Download pdf - THE HEALTH SYSTEM MATRIX 6.1: Understanding the Health Care

THE HEALTH SYSTEM MATRIX 6.1:

Understanding the Health Care Needs of the

British Columbia Population through Population

Segmentation

February 2015 Health Sector Planning and Innovation Division, British Columbia Ministry of Health

The Health System Matrix 6.1: Understanding the Health Care Needs of the British Columbia Population

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HEALTH SYSTEM MATRIX 6.X VERSIONS

Version Date Changes

6.0 Dec 30 2014 Major Update Version from 5.0 updating all data (2002/03 to 2012/13) and adding

2013/14 data. Changes from the 5.0 are highlighted as NEW in this document

6.1 Feb 02 2015 Added information from Inpatient care in 13/14 reported in hospital discharges in

2014/15 based on DAD file received from CIHI in January 2015. This additional

information impacted 2013/14 population segments and summaries of inpatient

hospitalizations.

The Health System Matrix is a project of the Health System

Planning and Innovation Division, British Columbia Ministry of

Health. The Matrix database, definitions and insights evolve

version to version as updates are available and as further

insights are gained. Therefore, comparisons should be made

within a Matrix version, and not between Matrix versions.

For further information please contact:

Martha Burd [email protected] or 250-952-2842


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THE HEALTH SYSTEM MATRIX 6.1: UNDERSTANDING THE HEALTH CARE NEEDS OF

THE BRITISH COLUMBIA POPULATION THROUGH POPULATION SEGMENTATION

CONTENTS

HEALTH SYSTEM MATRIX 6.X VERSIONS ....................................................................................... 2

INTRODUCTION ............................................................................................................................ 5

MAJOR CHANGES IN MATRIX 6 ..................................................................................................... 7

Figure 1: Impact from Change to Episodic Depression Registry ........................................................................ 7

BENEFITS OF USING A POPULATION SEGMENTATION APPROACH .................................................... 9

INSIGHT FROM THE HEALTH SYSTEM MATRIX: POPULATIONS AND THEIR USE OF HEALTH CARE

SERVICES ..................................................................................................................................11

Figure 2: Use of Publicly Funded Health Care, 2013/14, by Population Segment and Major Service Lines .... 12 Figure 3: Use of Publicly Funded Health Care Per Person, 2013/14, by Population Segment and Major Service Lines .................................................................................................................................................... 12 Figure 4: Distribution of Age Groups within Population Segments, 2013/14 ..................................................... 13 Figure 5: Per Capita Use of Health Care by Population Segments and Age Groups, 2013/14 ......................... 13

HEALTH SYSTEM MATRIX: POPULATION SEGMENT DEFINITIONS ...................................................15

PS14 End of Life ...................................................................................................................................................... 15

PS13 Frail in Care (In Residential Care) .................................................................................................................. 16

Figure 6: Residential Care Clients: Defining sub groups ................................................................................... 17

PS09 Frail in the Community ................................................................................................................................... 17

Populations with Chronic Conditions: PS11 Frail with High CC, PS10 High (without HCC), PS06 Medium CC, and

PS05 Low Complex Chronic Conditions .................................................................................................................. 18

Figure 7: Highlighting 6.1 Change in Population Segments from Using the Episodic Depression Registry ..... 20 Figure 8: Chronic Conditions: Defining High, Medium, and Low Complex Chronic Conditions Sub Groups ..... 20 Figure 9: Distribution of BC Residents with Diabetes across the Population Segments ................................... 21 Figure 10: Distribution of Chronic Condition Populations across the Population Segments ............................. 21 Figure 11: Percent of BC Residents in Each Population Segment who have Specific Chronic Conditions ....... 22

PS12 Cancer ........................................................................................................................................................... 22

PS08 Maternity & Healthy Newborns ....................................................................................................................... 23

PS07 Mental Health & Substance Use .................................................................................................................... 23

Figure 12: Hospitalization Diagnosis Codes used to Identify Severe Mental Health and Substance Use Population ......................................................................................................................................................... 23

Dividing the Remaining Population into Population Segments based on Utilization ................................................ 24

Figure 13: Allocation of the BC Population by Population Segments, 2013/14 ................................................. 24

PS03 Adult Major Conditions Age 18+ .................................................................................................................... 25

PS04 Child and Youth Major Conditions .................................................................................................................. 25

PS02 Healthy & Low User ....................................................................................................................................... 25

PS01 Non User ........................................................................................................................................................ 26

Assignment to a Unique Population Segment each Year ........................................................................................ 26

Figure 14: Unique versus Overlapping Population Segments: Counts of BC Residents ................................... 27 Figure 15: Unique versus Overlapping Population Segments: Distribution of BC Residents ............................ 27


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SERVICE LINES ...........................................................................................................................28

Figure 16: Crosswalk between Databases and Service Lines .......................................................................... 30 Figure 17: Definition of Service Lines ............................................................................................................... 31

ESTIMATING THE PUBLIC EXPENDITURES ON HEALTH CARE IN DOLLARS .......................................33

Figure 18: Estimation of Dollar Value of Health Care Services ......................................................................... 33 Figure 19 Unit Costs used in the Health System Matrix 6 ................................................................................. 34

