitalizations
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
Bac
teria
l pne
umon
ia
Deh
ydra
tion
Asthm
a
Epile
psy
Kidne
y/ur
inar
y infe
ction
Sev
ere
ENT in
fect
ion
Cellulitis
Gas
troen
terit
is
Hyp
oglyce
mia
Mas
toiditis
Ane
mia
Nut
ritio
nal d
eficie
ncy
Imm
unizat
ion
prev
enta
ble
cond
ition
s
Tuber
culosis
Pelvic in
flam
mat
ory dise
ase
Diabe
tes
Stre
toco
ccal m
enin
gitis
Seizu
res
Failu
re to
thriv
e
Ambulatory Sensitive Condition
Nu
mb
er
of
Ch
ild
ren
Ho
sp
ita
lize
d
24.8% of all CCS
hospitalizations
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Quality of Care:No Care After Hospital Discharge
78.9
51.9
67.8
39
61.1
33.6
56.3
30.3
0 10 20 30 40 50 60 70 80 90
No MD visits within 7 days Post-hospitalization
No Outpatient Visit of any kind within 7 days Post-Hospitalization
No MD visits within 14 days Post-hospitalization
No Outpatient Visit of any kind within 14 days Post-Hospitalization
No MD visits within 21 days Post-Hospitalization
No Outpatient Visit of any kind within 21 days Post-Hospitalization
No MD visits within 28 days Post-Hospitalization
No Outpatient Visit of any kind within 28 days Post-Hospitalization
Percent of hospitalized CCS enrollees
(Overall Readmission Rate: 9.6%)
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Cost DistributionBy Child
50
2
40
26
5
15
4
32
1
25
0
10
20
30
40
50
60
70
80
90
100
Children Annual expenditures
Pe
rce
nt
Chart Title
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Cost Distribution By Medical Complexity
47%
27%
26%
Complex Chronic
Non-complexChronic
Non-Chronic
85%
6%
9%
Among All CCS Enrollees Among “High Cost” Children*
**Pediatric Medical Complexity Algorithm (PMCA), Mangione-Smith R. 2014
*Top 10% of annual expenses
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Cost DistributionBy Type of Care Chart Title
36%
21%
9%
17%
1%
14%
2%
0%
0%
Inpatient Home healthPharmacy Residential facilityOutpatient clinic Other outpatientDME DentalED
Hospital
Home Health
Outpatient (nonMD)
Residential Facility
Pharmacy
DME Emergency Care
Outpatient (MD)
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Cost Distribution, by Medical Complexity
Complex Chronic Non-complex/non-chronic
67.7
6.6
13.9
0.8
8.4
1.2
Inpatient Home health Pharmacy Outpatient clinic Other outpatient DME
67.7
6.6
13.9
0.8
8.4
1.2
Inpatient Home health Pharmacy Outpatient clinic Other outpatient DME
31.1
21.5
16.1
2.4
27.7
0.7
Inpatient Home health Pharmacy Outpatient clinic Other outpatient DME
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Cost by Diagnostic Category
13.8
10.7
5.93.9
7.12.52.62.93.3
31.0
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
Neurolo
gy/N
eurosu
rger
y
Hemat
ology
NICU
Cardiol
ogy/C
ardio
thora
cic Su
rgery
Oncolo
gy ENT
Gastro
entero
logy
Pulmonar
y
Gen Peds
/Behav
Devt
Exte
rnal/
Injur
y
CCS-Eligible Diagnosis
Pe
rce
nt
of
Tota
l Exp
en
dit
ure
sfo
r al
l
dia
gno
ses
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Nu
mb
er
of
Ch
ildre
n
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Costs Distributionby Diagnostic Category
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$0
$20,000,000
$40,000,000
$60,000,000
$80,000,000
$100,000,000
$120,000,000
$140,000,000
$160,000,000
Neu
rolo
gy
Hem
atol
ogy
EN
T
Onco
logy
Car
diolo
gy
Pulmon
ary
Gas
troe
ntero
logy
Inju
ry
Endoc
rinol
ogy
Tota
l ex
pen
dit
ure
s
Inpatient Outpatient pharmacy Residential facility Home health
Outpatient physician DME ED Other outpatient
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“High Cost Children”Over Time
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Cost Distributionby Hospital Type
CCS Redesign Stakeholder Advisory Board
OtherHospitals
1%
CountyHospitals
6%
UCSystem
Hospitals
13%
Non-Profit&For-
ProfitHospitals
25%
Free-Standing
Children's
Hospitals
55%
OtherHospitals
1%
CountyHospitals
8%
UCSystem
Hospitals
11%
Free-Standing
Children'sHospitals
37%
Non-Profit&
For-ProfitHospitals
43%
Infants (< 12 months)
Free-StandingChildren's
Hospitals
64%
Non-Profit&
For-Profit
Hospitals
18%
UCSystem
Hospitals
13% CountyHospitals
5%
OtherHospitals
<1%
Medically Complex Children
All Children
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Summary
• Distinct patterns of care use – particularly by age and medical complexity.
• Wide variability in care patterns, particularly before and after hospitalization.
• Costs are highly skewed, driven by inpatient and residential care, and persistent over time.
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Implications forCCS Program Reform• Care System Innovation
– Redesign Outpatient Systems to reduce Inpatient Care– Enhance Regionalized Subspecialty and Primary Care
• Population Health Management– Tier Care Coordination by Clinical Complexity– Build Regional Learning Collaboratives
• Public Policy and Payment Reform– Establish Risk Pools for Skewed Cost Distribution – Monitor and Evaluate Impact of Reforms
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CPOP Policy Briefs
CCS Redesign Stakeholder Advisory Board
https://cpopstanford.wordpress.com/our-work/state/
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Thank You
CCS and DHCSCalifornia StakeholdersRobert Dimand, MDKatie Schlageter, AlamedaLouis Girling, MD, AlamedaMaya Altman, HPSMFiona Donald, MD; Anand Chabra, MDTeresa JuradoDavid Alexander, MDEd Schor, MDJuno DuenasEileen CrummLaurie SomanChristy Sandborg, MD, StanfordDavid Bergman, MD, StanfordJori Bogetz, MD; Doriel Pearson-NishiokaBert Lubin, MD, CHRCOTom Klitzner, MD, UCLAMoira Inkelas, PhD, UCLADylan Roby, PhD, UCLAMegie Okumura, MD, UCSFStanford University Center for
Policy, Outcomes and PreventionPaul Wise, MD, MPHJason Wang, MD, PhDVandana Sundaram, MPHEwen Wang, MDBen Goldstein, PhDMonica Eneriz-Wiemer, MDKeith van Haren, MDStafford Grady, MDSusan Fernandez, RN, PhDMyMy Buu, MDNathan Luna, MDRachel Bensen, MDStephanie Crossen, MDOlga Saynina, MSGene Lewitt, PhDMaureen Sheehan, RNRegan FoustSonja Swenson
