Benchmark Study of Healthcare Provided by Physician Organizations funded by the California...

Benchmark Studyof Healthcare Provided by Physician

Organizationsfunded by the California Healthcare Foundation

New Directions in Managing Health Care CostsPresentation for: www . Health Web Summit . com

Paul M. Katz, MBA Chief Executive OfficerIntelligent Healthcare LLC

www.intelHC.com (310) 458-6966 December 2002

Dec 2002 Intelligent Healthcare LLC Slide 2

Purpose … 1

Investigate the use of administrative data (medical claims, medical encounters, eligibility) from delegated/capitated medical groups and IPAs for quality measurement.

Often, medical record abstracts are used for quality measurement, which is too expensive for most physician organizations to use, especially when measuring individual physicians.


Purpose … 2

Test medical group/IPA data on some HEDIS, access, and cost measures.

For example, evaluate care provided to patients with diabetes: quality, access and cost measures.

Look for evidence of efficiencies or inefficiencies in providing evidence based care to these patients.


Purpose … 3

Prevalence of patients with diabetes, patients with asthma, patients with hypertension in the Study population.

Underlying risk factors within medical group/IPA patient populations.


Purpose … 4

Establish benchmarks that are meaningful and actionable to physicians, along with the methodology to test themselves on these measures.

Encourage self-measurement and self-improvement.


Why Self-Measure … 1

HMOs, State of California Department of Managed Healthcare, Pacific Business Group on Health, National Committee on Quality Assurance, and public advocacy organizations will measure and publish the results on the quality of care of physicians, medical groups and IPAs.



Every medical group and IPA should participate in self-measurement, making changes in processes to improve patient care and quality scores.

Healthcare purchase decisions are often based on cost -- no physician or physician organization wants to be known for poor quality scores.



Blue Cross of California established a Physician Incentive Program, paying a bonus to medical groups and IPAs based on the results of several quality measures. The bonus is reportedly between 5% and 10% additional monthly capitation.



Potential of $1 Million for approximately 25,000 capitated/delegated lives.



With IHA’s “Pay for Performance” program, other health plans are starting similar financial rewards based on quality measures applied to services beginning in 2003.



Quality measurement with compensation is here.

The medical groups and IPAs should be prepared in advance to use these programs to their advantage.


Benchmark Study… 1

Who’s involved: Study advisory group – health plan

and medical group/IPA medical directors, academics, and other interested parties.

The list of advisors and other Study information is posted on our web site www.intelHC.com; click on the “benchmark study” button.



Articles using data for measurement: Steve Asch, M.D. (Rand)

Measure conditions with a high prevalence. (The Study includes hypertension for its high prevalence in largely commercial populations.)

Steve Campbell, M.D. (University of Manchester UK)

Measure processes, or outcomes from processes that physicians have control over.



Articles using data for measurement: Paul Newacheck PhD (UCSF)

Used data to test differences in access to primary care services between managed care and non-managed care populations.

Sheldon Greenfield M.D. (Tufts University) Consider how the population case mix

can impact results.



Articles using data for measurement: The articles are available on our

web site. Under Benchmark Study, click on “Paper: Review of Research…”


Study Methodology Collect data on a statistically

significant sample of HMO enrollees. Invitations sent to 110 of the larger

delegated/capitated medical groups and IPAs (with at least 35,000 HMO) enrollees. Received 35 responses.

Sent out detailed technology surveys, and received 31 completed surveys.


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Information Tech Survey…1

Survey response for MIS systems IDX – 10 OAO – 5 EZCap – 4 Diamond, EPIC, MC2000, Med

Manager, & Synertech – 1 each Custom/in-house – 3


Information Tech Survey…2

Survey response by organization type: IPAs – 20 Medical Groups – 11

Survey response enrollment: 2.5 million lives


Participating Organizations

20 medical groups/IPAs have provided data - no two provided in the same or similar formats.

16 medical groups/IPAs are in the indicator database, following:


Data warehouse…1

1. Scrubbed the data (including claims, encounter, enrollment, member demographics) and moved it into our data warehouse


Data warehouse…2

2. Tested the data, calculated per member per month costs by provider specialty, and procedures per 1,000 enrollees against our benchmarks and the other participating medical groups and IPAs to see that their data is substantially complete and enrollment is substantially accurate.


Data warehouse…3

3. Select members meeting study criteria (2 years of consecutive eligibility with up to one 45 day break). Two years selected to mitigate differences in enrollment turnover rates. Copy into database.


Data warehouse…4

4. Copy the member’s claims and encounters into the indicator database.


Data warehouse…5

5. Link the medical group/IPA member number to the health plan assigned member ID, find pharmacy data within each of the 6 pharmacy databases (6 participating HMOs). Copy the member’s pharmacy data to the indicator database.


Data warehouse…6

6. Look for laboratory test values in the laboratory test value database. Unilab provided data for 5 medical groups/IPAs. 5 medical groups/IPAs reported some data for the Study.