BEHIND THE NUMBERS – DATA SOURCES, INCLUSIONS AND EXCLUSIONS .......................................35

Figure 20: Summary of Publicly Funded Health Care Expenditures in the Health System Matrix, as a share of Provincial Government Health Expense by Function, 2013/14 ......................................................................... 35 Figure 21: Estimate of BC Government Health Function Expenditures Included or Missing from the Health System Matrix 6, 2013/14 ................................................................................................................................. 36

BACKGROUND: INTRODUCTION TO THE BRITISH COLUMBIA HEALTH CARE SYSTEM .......................37

GLOSSARY .................................................................................................................................38


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INTRODUCTION

The Health System Matrix is the BC Ministry of Health Services’ unique and innovative

approach to understanding the current and future health care needs of the province’s residents.

Now in its fourth year, the Matrix project is also a demonstration of how data from divergent

administrative databases can be transformed into information and insight into the health of the

population and their use of health care services.

During a year, a patient may have multiple encounters with

the health system, and information on the encounters may

be collected in separate databases. This presents a huge

challenge, for both providers and those managing the

health care system, because every encounter may only tell

part of the story. The Health System Matrix created a

summary view of a person’s encounters with the health

system over the year, to be able to put the pieces together

to show the trajectory story.

To create the Matrix, we started with a question: “If you were creating an annual profile for each

BC resident, what information would you want to know?” Our answer was to bring together into

a single database, basic socio-demographics, chronic conditions, and summaries of health care

services each resident used each year. Then we asked ourselves “How can we use this data to

identify the different health care needs within our population.” With analysis and consultation,

we developed a population segmentation approach, dividing the population into 14 health status

categories ranging from Healthy to End-Of-Life according to their highest health care need each

year and categorized the health care services they used into 25 service lines.

The Matrix works on three levels. First, as a concept it emphasizes the importance of thinking

across the health care system, and the different populations that use services. Second, as Big

Data, it is a database summarizing selected information from linkage between all major BC

public health system data sources available to the Ministry (services provided by physicians,

hospitals, community pharmacies, residential care facilities and other community supports for

activities of daily living; information from chronic condition registries; and socio-demographic

information from registration administrative data). And third, as an interactive analysis tool which

summarizes information from the ‘big data’ to show how the population segments use health

care service lines over time.

The key learning from the Heath System Matrix approach is that the population is not

homogeneous – it is made up of groups who have different

health care needs, using different bundles of services, that

transition between health states at different rates. This

insight has helped to focus the Ministry’s strategic

planning agenda, especially on prevention, care for people

with chronic conditions, and those on the trajectory to

residential care. The matrix has been used in modelling

health care and estimating future demand for health care,

and has been incorporated into the Population Needs

Based Funding Allocation Model which is one of the

Ministry tools uses to fund health authorities.


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The Health System Matrix is widely known as The Blue Matrix. High level summaries of

population segments and their use of publicly funded services in the fiscal year are distributed in

a user-friendly interactive Excel analysis tool. The Excel version of the matrix presents

population segments in rows, and health care services divided into 25 broad service lines

presented in columns. The cells of the matrix presents the populations’ use of services with

blue shading indicating the intensity of use – hence the name ‘The Blue Matrix’.

In building the Health System Matrix, many choices had to be made. The main decision was to

take a patient-centred approach in building the underlying database and summarizing how

people use health care services each year. From that perspective, the Matrix can explore how

BC Residents use publicly funded services anywhere in the province, disaggregated by

population groups, age group, where they live in the province, whether they have a regular

family doctor, or other characteristics. As a result, the underlying Matrix data cannot provide a

provider view – who provided the services, or where and when they were provided within the

fiscal year.

In this document, unless otherwise stated, the analysis refers to information at the BC level in

2013/14.


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MAJOR CHANGES IN MATRIX 6

The definitions of Population Segments are updated with each version of the matrix, as more

data becomes available. For this reason, analysis should always use the same version of the

matrix throughout, and not combine results from different versions.

Major Update 6.0 (December 2014)

Data has been added for 2013/14, and updated for 2002/03 to 2012/13;

List of BC residents and their demographic information based on updated/revised Client

Roster.

Population segments regenerated back to 2002/03 based on updated data.

Major Changes in Population Segments Matrix 6

Population segments re-numbered because High Complex Chronic Conditions was

split into two populations: Frail with High Complex Chronic Conditions (with HCC) and

High Complex Chronic Conditions (without HCC) to identify the population segment with

high complex chronic conditions who are also ‘frail’. The definition of ‘frail high complex

chronic’ are people with high complex chronic conditions who use services to support

activities of daily living – home support, assisted living, adult day services, short term

convalescent care.

Low Complex Chronic Conditions definition: Matrix 6 used a new Episodic

Depression Registry which counted 359,000 BC residents with depression in 2012/13.

This replaced the previous Depression Registry which counted over 1,142,000 BC

residents with depression.

