Quality and Use in Managed CareQuality and Use in Managed Care

Sarah Hudson Scholle

Academy Health Annual Research Meeting Seattle June 26, 2006

BackgroundBackgroundBackgroundBackground

• Health care costs continue to increase

• Greater emphasis on demonstrating value in health care.

• Evidence about the relationship between utilization/ costs of care and quality is limited.

– Studies in ambulatory settings show no relationship

– A recent Medicare study found higher spending was correlated with poorer quality of care.

PurposePurposePurposePurpose

• To examine the relationship between quality and utilization of health care among commercial health plan – correlation of HEDIS® 3.0 effectiveness measures

with outpatient and inpatient utilization – regression analyses controlling for patient and

plan covariates

Data SourcesData SourcesData SourcesData Sources

• NCQA’s Commercial HEDIS/CAHPS data set

• Includes plans that do not allow public reporting of data

• Reporting year 2003 (Measurement year 2002)

316 Commercial Plans submit data in 2003

254 included in analysis

62 (excluded: 20%)29 No data on any of the Dependent variables

10 No data on the patient characteristics23 Missing 4 or more of the 11 quality measures

StudyStudy GroupGroup

Represents 83% of commercial managed care enrollees

Utilization MeasuresUtilization MeasuresUtilization MeasuresUtilization Measures

• Limited to adults age 20-64• Excluded behavioral health, maternity, &

surgical care• Measures

– Outpatient visits per 1,000 members per year– Emergency visits per 1,000 members per year– Medical discharges per 1,000 members per year– Inpatient days per 1,000 members per year

Quality Indicators and CompositeQuality Indicators and CompositeQuality Indicators and CompositeQuality Indicators and Composite

67.4%, 5.0%QUALITY COMPOSITE

73.6%, 9.8%Follow-up after Hosp for Mental Illness

44.5%, 7.5%Flu Shots

59.9%, 7.8%Acute phase antidepressant treatment

67.8%, 11.5%Diabetic HbA1c control

62.6%, 12.0%LDL-C control

75.9%, 5.2%Breast Cancer Screening

59.1%, 7.7%Blood Pressure control

93.8%, 7.6%Beta Blocker After Heart Attack

68.8%, 5.6%Asthma medication management

67.8%, 5.1%Advising Smokers to Quit

Mean, SDMeasure

CovariatesCovariatesCovariatesCovariates

• Plan Characteristics– Public reporting, Profit status, type of plan (HMO

vs POS vs both), Geographic location

• Member Characteristics– Age and gender distribution– CAHPS data on race, education and health status

Correlation: Quality Composite Correlation: Quality Composite and Outpatient Visitsand Outpatient Visits

Correlation: Quality Composite Correlation: Quality Composite and Outpatient Visitsand Outpatient Visits

0.45

0.55

0.65

0.75

0.85

1000 3000 5000

Outpatient Visits

Qu

alit

y C

om

po

site

Correlation: Quality CompositeCorrelation: Quality Compositeand Hospital Dischargesand Hospital Discharges

Correlation: Quality CompositeCorrelation: Quality Compositeand Hospital Dischargesand Hospital Discharges

0.45

0.55

0.65

0.75

0.85

0 10 20 30 40

Hospital Discharges

Qu

alit

y C

om

po

site

Correlations between Quality and UtilizationCorrelations between Quality and UtilizationCorrelations between Quality and UtilizationCorrelations between Quality and UtilizationOutptVisits

ER visits

MedicalDischarges

HospitalDays

Smoking Cessation 0.22*** -0.12 -0.26*** -0.22**

Asthma Medication Mgmt 0.19** -0.24*** -0.26*** -0.30***

Beta Blocker after MI 0.09 0.00 -0.21*** -0.20**

Blood Pressure Control 0.08 0.01 -0.06 -0.04

Breast Cancer Screening 0.20** -0.07 -0.28*** -0.30***

Cholesterol LDL Control 0.12 -0.20** -0.17** -0.18**

Diabetic HbA1c Control 0.10 -0.10 -0.20** -0.23***

Acute Phase Antidepressant Tx 0.01 0.22*** -0.46*** -0.42***

Flu Shots 0.09 -0.23*** -0.29*** -0.30***

MH Inpt Follow-up(30) 0.15* -0.06 -0.17** -0.16*

Quality Composite 0.19* -0.18** -0.36*** -0.35***

Regression Results: Regression Results: Relationship of Quality to UtilizationRelationship of Quality to Utilization

Regression Results: Regression Results: Relationship of Quality to UtilizationRelationship of Quality to Utilization

Based on loglinear regressions using Poisson distributions. Covariates include plan region and profit status as well as plan rates of patient covariates from CAHPS data - age, gender, minority status and health status.

0.0207-0.7781Hospital Days

0.0365-0.6900Hospital Admissions

0.12750.5702Outpatient Visits

0.3677-0.4735Emergency visits

P-valueEstimateDependent Measure

Summary of FindingsSummary of FindingsSummary of FindingsSummary of Findings

• Positive Correlation between Quality and Access: Plans with higher quality score have a higher proportion of members with at least one visit.

• Negative Correlation between Quality and Hospital Use: Plans with higher quality score have lower average admissions and hospital days.

• There is no correlation between quality and the outpatient visit rate.

DiscussionDiscussionDiscussionDiscussion

• Findings are consistent with prior research focusing on the Medicare population.

• Impact is important: – A 5% improvement in quality is related to a 4%

decrease in hospital days. – This translates to $12 per member per month

(based on a conservative estimate of hospital costs of $3,000 per inpatient day).

LimitationsLimitationsLimitationsLimitations

• This cross-sectional study cannot address causality.

• Measurement of quality is limited to available measures.

• Using CAHPS data as a proxy for population socioeconomic and health status is an indirect method of adjustment.

• Controlling for health plan region may not be sufficient for disentangling impact of supply on utilization.

What mechanism links quality to What mechanism links quality to utilization and costs?utilization and costs?

What mechanism links quality to What mechanism links quality to utilization and costs?utilization and costs?

• Quality reduces unnecessary hospitalization.

• Quality reflects better data collection.

• Quality is a marker of better organization for managing hospitalization days and HEDIS quality efforts.

ImplicationsImplicationsImplicationsImplications

• The IOM envisioned restructuring the health care system to address both quality and costs simultaneously.

• These data give hope that improvements in effectiveness of care may reduce both the human costs of poor care and their financial implications as well.

• More research is needed on the relationship between quality and utilization and potential mechanisms affecting that relationship.

For More Information…For More Information…For More Information…For More Information…

Sarah Hudson Schollescholle@ ncqa.org

202-955-1726

www.ncqa.org