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

Benchmark Study of Healthcare Provided by Physician Organizations funded by the California Healthcare Foundation. New Directions in Managing Health Care Costs Presentation for: www . Health Web Summit . com Paul M. Katz, MBA Chief Executive Officer Intelligent Healthcare LLC

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

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  1. Benchmark Studyof Healthcare Provided by Physician Organizationsfunded by the California Healthcare Foundation New Directions in Managing Health Care Costs Presentation for: www . Health Web Summit . com Paul M. Katz, MBA Chief Executive Officer Intelligent Healthcare LLC www.intelHC.com (310) 458-6966 December 2002

  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. Intelligent Healthcare LLC

  3. 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. Intelligent Healthcare LLC

  4. 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. Intelligent Healthcare LLC

  5. 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. Intelligent Healthcare LLC

  6. 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. Intelligent Healthcare LLC

  7. Why Self-Measure … 2 • 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. Intelligent Healthcare LLC

  8. Why Self-Measure … 3 • 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. Intelligent Healthcare LLC

  9. Why Self-Measure … 4 • Potential of $1 Million for approximately 25,000 capitated/delegated lives. Intelligent Healthcare LLC

  10. Why Self-Measure … 5 • 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. Intelligent Healthcare LLC

  11. Why Self-Measure … 6 • Quality measurement with compensation is here. • The medical groups and IPAs should be prepared in advance to use these programs to their advantage. Intelligent Healthcare LLC

  12. 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. Intelligent Healthcare LLC

  13. Benchmark Study… 2 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. Intelligent Healthcare LLC

  14. Benchmark Study… 3 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. Intelligent Healthcare LLC

  15. Benchmark Study… 4 Articles using data for measurement: • The articles are available on our web site. Under Benchmark Study, click on “Paper: Review of Research…” Intelligent Healthcare LLC

  16. 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. Intelligent Healthcare LLC

  17. Sample Info Tech Survey Intelligent Healthcare LLC

  18. 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 Intelligent Healthcare LLC

  19. Information Tech Survey…2 • Survey response by organization type: • IPAs – 20 • Medical Groups – 11 • Survey response enrollment: • 2.5 million lives Intelligent Healthcare LLC

  20. 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: Intelligent Healthcare LLC

  21. Data warehouse…1 • Scrubbed the data (including claims, encounter, enrollment, member demographics) and moved it into our data warehouse Intelligent Healthcare LLC

  22. Data warehouse…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. Intelligent Healthcare LLC

  23. Data warehouse…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. Intelligent Healthcare LLC

  24. Data warehouse…4 • Copy the member’s claims and encounters into the indicator database. Intelligent Healthcare LLC

  25. Data warehouse…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. Intelligent Healthcare LLC

  26. Data warehouse…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. Intelligent Healthcare LLC

  27. Data warehouse…7 • Run each indicator, or part of each indicator for each medical group/IPA. Intelligent Healthcare LLC

  28. Flow chartBenchmark Study Indicator Database DATA WAREHOUSE Groups A, B, C ….. Z HMO Rx C HMO Rx A HMO Rx D HMO Rx B INDICATORS Diabetes, Asthma Hypertension Intelligent Healthcare LLC

  29. 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. Intelligent Healthcare LLC

  30. Study groups by enrollment size Intelligent Healthcare LLC

  31. 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 Intelligent Healthcare LLC

  32. 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. Intelligent Healthcare LLC

  33. 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. Intelligent Healthcare LLC

  34. Preliminary Findings…2 • 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. Intelligent Healthcare LLC

  35. Preliminary Findings…3 • 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 Intelligent Healthcare LLC

  36. Preliminary Findings…4 • 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. Intelligent Healthcare LLC

  37. 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 Intelligent Healthcare LLC

  38. 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. Intelligent Healthcare LLC

  39. Study Measures…3 • Utilization measures • Obstetrics • cardiovascular services • radiology scans Intelligent Healthcare LLC

  40. Preliminary Results…1 • Patients with Diabetes • Eye Exam Completed: Results vary between 15%* and 75%. • * missing data or patients with eye exam carve-outs. Intelligent Healthcare LLC

  41. Preliminary Results…2 • Patients with Diabetes • Hemoglobin Test Rates: Results vary from data missing to 85%. Intelligent Healthcare LLC

  42. Preliminary Results…3 • 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. Intelligent Healthcare LLC

  43. Preliminary Results…4 • 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 Intelligent Healthcare LLC

  44. 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. Intelligent Healthcare LLC

  45. 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. Intelligent Healthcare LLC

  46. Preliminary Conclusions…2 • 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 Intelligent Healthcare LLC

  47. Preliminary Conclusions…3 • 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. Intelligent Healthcare LLC

  48. Preliminary Conclusions…4 • 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. Intelligent Healthcare LLC

  49. Preliminary Conclusions…5 • However, in most physician offices, only when a patient makes an appointment to see a physician will all of these services be provided. Intelligent Healthcare LLC

  50. Preliminary Conclusions…6 • 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. Intelligent Healthcare LLC

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