Figure 1: Impact from Change to Episodic Depression Registry

The difference between the two

registries are the time frames

used in the definitions. While the

previous Depression Registry

counted people who had been

treated for depression at any time

(from the mid-1990s onwards),

the new Episodic Depression

Registry counts only those with

recent treatment. Consequently,

the large number of BC residents

who were previously in Low

Complex Chronic Conditions

population solely because of

depression have moved to lower (healthier) population segments in Matrix 6.1. The

change to the Episodic Depression Registry was applied to all years 2002/03 to 2013/14.

Major Changes in Service Lines

Change in how hospitalizations are counted in fiscal years: For hospitalizations

which span two fiscal years, Matrix 6 has split the hospitalization to count the days in the

year they occurred. Earlier versions of the matrix followed standard practice for hospital

analysis which allocates all hospital days to the year of discharge. For the matrix, this

created problems for patients who were hospitalized over the March 31 to April 1 date.


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For example, if they entered hospital March 22, 2012 and were discharged April 5, 2012,

their entire 15 day stay would be reported in 2012/13 while the physician costs related to

that hospitalization would be counted correctly in each fiscal year (physician care

provided in hospital for 10 days in 2011/12 and 5 days in 2012/13). To address this issue

Matrix 6.1 has counted all hospital days in the year they occurred, and adjusted the

count of cases (hospitalizations) and hospital costs to reflect this split. This change will

have a small impact on all population segments that use hospital data in the definition.

See introduction to Service Lines for more information.

SL01 Primary Health Care: Professional Home Nursing. In Matrix 6 rehabilitation

services provided by the health authorities have been separated out and moved to SL20

Rehabilitation.

SL02 Obstetrics: Matrix 6.1 excludes abortions.

SL20 Rehabilitation: Now includes rehabilitation services (physiotherapy, occupational

therapy) provided by the health authorities.

SL22 Community Supports for Daily Living: Case Management has been added to

the service line.

Changes in cost estimates

All hospital service lines: Unit costs have been revised for hospital care (cost per

weighted case)

SL01 and SL22: Unit costs have been revised for the home and community care

services provided by the health authorities.

SL24: The dollar value of drugs used by residential care clients in extended care

facilities associated with acute facilities have been estimated based on a regression

analysis of drug costs used by residential care clients in publicly paid stand-alone

licensed facilities.

SL07: The dollar value of physician costs of emergency department visits have been

estimated for APP ED shadow billings and NACRS ED visits, based on the average

dollar billings by 3 levels of care and 3 times of day (day/evening/night) recorded in MSP

ED physician billings.

Minor Update 6.1 (February 1 2015)

Added inpatient hospitalizations in 2013/14 for cases that were discharged in 2014/15,

based on the January 2015 DAD files. Resulted in revised hospitalization summaries for

2013/14 and minor changed in assignment to population segments that use hospital

data in their definitions.


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BENEFITS OF USING A POPULATION SEGMENTATION APPROACH

In analysis of the health system, population segmentation is a useful tool to describe the health

and health care needs of groups in a population, and understand how they differ from one

another. The initiative to develop a population segmentation methodology was inspired by the

“Bridges to Health”1 article by Joanne Lynn et al, published in the Milbank Quarterly in 2007.

The article outlined “how the concept of segmenting patient populations can lead to more

creative and effective strategies for safe, efficient, effective, timely, patient centered, and

equitable health care and thus a better understanding of how to achieve better health for both

the individual and all people.2”

Why create another system of population segmentation? In hospital care, there are many well

established ‘case mix groupers’ which categorize hospitalizations into a groups that share

similar clinical characteristics and costs, and which are different from other groups. Although the

strength of these groupers is their ability to categorize thousands or millions of hospitalizations

into a smaller number of meaningful categories, the groupers have a significant shortcoming -

they cannot describe the health of an entire population because the grouping methodology can

only be applied to hospitalizations, not people, and only a small portion of the population is

hospitalized in any year. In contrast, a Population Risk Adjustment Grouper provides a broader

approach, as it segments the entire population into different groups, usually based on

information from health care encounters with physicians, hospitals, and prescription drugs in

one or multiple years. Population groupers, such as the John Hopkin’s Adjusted Clinical Groups

(ACG) methodology and 3M’s Clinical Risk Grouper (CRG), have many uses for policy makers

and researchers, including risk adjusting indicators and estimating prospective health care costs

for funding models. Although the complexity and detailed methodology is a strength of these

population groupers, it is also a weakness since it is difficult for a layman to understand the

differences between the groups, and specific characteristics which cause a person to be

assigned to a specific group. In developing our own population segmentation model, we could

see the need for a simpler approach which would have a relatively small number of intuitively

different segments, each defined by easy to understand and measure characteristics.

The Health System Matrix project developed our own population segmentation approach,

dividing the entire provincial population into 13 categories that represented different health

status or health care needs. The number and definition of the segments, and the segmentation

methodology is intentionally simple, following the approach in the Bridges to Health:

1. “The set of population segments must be limited if the health care system is to

offer a sensible array of integrated services for each segment and to make those

services available almost everywhere.

2. The set of population segments should include everyone; that is, at every point in

his or her life, every person should fit into one of these categories.

