california regional health care cost & quality atlas · 2019-12-17 · higher quality, lower...

Dolores Yanagihara, MPH

September 23, 2016

IHA Stakeholders Meeting

California Regional Health Care Cost & Quality Atlas

© 2016 Integrated Healthcare Association. All rights reserved. 2

• 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


Atlas MeasuresC

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


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

123

19

17

18

1214

13

13

1615

9 10

10

1178

564


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

CommercialHMO 10.1 M

14.5 M

24.4million

Californians

PPO 4.3 M

Medicare

Advantage 1.6 M

1.6 MFFS

No member-level data

Medi-CalManaged Care 5.7 M

8.3 MFFS 2.6 M

Source: California Regional Health Care Cost & Quality Atlas.


Atlas Interactive Web Tool:Compare Measures and Products


Add Map, Download Data, Share Display


Commercial Insurance:Regional Variation


• 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

1.00Better

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.


• 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.


• 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



• 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 MeasureMinimum

Region RateStatewide

Average RateMaximum

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


Commercial Insurance:HMO vs. PPO Performance


• We’ve had Commercial HMO clinical results via P4P, but not the broader context for assessing level of performance

Commercial HMO Clinical Quality

-1

-0.5

0

0.5

1

1.5

Clin

ical

Qu

alit

y C

om

po

site

HMO

Better

Worse


California Regional Clinical Quality Composite for HMOs, 2013



• The Atlas provides that context—and HMO performs above the Commercial statewide average in all but one rural region

HMO Clinical Quality Above Statewide Average

-1

-0.5

0

0.5

1

1.5

Clin

ical

Qu

alit

y C

om

po

site

HMO Commercial statewide average

Better

Worse

California Regional Clinical Quality Composite for HMOs, 2013




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



• Northern California more costly than Southern California for HMO

• Northern California above Commercial statewide average

• Southern California below Commercial statewide average

HMO Total Cost of Care

$3,000

$3,500

$4,000

$4,500

$5,000

$5,500

$6,000

$6,500

Ris

k A

dju

sted

To

tal C

ost

of

Car

e ($

PM

PY

)

HMO Commercial statewide average


California Regional Total Cost of Care for HMOs, 2013


• Northern California also more costly than Southern California for PPO

• Northern California above Commercial statewide average

• Southern California below Commercial statewide average

PPO Total Cost of Care

$3,000

$3,500

$4,000

$4,500

$5,000

$5,500

$6,000

$6,500

Ris

k A

dju

sted

To

tal C

ost

of

Car

e ($

PM

PY

)

PPO Commercial statewide average


California Regional Total Cost of Care for PPOs, 2013


• 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.


• 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


• 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.


• 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


Performance of Other Insurance Types


Measure Best Performer CA Average Worst Performer

Breast Cancer Screening66.4%

Orange County50.7%

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 visitsOrange County

450 visits736 visits

Eastern Region

All-Cause Readmissions12.3%

Central Coast – North16.4%

20.8%Northern Counties

Inpatient Bed Days (PTMY)

66 days

Contra Costa County236 days

326 daysGreater Sacramento

Observed Total Cost of Care (PMPY)

$2768Eastern Region

$4431$7985

San Francisco

Medi-Cal Managed Care Performance Variable; No Geographic Patterns

PTMY= Per Thousand Member Years; PMPY = Per Member Per Year


• Managed Care shows better clinical quality and fewer inpatient bed days, but higher ED visits and costs

MeasureManaged Care

AverageFFS 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


MeasureMedicare

AdvantageMedicare

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.


Coming Next: Atlas 2


Planned Expansion for Atlas 2

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• ACA Coverage expansion• Medicare FFS

Potentially split out results for:• ACOs• Market segments (lg/sm group, individual)• Chronic conditions


Spring/ Summer 2016:

Update health plan

agreements; explore new data sources

Fall 2016:

Data collection

from participating

plans

Winter 2016/2017:

Calculate measure results

Spring/ Summer 2017:

Analyze results; write issue brief;

update Atlas tool

Summer/Fall 2017:

Publicly release Atlas 2

Atlas 2 Timeline


Moderator:

• Maribeth Shannon, California Health Care Foundation

Panel:

• Lance Lang, MD, Covered California

• Melissa Welch, MD, Blue Shield of California

Panel


• Interactive Web Mapping Tool

• Issue Brief

• Fact Sheet

Atlas Resource Links

california regional health care cost & quality atlas · 2019-12-17 · higher quality, lower...

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