Health System Improvement

Opportunities In Louisiana:

Analysis Through the Lens of Unwarranted

Variation

June 9, 2008

© Health Dialog 2007 2

Effective Care – includes services of proven clinical effectiveness derived from randomized controlled trials (traditionally defined measures of quality)

Preference-Sensitive Care – conditions for which treatment options exist that carry significant tradeoffs in terms of risks and benefits for the patient

Supply-Sensitive Care – care where the amount given is strongly correlated with health system resource capacity (efficiency)

Unwarranted Variation

*Dartmouth Atlas of Health Care: http://www.dartmouthatlas.org/agenda.shtm

Geographic variation that cannot be explained by illness or need, the dictates of evidence based medicine, or patient preferences*

© Health Dialog 2007 3

Project Impetus and Purpose

Louisiana Health Care Redesign Collaborative - strategy for New Orleans and State

The Blue Cross Blue Shield of Louisiana (BCBSLA) Foundation & Tulane – utilize data to inform decisions

Health Dialog – build a multi-payer data warehouse using pre-storm data for benchmarking and analysis

© Health Dialog 2007 4

Distribution of FloodingOrleans Neighborhoods (post-storm)

Population decrease of almost 50% Primary Care Physician decrease of 50% Hospital inpatient capacity decrease of 80%

Health care issues in Louisiana did not start with Hurricanes Katrina or Rita

© Health Dialog 2007 5

MCAID44%

MCARE26%

DUALS4%

PRIVATE 26%

Data Warehouse: 2.3 Million State Residents, 2005 (pre-storm)

Data Warehouse Payer Mix

*U.S. Census Bureau (www.census.gov/popest/states/tables/NST-EST2005-01.xls)

2005 total State population: 4.5 million* Data represents complete Medicare & Medicaid

eligibility files – 977,000 Medicaid beneficiaries– 584,000 Medicare beneficiaries– 100,000 Dual-eligibles

Private/BCBSLA data fully-insured book of business – 591,000 members

© Health Dialog 2007 6

Geographic Units of Analysis

1- New Orleans

9 – Northshore

5 – Southwest

6 – Central

7 – Northwest

8 – Northeast

2- BatonRouge

3- Houma

4- Acadiana

LA Department of Health and Hospital’s health care regions Hospital Service Areas*

*Dartmouth Atlas defined empirically derived local health care markets (67 in LA)

© Health Dialog 2007 7

Utilization Variation by Region: Population with Chronic Disease – Admits/1,000

*Age & sex adjusted

Average: 750 Admits/1,000

615

778

700

824

938

743

696

848

724

0

100

200

300

400

500

600

700

800

900

1000

8 - Northeast 6 - Central 7 - Northwest 9 - Northshore 1 - New Orleans 4 - Acadiana 2 - Baton Rouge 5 - Southwest 3 - Houma

© Health Dialog 2007 8

Does chronic disease influence utilization variation?

Diamonds represent Louisiana Hospital Services Areas (HSAs) with ≥ 10,000 people*Chronics: CHF, COPD, Diabetes, Asthma, CAD

R2 = 0.69

50

100

150

200

250

300

350

400

20 30 40 50 60 70 80 90 100 110

Admits/1,000: Children (0-17), Non-chronic

Ad

mit

s/1,

000:

Ch

ilrd

en (

0-17

) C

hro

nic

Natchitoches

Bogalusa

Variation in Healthcare Utilization for Chronic Disease* & Non-chronic Populations - Children

© Health Dialog 2007 9

Does insurance type influence utilization variation?

Diamonds represent Louisiana Hospital Services Areas (HSAs) with ≥ 45,000 people

R2 = 0.56

30

40

50

60

70

80

10 15 20 25 30 35 40

Admits/1,000: Private/0-17/Non-chronic/Non-maternity

Ad

mit

s/1,

000:

Med

icai

d/0

-17/

No

n-c

hro

nic

/No

n-m

ater

nit

y

New Orleans

Alexandria

Variation in Healthcare Utilization by Payer: Admission Rates for Children – Medicaid vs. Private

© Health Dialog 2007 10

Does race influence cost variation?

Diamonds represent Louisiana Hospital Services Areas (HSAs) with ≥ 45,000 people Only Medicare claims data identifies race

R2 = 0.82

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

$4,000 $6,000 $8,000 $10,000 $12,000 $14,000

PPPY Expenditures - White

PP

PY

Exp

en

dit

ure

s -

Bla

ck

1.72x

2.11x

Medicare Variation: Impact of Race on Cost

© Health Dialog 2007 11

Is there a correlation between cost and quality?

Average Beta blocker use 56% Average cost $27,000

40%

45%

50%

55%

60%

65%

70%

$15,000 $17,000 $19,000 $21,000 $23,000 $25,000 $27,000 $29,000 $31,000 $33,000 $35,000

PPPY Expenditures: CAD Patients

Bet

a B

lock

ers

for C

AD

Pat

ient

s

R² =0.24

Quality & Cost – Beta Blocker Adherence & Annual Expenditures for CAD Patients

© Health Dialog 2007 12

Variation in Preference Sensitive Care

The Statewide average is approximately 3/1,000 A 6-fold difference exists between the highest and lowest HSAs Diamonds represent Louisiana Hospital Services Areas (HSAs) with ≥ 10,000 people

Back Surgery/1,000

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

Sul

phur

Ope

lous

as

De

Rid

der

Win

nsbo

ro

Eun

ice

Wes

t Mon

roe

Lake

Cha

rles

Cha

lmet

te

Shr

evep

ort

Cov

ingt

on

Jenn

ings

Lafa

yette

Mon

roe

Bog

alus

a

Thi

boda

ux

Hou

ma

Lees

ville

Ale

xand

ria

Rac

elan

d

Abb

evill

e

Fra

nklin

ton

Slid

ell

Mor

gan

City

Bas

trop

Ham

mon

d

Vill

e P

latte

New

Iber

ia

Nat

chito

ches

Zac

hary

Rus

ton

Met

airie

Gon

zale

s

Gal

liano

Lapl

ace

Cro

wle

y

Bat

on R

ouge

Fra

nklin

Min

den

Mar

rero

New

Orle

ans

Lulin

g

Preference Sensitive Care: Back Surgery Rates/1,000

© Health Dialog 2007 13

Summary of Findings

1. Prior to Hurricane Katrina, significant geographic variation in utilization, cost, and quality existed within Louisiana Not due to conditions, payer, race, or gender

2. Higher costs are not correlated with higher quality

3. Significant variation in Preference Sensitive Care exists throughout the State

Local health care system factors play a significant role in Unwarranted Variation– Supply – Idiosyncratic decisions by providers

Louisiana Health Care Quality Forum adopting project as part of mission to help improve quality in the State– Report available at LHCQF.ORG