3. The people in each population segment must have sufficiently similar health care

needs, rhythms of needs, and priorities to make the segment useful for planning,

but each segment must be different enough to justify separate consideration.3”

1 Using Population Segmentation to Provide Better Health Care for All: The “Bridges to Health” Model

Joanne Lynn, Barry M. Straube, Karen M. Bell, Stephen F. Jencks, and Robert T. Kambicps13, The Milbank Quarterly, Vol. 85, No. 2, 2007 (pp. 185–208) 2 IBID, pp 186.

3 IBID pp 187.


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For the Health System Matrix, we derived a list of potential population segments that had

different health care needs, and could be identified through data in the Ministry’s administrative

databases. The resulting segmentation approach is based on 20+ chronic condition registries,

diagnoses from physician or hospital encounters, or use of specific services in single or over

multiple years. The list has evolved over time, and is expected to continue to evolve as

additional information becomes available. The following lists the 14 population segments in the

Matrix version 6.1. People with multiple conditions can ‘qualify’ for multiple population

segments, but for most analysis people are assigned to the population segment which

represents their highest need for health care in the year, in the order shown below. Please refer

to Assignment to a Unique Population Segment Each Year for details of the unique assignment.

PS14 End of Life

PS13 Frail in Care (In Residential Care)

PS12 Cancer

PS11 Frail with High Complex Chronic Conditions (with HCC)

PS10 High Complex Chronic Conditions (without HCC)

PS09 Frail In The Community

PS08 Maternity and Healthy Newborns

PS07 Mental Health and Substance Use

PS06 Medium Complex Chronic Conditions

PS05 Low Complex Chronic Conditions

PS04 Child and Youth Major <18 years

PS03 Adult Major Age 18+

PS02 Healthy

PS01 Non User

In Ministry Strategic Planning, the population segments are grouped into Staying Healthy,

Getting Healthy, Living with Illness and Chronic Conditions, and Towards the End of Life.


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INSIGHT FROM THE HEALTH SYSTEM MATRIX: POPULATIONS AND THEIR USE OF

HEALTH CARE SERVICES

The Health System Matrix provides insight into the health of British Columbians and an

overview of their use of publicly funded services.

It is very important to note that the Health System Matrix includes only selected publicly

funded health services - those that are reported to the Ministry on a person specific

basis. The BC Government’s total Health Expense by Function was forecast at $18.2

billion for 2013/144, of which the Health System Matrix summarizes approximately $11

billion in publicly funded services. Important services are not included, such as salaried

physician services, and BC Cancer Agency activities. See the Behind the Numbers –

Data Sources, Inclusions and Exclusions section for data sources and a table of

included/excluded services.

The accomplishments from the Health System Matrix project can be grouped into three levels.

First, it has provided a common language or categorization to describe the different populations

who use publicly funded health care services. It has moved analysis away from age-based

analysis which tended to group all seniors into high users of health care, towards understanding

the health conditions that drive the need for health care. The second accomplishment was

creating the underlying database that combined person-based fiscal year summaries from the

separate administrative databases into a common data structure and common terminology,

making it easier to undertake cross program and time series analysis. Although the Health

System Matrix cannot answer questions about where services were delivered, or the

chronological order of services used within a fiscal year, it can provide a view across the health

care system that is not possible from any individual database. The third accomplishment is the

set of high level analysis tools and summaries from the Matrix project team, and the insights

gained from them.

One of the first and most important insights from the matrix was being able to measure the use

of major health care services by the population segments. In 2013/14, the matrix could track

$11 billion of selected publicly funded health care services provided to BC residents. This

summary, shown in figures 2 and 3 for 2013/14, highlight the key populations for strategic

planning – the frail populations living in the community or in residential care, and those with

chronic conditions. The fact that these were high user populations was not a new discovery; the

contribution of the Matrix was to provide a way to measure the size of these populations, and

put a dollar value on their use of health care services. It focused attention on the care for

people with chronic conditions, and raised the profile of prevention activities. By summarizing

the use of health care over the entire year, the matrix showed that people in residential care

were the highest cost group per person; although they made up less than 1% of the population,

they used 20% of the services tracked in the matrix. On average, people in residential care

used over $60,000 of health care services per person. Further analysis showed that for those

entering residential care during the year, hospital costs accounted for almost two thirds of their

total costs in the year. This focussed attention on the need for care in the community that would

improve quality of life and allow people to remain in their homes for longer, delaying entry into

residential care.

4 Budget and Fiscal Plan 2014/15 – 2016/17, Table 4.9 2013/14 Expense By Function, p 99.


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Figure 2: Use of Publicly Funded Health Care, 2013/14, by Population Segment and Major Service Lines

A major strategic planning document from the British Columbia Ministry of Health ‘Setting

Priorities for the B.C. Health System’ can be found on the Ministry’s website at http://www.health.gov.bc.ca/library/publications/year/2014/Setting-priorities-BC-Health-Feb14.pdf

The section on Health Outcomes in the document (page 21 onwards) shows how the insight

from the Matrix’s population segments has been used in the province’s strategic planning.

Figure 3: Use of Publicly Funded Health Care Per Person, 2013/14, by Population Segment and Major Service Lines

The Matrix approach has shown the insight that can be gained categorizing people by health

status rather than age. Figure 4 shows the age distribution in each population segment. As

http://www.health.gov.bc.ca/library/publications/year/2014/Setting-priorities-BC-Health-Feb14.pdf


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expected, it shows the increasing age of the low, medium and high chronic condition

populations and those populations receiving assistance with activities of daily living – but it also

shows the range of ages in these populations. Just as it is misleading to make broad

statements about the health of ‘seniors’, it is also inaccurate to assume that all people receiving

supports for daily living are seniors.

