Measuring the Quality of Pennsylvania’s Commercial HMOs Joe Martin Director of Communications and Education Pennsylvania Health Care Cost Containment Council

Measuring the Quality Measuring the Quality of Pennsylvania’s of Pennsylvania’s Commercial HMOsCommercial HMOs

Joe MartinJoe MartinDirector of Communications and EducationDirector of Communications and Education

Pennsylvania Health Care Cost Containment CouncilPennsylvania Health Care Cost Containment Council

Pennsylvania Health Care Cost Containment Council (PHC4)Pennsylvania Health Care Cost Containment Council (PHC4)


““Knowledge is two kinds:Knowledge is two kinds:””

“We know a subject ourselves, or we know where we canfind information upon it.”

Samuel Johnson – Author (1709-1784)Samuel Johnson – Author (1709-1784)


Wall Street JournalWall Street Journal

Due to the Council, Due to the Council, Pennsylvanians can Pennsylvanians can get far more get far more information about information about their hospitals than their hospitals than can most can most Americans.Americans.


Commercial HMO ReportCommercial HMO Report

Combines clinical Combines clinical outcomes, outcomes, prevention prevention measures and measures and member satisfaction member satisfaction informationinformation


Why is Pennsylvania’s HMO Why is Pennsylvania’s HMO Report unique?Report unique?

Linked hospitalization data to health plan data Linked hospitalization data to health plan data using:using: NCQA dataNCQA data Clinical dataClinical data

Established collaborative relationship with health Established collaborative relationship with health plans which participated in data verification.plans which participated in data verification.

Analyzed preventive measures (HEDIS) against Analyzed preventive measures (HEDIS) against outcomes (hospitalization rates) to test for outcomes (hospitalization rates) to test for statistical significance.statistical significance.


PA HMO EnrollmentPA HMO Enrollment

0.0

1.0

2.0

3.0

4.0

5.0

6.019

90

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

Mil

lio

ns

of

enro

llee

s

Enrollment growth in the early 1990’s tapered off beginning in 1998.Enrollment growth in the early 1990’s tapered off beginning in 1998.


Why Look at HMOsWhy Look at HMOs

20012001

Fourth highest state HMO enrollment – Fourth highest state HMO enrollment – approximately 4 million *approximately 4 million *

Strong managed care penetration in PA – Strong managed care penetration in PA – approximately 35% *approximately 35% *

Gatekeeper managed care plans emphasize Gatekeeper managed care plans emphasize preventive care activitiespreventive care activities

* Source is Henry J. Kaiser Family Foundation State Health Facts Online* Source is Henry J. Kaiser Family Foundation State Health Facts Online


HMO Report: HEDIS MeasuresHMO Report: HEDIS Measures

- Childhood Immunizations - Childhood Immunizations

- Timely Prenatal Care - Timely Prenatal Care

- Beta Blockers after Heart Attack - Beta Blockers after Heart Attack

- Mental Health Services- Mental Health Services

- Antidepressant Medication Management- Antidepressant Medication Management

- Control of High Blood Pressure - Control of High Blood Pressure

- Appropriate Medication, Members with Asthma- Appropriate Medication, Members with Asthma


HMO Report: HEDIS MeasuresHMO Report: HEDIS Measures

DiabetesDiabetes

- Hemoglobin A1c Levels - Hemoglobin A1c Tests - Hemoglobin A1c Levels - Hemoglobin A1c Tests

- Eye Exam- Eye Exam - Monitor for Kidney Disease - Monitor for Kidney Disease

- Control Bad Cholesterol - Control Bad Cholesterol

ScreeningsScreenings

- Breast Cancer- Breast Cancer

- Cervical Cancer- Cervical Cancer

- Cholesterol Post Acute Cardio Events- Cholesterol Post Acute Cardio Events

- Bad Cholesterol Controlled Post Acute Cardio Events- Bad Cholesterol Controlled Post Acute Cardio Events


Hemoglobin A1c Blood Tests Hemoglobin A1c Blood Tests for Members with Diabetesfor Members with Diabetes