Data warehouse…7

7. Run each indicator, or part of each indicator for each medical group/IPA.


Flow chartBenchmark Study Indicator Database

HMORx A

DATA WAREHOUSEGroups A, B, C ….. Z

HMORx B

HMORx D

HMORx C

INDICATORSDiabetes, Asthma

Hypertension


Study Group Population represented in the

indicator database (as of today) is drawn from 16 medical groups/IPAs with approximately 1.6 Million HMO enrollees during 2001.


Study groups by enrollment size

0

1

2

3

4

5

6

7

8

Groups

<50,00050-100,000>100,000


Indicator Methodology…1

Example - Patients with Diabetes: Denominator (per HEDIS specifications)

- Patients are identified with diabetes by having one of 4 specifications:

Specific prescriptions 1 inpatient admit with diabetes diagnosis 1 ER visit with diabetes diagnosis 2 ambulatory encounters with diabetes

diagnosis


Indicator Methodology…2

Example - Patients with Diabetes: 4 pre-denominator searches of the

data for each specification is conducted.

The “outer join” of the 4 searches finds the unique member occurrences from any one of the specifications.


Preliminary Findings…1

Patients with Diabetes (based on the HEDIS specifications) account for approximately 3% of commercial HMO enrollees, and 14% of Medicare HMO enrollees.



For a medical group/IPA with 50,000 commercial enrollees - approximately 1,500 are patients with diabetes. 700 patients among 5,000 Medicare HMO enrollees.



For the numerator of each indicator tested, identify the patients with diabetes having specific services - Eye exams Emergency medical services Hemoglobin A1c lab test Average test value Physician encounters Resources used



Similar processes were followed for patients with asthma and patients with hypertension.

Specifications require an “inner join” identifying patients meeting both a pharmacy and medical service specification.


Study Measures…1

Access measures count the prevalence of patients with specific services (visits), to specific provider types: emergency medicine primary care several medical specialties


Study Measures…2

A visit is a patient encounter with a provider of a specific specialty on a unique date. Visit counts were assumed to be more consistent across medical groups and IPAs then counting instances of CPT or other service codes.


Study Measures…3

Utilization measures Obstetrics cardiovascular services radiology scans


Preliminary Results…1

Patients with Diabetes Eye Exam Completed: Results vary

between 15%* and 75%. * missing data or patients with eye

exam carve-outs.



Patients with Diabetes Hemoglobin Test Rates: Results

vary from data missing to 85%.



Patients with Diabetes Seen during the year - 65%* to

99% seen by a medical group/IPA provider.

* incomplete data likely from capitated primary care physicians.



Patients with Diabetes Cost per Patient Per Year to the

Medical Group/IPA $1,400 to $2,200 Commercial $2,300 to $5,200 Medicare HMO


Case Mix

Medical group/IPA risk for their patient population: With 1.0 the average And a range of 0.9 to 1.1 Equals a potential 22%

difference in expected population costs based on age, sex and acuity.


Preliminary Conclusions…1

All health care organizations have some data problems, and some information reporting limitations.

Organization size is not the sole determining factor for the quality of data and information reporting.



Incomplete claims/encounter data is a problem for IPAs and medical groups that sub-capitate physicians.

Without this data, these organizations will have lower quality scores on some measures



Matching data from three different sources (medical claims, pharmacy, laboratory test results) is complicated because of differences in data formats, member/patient ID codes and spelling of patient names.



Primary care physicians and medical group/IPA medical director know what evidence based services are necessary for patients with diabetes: periodic physical examinations (blood

pressure, weight measurements, and foot exam),

hemaglobin, LDL, and microalbuminuria tests, dilated eye exam, and self management training.



However, in most physician offices, only when a patient makes an appointment to see a physician will all of these services be provided.



The managed healthcare system has been focused on providing faster access to patient demands for services, out of concern that managed care was hindering access to services.



To improve quality scores, the medical groups and IPAs will need to learn to better manage and anticipate the care for patients with diabetes, asthma, and cardiovascular diseases, children under age two (for immunizations) and women (for various screenings).


Disease Registry…1

Intelligent Healthcare is proposing to provide a disease registry care management tool to each of the Benchmark Study participating medical groups and IPAs, and to other interested medical groups and IPAs.



Uses the methodology from the Benchmark Study, and identifies patients with special needs.

Then focuses on a manageable amount of information where it can do the most good for these patients, and the medical group/IPA quality scores.



The tool will… report patients that are due for

evidence based care, or need follow up care.

provide reminders to the primary care physician and patients of services that should be provided.

identify and share best practice information among physicians.



The tool will… maintain the links current between

medical, pharmacy, and laboratory data.

collect necessary medical record information (i.e. blood pressures, weight, etc.)

store and report the data that will be needed for quality self-measurement and pay-for-performance.


Intelligent Healthcare LLC

Final Benchmark Study Report by November 2002.

Disease Registry starting before 2003.

Benchmark Study of Healthcare Provided by Physician Organizations funded by the California...

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