Figure 4: Distribution of Age Groups within Population Segments, 2013/14

The importance of using population segments rather than age to understand health care

utilization is shown in figure 5, which presents per person health care services by age. While

the average services used increased dramatically by population segment, there was much less

variation between the age groups within each population segment.

Figure 5: Per Capita Use of Health Care by Population Segments and Age Groups, 2013/14

The Health System Matrix project has shown the insight that can be gained from using

population segments as an analysis approach. It has also shown the benefits that analysts

have gained from summarizing and synthesizing information into a single database. For others

who do not have access to the underlying database, the matrix data is summarized into an


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analysis tool in Microsoft Excel that shows summaries of population size by population segment,

broad age groups, and health region of usual residence in the province for each fiscal year.

Utilization data for each of the detailed services lines is summarized into number of users of

each service line, percent of the population using the service, number of encounters for that

service line (generally days, but also visits and hours), average number of encounters per user

of the service line, estimated dollars of service, average dollars of service per user of the

service line, and summaries by broad service lines. For most analysis we have found that

‘Users’ is more informative when examining specific service lines than calculations ‘per capita’;

service providers only see ‘users’, not the entire population that could use the service, and

therefore their notional estimate of average use is actually the average per user.


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HEALTH SYSTEM MATRIX: POPULATION SEGMENT DEFINITIONS

The definition of each population segment is outlined below. The process of assigning people

to population segments begins after all the data is compiled. Then the definitions of the

population segments are applied, and each person is flagged for each of the population

segments they ‘qualify’ for each year, based on information available in the Ministry’s

administrative databases. Then, they are assigned uniquely to the single population segment

which represents their highest need for health care in the year. For most analysis, these

‘unique population’ assignments are used to avoid double counting people, encounters and

dollars. Please refer to Assignment to a Unique Population Segment Each Year for details of the

unique assignment.

In this definition section, some population segments are discussed out of order for ease of

explanation. See Glossary for terminology used in descriptions.

The definitions of Population Segments are updated with each version of the matrix, as more

data becomes available. For this reason, analysis should always use the same version of the

matrix throughout, and not combine results from different versions. Changes to the definition in

Matrix 6 are highlighted throughout the definitions.

New to 6: For hospitalizations which span two fiscal years, Matrix 6 has split the

hospitalization to count the days in the year they occurred. Earlier versions of the matrix

followed standard practice for hospital analysis which allocates all hospital days to the year of

discharge. For the matrix, this created problems for patients who were hospitalized over the

March 31 to April 1 date. For example, if they entered hospital March 21,2012 and were

discharged April 5, 2012, their entire 15 day stay would be reported in 2012/13 while their

physician costs related to the hospitalization were properly reflect hospital care for 10 days in

2011/12 and 5 days in 2012/13. To address this issue Matrix 6 has counted all hospital days in

the year they occurred, and adjusted the count of cases (hospitalizations) and hospital costs to

reflect this split. This change will have a small impact on all population segments that use

hospital data in the definition.

PS14 End of Life Living in the Community with Palliative Needs Broad Category: Towards End of Life

People who received any health care services specifically for palliative care in the year.

Detailed Definition: This includes palliative care services from physicians (based on physician’s

MSP FFS billing for palliative care), were hospitalized specifically for palliative care (CMG810),

received palliative services from health authority’s home and community care programs (HCC),

or were registered in PharmaCare’s BC Palliative Care Benefits Program (Plan P) for BC

residents who have reached the end stage of a life-threatening disease or illness with a life

expectancy of up to six months and who wish to receive palliative care at home.

New to 6: People receiving HCC palliative care services from health authorities are

included in definition.


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The main reason for creating a separate End of Life population segment was to be able to count

the number of people who were receiving palliative care from the different parts of the health

care system, and to measure their service utilization in the year, separately from the rest of the

population. It is widely recognized that service utilization rises in the last year of life; the matrix

summarizes services by fiscal year so it is not a perfect reflection of services in the last year of

life.

This population segment is highest in the priority assignment to a person’s unique population

segment. Therefore, a person who received palliative care in the community and then entered

residential care will still be counted in the End of Life population segment.

PS13 Frail in Care (In Residential Care) Frail Population, Living in Residential Care Broad Category: Towards End of Life

People in the Frail in Care (Residential Care) population are permanent residents of a

residential care facility that provides 24 hour nursing care and assistance with activities of daily

living.

Detailed Definition: People in this segment are either registered with PharmaCare’s Plan B

which covers prescription drugs for Permanent Residents of Licensed Residential Care

Facilities, or they are long term residential care clients in the Health Authorities residential care

reporting system.

Ideally, the description of a population segment should be based on clinical, functional or

cognitive assessments, rather than use of specific services. In this case, however, there were

solid reasons for creating a separate population segment for permanent residential care clients.