Ambulatory Sensitive ConditionsAmbulatory Sensitive Conditions

Ear, Nose and Throat InfectionsEar, Nose and Throat Infections Pediatric or AdultPediatric or Adult

High Blood Pressure High Blood Pressure

Gastrointestinal Infections Gastrointestinal Infections

Kidney/Urinary Tract InfectionsKidney/Urinary Tract Infections

Hospitalization RatesHospitalization Rates


Gastrointestinal Gastrointestinal InfectionsInfections(Per 10,000)(Per 10,000)


Preventive Care MeasuresPreventive Care Measures

COPDCOPD AsthmaAsthma DiabetesDiabetes Mental HealthMental Health Heart AttackHeart Attack



Surgical ProceduresSurgical Procedures

Hysterectomy Hysterectomy

Breast Cancer Breast Cancer

Neck and Back Neck and Back

ProstatectomyProstatectomy


Neck and Back ProceduresNeck and Back Procedures


Selection of Clinical Selection of Clinical ConditionsConditions

Degree of manageability by an HMODegree of manageability by an HMO Preventing Hospitalization Preventing Hospitalization Managing On-Going IllnessManaging On-Going Illness Appropriateness of Surgical ProceduresAppropriateness of Surgical Procedures

Significant risk and cost factorsSignificant risk and cost factors Health issues important to purchasers Health issues important to purchasers

and consumersand consumers


Clinical Outcome MeasuresClinical Outcome Measures

Outcome measures reviewed included:Outcome measures reviewed included: Readmission RatesReadmission Rates In-hospital MortalityIn-hospital Mortality Complication RatesComplication Rates Length of StayLength of Stay


Member SatisfactionMember Satisfaction

Getting Needed CareGetting Needed Care

Getting a Referral to a Specialist Getting a Referral to a Specialist

Customer Service Customer Service

Overall RatingOverall Rating

Accreditation StatusAccreditation Status


Report HighlightsReport Highlights

For the fourth consecutive year, Pennsylvania For the fourth consecutive year, Pennsylvania

HMOs achieved higher member satisfaction HMOs achieved higher member satisfaction

rates than the national average.rates than the national average.

86% of members reported no problems in 86% of members reported no problems in

receiving care they felt they needed.receiving care they felt they needed.



For the second consecutive year, For the second consecutive year,

Pennsylvania HMOs improved their Pennsylvania HMOs improved their

results in all 15 preventive care measures results in all 15 preventive care measures

in the report and outperformed their in the report and outperformed their

national counterparts in these categories.national counterparts in these categories.



Surgical ProceduresSurgical Procedures• Complications After Surgery – More Complications After Surgery – More

Likely for HMO Members than those Likely for HMO Members than those in fee-for-service plansin fee-for-service plans



Surgical ProceduresSurgical Procedures• Reconstruction Surgery – There Reconstruction Surgery – There

continues to be significant variation continues to be significant variation in breast reconstruction surgery in breast reconstruction surgery following mastectomy among the following mastectomy among the HMOsHMOs



Studies have cited the following possible Studies have cited the following possible reasons for such differences:reasons for such differences:

1)1) Variation in preoperative counselingVariation in preoperative counseling2)2) Surgeon preferencesSurgeon preferences3)3) Availability of trained surgeonsAvailability of trained surgeons4)4) Patient preferencesPatient preferences5)5) Practice patternsPractice patterns



Surgical ProceduresSurgical Procedures• Hysterectomy Between 1998 – 2001Hysterectomy Between 1998 – 2001

Procedure rate for all hysterectomies Procedure rate for all hysterectomies increased from 42.7 to 55.8 per 10,000 increased from 42.7 to 55.8 per 10,000 female membersfemale members

Complications rates for both abdominal and Complications rates for both abdominal and vaginal hysterectomies decreasedvaginal hysterectomies decreased



Surgical ProceduresSurgical Procedures• Hysterectomy 2001Hysterectomy 2001

Abdominal procedure* more likely than Abdominal procedure* more likely than vaginal procedure for HMO Members than vaginal procedure for HMO Members than for those in fee-for service plansfor those in fee-for service plans

(*higher length of stay and complication (*higher length of stay and complication rate)rate)



• The study statistically shows a correlation The study statistically shows a correlation between well-controlled blood pressure between well-controlled blood pressure levels and lower hospitalization rates.levels and lower hospitalization rates.