First, since health authorities use specific physical / cognitive assessment tools to determine

clinical need and eligibility for publicly funded residential care, being in residential care can be

used as a proxy measure of assessed need for complex care. Second, since people in

residential care have 24 hour nursing, they use health care services differently than the frail

population living in the community, and should be separated out in any planning for community

based services.

Past analysis of the residential care population found that within the group, there are different

patterns of health care use depending on the type of residential facility. The Matrix found that

valuable insight can be gained by sub-dividing the population into three separate groups: Public

Stand Alone Residential Care facilities, Public Extended Care, and Privately funded Residential

Care. Residential care clients in these different categories use health care services differently

Publicly funded Stand Alone Residential Care facilities are licensed residential care

facilities located in the community which are registered under the PharmaCare Plan B.

Regardless of whether the facility is privately owned or owned by the health authority,

clients’ publicly funded residential care days are reported to the Ministry through the Home

and Community Care reporting systems.

Publicly funded Extended Care facilities are attached to an acute care facility or co-

located on the same grounds. Regardless of whether the facility is owned by the health

authority or religious affiliates, the clients’ publicly funded residential care days are reported

to the Ministry through the Home and Community Care reporting systems.


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Private Residential Care: BC resident’s have the option of choosing private licensed

residential care. PharmaCare Plan B covers the drug cost of all residents in licensed

residential care facilities, regardless of whether their care is publicly or privately funded.

Although the privately funded residential care days are not reported to the Ministry through

the health authorities, the Matrix project has estimated the number of privately funded

residential care days based on the start and end dates of private care based on the dates of

Plan B prescriptions. It is important to be able to exclude this group from the denominator

when calculating publicly funded residential care indicators.

Further analysis into the residential care population highlighted the importance of separating the

‘new entrants’ in a population segment from those who were in that segment in the previous

year, since those that enter residential care during the year user services very differently; a

large portion of their health care costs come from hospitalization, compared to people who

entered residential care the previous year.

Figure 6: Residential Care Clients: Defining sub groups

Residential Care Client Group Long Term RC flag

from Health Authority

PharmaCare

Plan B

Publicly funded in Extended Care associated with acute facility Y N

Publicly funded in stand-alone RC facility Y Y

Privately funded in stand-alone RC facility N Y

For these sub-category assignments, clients with only publicly funded days in the year are

assigned to the Extended Care group; clients with only Plan B coverage in the year are

assigned to the Private Care group. Clients with both publicly funded days and Plan B in the

year are assigned to the Public Stand Alone group; since the Matrix project only looks at annual

use of services, anyone who used two types of residential care in the year will be assigned to

the Public Stand Alone category.

The Frail in Residential Care population segment (PS14) only includes people who were

permanent residents of residential care at any time in the year. Use of short term residential

care, such as transitional care / convalescent care (usually following a hospitalization) or respite

care, would ‘qualify’ the person for Frail in the Community population segment (PS09).

PS09 Frail in the Community Frail Population, Living in the Community Broad Category: Towards End of Life

People who live in the community and receive professional home care services or publicly

funded services to assist with activities of daily living.

Definition: For adults, the following services reported to the Ministry through the Continuing

Care reporting system are used to identify this population:

Professional home care services provided by the health authorities, delivered to clients

in the community by registered nurses and rehabilitation therapists.

Home support services provide personal assistance with the activities of daily living to

seniors and adults with disabilities living in their homes, such as bathing, dressing,

grooming and, in some cases, light household tasks that help maintain a safe and

supportive home. This includes CSIL (Choice in Supports for Independent Living) which


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is a program in which the client can independently manage their publicly funded home

support services.

Adult Day programs for seniors and adults with disabilities provide community-based

supportive group programs and activities that assist with daily activities or give clients a

chance to be more involved in their community, including personal care services,

therapeutic recreation, social activities, and caregiver respite.

Assisted living residences provide housing and a range of supportive services for

seniors and people with disabilities, including personalized assistance with activities of

daily living.

New to 6: Case Management services, even if they did not use other publicly funded

HCC services.

Short term residential care including convalescent and transitional care (usually following

a hospitalization), and respite care.

Definition: For children age 18 and under, the Ministry of Children and Family Development

(MCFD) provides community-based, family-style care for severely handicapped children age 18

or under who would otherwise become reliant on institutional care. The Frail in Community

population segment identifies these children and youth through registration in the PharmaCare

At Home Program of the Ministry of Children and Family Development (Plan F). However, the

services provided by MCFD are not included in the services summarized in the matrix.

Populations with Chronic Conditions: PS11 Frail with High CC, PS10 High (without HCC),

PS06 Medium CC, and PS05 Low Complex Chronic Conditions Frail in the Community with High Complex Chronic Conditions Broad Category: Towards End of Life

High Complex Chronic Conditions without Frail ADL supports Living with Illness and Chronic Conditions

Medium Complex Chronic Conditions Living with Illness and Chronic Conditions

Low Complex Chronic Conditions Living with Illness and Chronic Conditions

The Chronic Condition populations are based on 23 specific chronic condition registries.

The Ministry of Health’s Chronic Disease Management program

develops and maintains a set of ‘virtual’ registries for selected

chronic conditions. Identifying chronic conditions within

administrative databases has its challenges. A chronic condition

may be recorded in administrative data when initially diagnosed

but may not appear on later encounters if the condition is stable,

especially if the data set only collects a single diagnosis per

encounter. Therefore, in identifying chronic conditions it is

necessary to look across encounters and across years. The

Ministry’s chronic condition registries are lists of BC residents who

are likely to have a chronic condition based on national definitions/algorithms applied to multiple

years of data in Ministry databases (such as two diagnoses recorded on physician encounters in

a 365 day period or a single instance of a diagnosis recorded on a hospitalization, or use of

specific drugs). Two physician encounters are used to eliminate the ‘suspect’ diagnoses; the

second encounter within 365 days is considered to be the confirmation of the condition. For all

registry definitions except the new Episodic Depression Registry, once a person is added to a

registry, they remain in the registry for their lifetime. For the Matrix, Cystic Fibrosis is added to


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the list of chronic conditions based on people registered in the PharmaCare Cystic Fibrosis plan

D for that year.

Chronic Conditions included in the definition of Chronic Condition Population Segments:

Acute Myocardial Infarction (AMI, heart attack)

Alzheimer’s

Angina

Asthma

Chronic Kidney Disease on Dialysis

Chronic Obstructive Pulmonary Disease (COPD)

Coronary Artery Bypass Graft

Cystic fibrosis (PharmaCare Plan D)

Dementia

Depression

Diabetes

Epilepsy

Heart Failure

Hypertension

Percutaneous Transluminal Coronary Angioplasty (PTCA)

Kidney Transplant

Multiple Sclerosis

Osteoarthritis

Osteoporosis

Parkinson’s

Pre-dialysis Chronic Kidney Disease

Rheumatoid Arthritis

Stroke

In the first version of the Matrix, there was a single population segment for all Chronic

Conditions. Analysis and common sense pointed out that this broad chronic conditions group

was not homogeneous, and needed to be divided into more meaningful populations. Although

many studies use the number of chronic conditions to distinguish groups (typically 1, 2, or 3+

chronic conditions), expert advice in the ministry made the point that we needed to consider the

specific condition, rather than the number of conditions; for example, heart failure alone would

put a person in the ‘high complex’. Based on expert advice and analysis, the chronic condition

population was divided into three population segments - High, Medium, and Low Complex

Chronic Conditions - based on specific conditions or interventions and combinations of

conditions/interventions. The registries for interventions almost entirely overlap the registries for

specific diagnoses, but are included to ensure that total number of patients aligns with

information presented by the Chronic Disease Management branch.

New to 6: The Matrix now uses the new Episodic Depression Registry to identify people

with depression.

The new Episodic Depression Registry identifies approximately 360,000 BC residents (2013/14)

with depression. Previous versions of the Matrix used a broad Depression Registry (approx. 1.3

million BC residents) that contained all people who had ever met the criteria for inclusion (one

hospitalization or two physician billings in 365 days with specific depression/anxiety diagnoses).

The new Episodic Depression Registry is a subset. The nationally developed criteria for adding

a person to the registry is the same as the broad Depression Registry. The difference is that

once added the person will remain in the registry for following years as long as they have at

least one condition-related code or condition-related service (such as a prescription for the

condition) in that year; if they don’t, then they ‘drop out’ of the Episodic Depression Registry and

will need to meet the full inclusion criteria to be included again. For that reason, the Low

Chronic Condition registry is significantly smaller in Matrix 6 since the large number of BC

residents who were previously in Low Complex Chronic Conditions population solely because of

depression have moved to lower (healthier) population segments in Matrix 6. The change to the

Episodic Depression Registry was applied to all years 2002/03 to 2013/14.


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Figure 7: Highlighting 6.1 Change in Population Segments from Using the Episodic Depression Registry

New to 6: Previously, combination of osteoporosis and rheumatoid arthritis would put the

person in High Complex Chronic Conditions. Based on analysis, this combination remains in

Medium Chronic Conditions in Matrix 6.

The definition of the High, Medium, and Low chronic condition categories are shown in the

following table that outlines the single or combinations of conditions that would assign a person

to a specific level.

Figure 8: Chronic Conditions: Defining High, Medium, and Low Complex Chronic Conditions Sub Groups


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Using the 3-level approach has also provided an insight into comorbidities, beyond the specific

combinations used in the definitions, because people are assigned to the chronic condition level

that represents their ‘highest’ chronic condition.

For example, in 2013/14 there were 402,200 diabetics in British Columbia, 46% of which were

uniquely assigned to the Low Chronic Condition population. Those with specific comorbidities

were assigned to ‘higher’ population segments, most notably 17% to Medium and 24% to High

Complex Chronic Condition populations. The other 13% of diabetics were uniquely assigned to

other population segments (from Mental Health to End of Life), based on their highest need for

care in the year. Please see Assignment to a Unique Population Segment Each Year section

for an explanation of how people with multiple health care needs were assigned to a single

population segment for analysis purposes.

Figure 9: Distribution of BC Residents with Diabetes across the Population Segments

The following table shows the distribution BC residents in the chronic condition registries across

the population segments in 2013/14. In the table, people are counted in the population segment

that represents their ‘highest’ need in the year, and each row in the table sums to 100%.