• Overall hospitalization rates for diabetes Overall hospitalization rates for diabetes decreased which may also suggest that decreased which may also suggest that HMO prevention measures are having a HMO prevention measures are having a positive effect. positive effect.


Disease Management

Value to the benefits purchaser:

•Helps control costs associated with chronic diseases

•Increases employee productivity

•Fewer days of lost work time

Pennsylvania Health Care Cost Containment Council (PHC4)Pennsylvania Health Care Cost Containment Council (PHC4)Pennsylvania Health Care Cost Containment Council (PHC4)Pennsylvania Health Care Cost Containment Council (PHC4)

Are Prevention Strategies Are Prevention Strategies Effective? Effective?

Health Plan PerspectiveHealth Plan Perspective

A Pennsylvania Health Plan study of 6,799 A Pennsylvania Health Plan study of 6,799 diabetic patients showed those enrolled in diabetic patients showed those enrolled in a disease management program averaged a disease management program averaged $394.62 per month in health care costs. $394.62 per month in health care costs. Those not enrolled in a program cost Those not enrolled in a program cost $502.48 per month. $502.48 per month.

The difference amounts to $1,200 per The difference amounts to $1,200 per member per year.member per year.


ConclusionsConclusions Wide variations in rates and preventive care Wide variations in rates and preventive care

measures suggest an uneven approach to measures suggest an uneven approach to disease management.disease management.

PHC4’s data shows that better preventive PHC4’s data shows that better preventive and primary care helps patients avoid and primary care helps patients avoid unnecessary trips to the hospital. unnecessary trips to the hospital.

The cost implications could have a major The cost implications could have a major impact on the health care delivery systemimpact on the health care delivery system..



““We want to use indicators that are We want to use indicators that are fairly well accepted.”fairly well accepted.”

Among those sources are statistics gathered Among those sources are statistics gathered by Pennsylvania Health Care Cost by Pennsylvania Health Care Cost Containment Council, a state agency that Containment Council, a state agency that collects and analyzes information related to collects and analyzes information related to the performance of hospitals in the state.the performance of hospitals in the state.Sept. 13, 2002Sept. 13, 2002



HMO Report DistributionHMO Report Distribution

1998 HMO Report: 3,0001998 HMO Report: 3,000

1999 HMO Report: 8,000 1999 HMO Report: 8,000

2000 HMO Report: 7,500 2000 HMO Report: 7,500

2001 HMO Report: 23,8002001 HMO Report: 23,800


HMO Report Web DownloadsHMO Report Web Downloads

HMO 2001 Data = 14,605HMO 2001 Data = 14,605

- Released March 2003- Released March 2003

HMO 2000 Data = 130,569HMO 2000 Data = 130,569


The WebThe Web - - WWW.PHC4.OrgWWW.PHC4.Org

New Interactive DatabasesNew Interactive Databases

Easy Access to PHC4’s Free Public ReportsEasy Access to PHC4’s Free Public Reports

DownloadableDownloadable PDF FilesPDF Files

New Purchaser SectionNew Purchaser Section


Create Your Own Create Your Own Reports on the WebReports on the Web


For more information on PHC4:For more information on PHC4:

225 Market Street, Suite 400225 Market Street, Suite 400

Harrisburg, PA 17101Harrisburg, PA 17101

(717) 232-6787(717) 232-6787

www.phc4.orgwww.phc4.org

Documents

Measuring the Quality of Pennsylvania’s Commercial HMOs Joe Martin Director of Communications and Education Pennsylvania Health Care Cost Containment Council