Figure 10: Distribution of Chronic Condition Populations across the Population Segments


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Figure 11 presents another view of the information: the percent of BC residents in each

population segment with the specific chronic condition. Because people can have multiple

conditions, these percentages are not summable. This table shows, for example, that 69% of

the population living in residential care (PS13) have dementia, compared to those who live in

the community, for example 41% of the Frail with High Complex Chronic Condition population

(PS11) and 11% of the High Complex Chronic population without supports for daily living.

Figure 11: Percent of BC Residents in Each Population Segment who have Specific Chronic Conditions

It is recognized that the current population segment definitions do not adequately identify

children and youth with chronic conditions. The Health System Matrix team is working with

groups such as Child Health BC to develop better ways of identifying chronic conditions for

children and youth.

PS12 Cancer Population with Cancer Broad Category: Living with Illness and Chronic Conditions

A separate population segment was created for people with cancer because people in this

group require a specific set of health care services, and there is a gap in the information

available through ministry administrative databases.

The best way to identify people undergoing active treatment for cancer would be through the

cancer registry maintained by the BC Cancer Agency. However, since the Ministry does not

have access to this database, the health system matrix project needed to create a ‘virtual’

cancer registry to estimate the number of people receiving cancer treatment each year.

Following the same approach as the Ministry’s chronic disease registries, the matrix flagged a

person for the cancer registry for that year if they had specific malignant diagnoses (non-skin

cancer) recorded on two physicians’ Fee for Service billings in a year or a hospitalization.

A person is assigned to the cancer population segment for the year in which they meet the

cancer registry criteria, and for the following year. Adding the second year was necessary

because of the way cancer specialists are paid in the province. Physicians working for the BC

Cancer Agency (BCCA) are not paid through the MSP FFS billing system, and their patient

encounters (and diagnoses) are not reported to Ministry administrative databases. Therefore,


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once a family physician refers a patient to a BCCA physician, most of the interventions with

BCCA physicians are missing from ministry databases, and it will appear as if the patient has

concluded their cancer treatment. The Matrix assumes that cancer treatment continues in the

year after the original diagnosis and therefore a person is identified in the cancer population

segment in the year of diagnosis and the following year.

PS08 Maternity & Healthy Newborns Maternity and Healthy Newborns Broad Category: Staying Healthy

Women who were pregnant or delivered in the fiscal year, and healthy newborns.

Detailed definition: Women who received obstetric services from a physician (MSP FFS billing)

or a hospital during the fiscal year and their ‘healthy’ newborns. Healthy newborns are defined

as normal newborns in singleton vaginal deliveries (CMG576), normal newborns in multiple or

caesarean deliveries (CMG 577), newborns who had a typical length of hospital stay, newborns

who did not use any of the 16 flagged interventions, and newborns who had no special care unit

days. (Newborns who did not meet these ‘healthy’ criteria are assigned to the Child and Youth

Major Conditions population segment (PS04), unless they had other conditions which would

assign them to a higher population segment).

Since this population segment includes mothers, most of the newborns, and pregnant women,

the total population of this group will not match statistics from other sources that count

newborns and deliveries.

PS07 Mental Health & Substance Use Mental Health and Substance Use Needs Broad Category: Living with Illness and Chronic Conditions

People who suffer from severe mental illness or drug addiction.

Detailed definition: People who were hospitalized with a specific range of mental health

conditions (such as schizophrenia, bipolar affective / mood / manic or depressive disorders) or

drug addiction (recorded as most responsible diagnosis in the hospital abstract) in the fiscal

year or in the previous 4 years. Or in the fiscal year, they were in the methadone replacement

program, or were registered in the PharmaCare No-Charge Psychiatric Medication Plan (Plan

G) which provides coverage of certain psychiatric medications for people registered in a mental

health services centre and demonstrate clinical and financial need.

New to 6: The ICD10 codes used in the definition of this population have been simplified

Figure 12: Hospitalization Diagnosis Codes used to Identify Severe Mental Health and Substance Use Population

Categories ICD10 Codes

Substance-related Disorders

Mental and behavioral disorders due to psychoactive substance use (F10 to F19)

Severe Mental Illness

Mild cognitive disorder (F06.7) Organic personality disorder (F07.0) Postconcussional syndrome (F07.2) Other organic personality and behavioural disorder due to brain disease, damage and dysfunction (F07.8) Unspecified organic personality and behavioural disorder due to brain disease, damage and dysfunction (F07.9) Schizophrenia, schizotypal and delusional disorders (F20 to F29) Mood [affective] disorders (F30 to F39)


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There is no available measure of severity for the mental health population in the Ministry’s

administrative databases. As a proxy for ‘severe’, the population segment definition used

hospitalization for these specific diagnoses anytime in a 5 year period. The 5 year period was

chosen because these conditions are considered to be chronic (i.e. long duration).

Subsequently, we found that a 5 year period was used by the National Health Service in

England to determine if a mental health condition was in remission5. Therefore the definition of

this population segment was based on people hospitalized for these specific mental health and

substance use issues in the current year or anytime in the previous four years.

Data from the Mental Health and Substance Use Community services and services provided by

Psychiatrists were not available and therefore were not used in the definition of this population

segment, and are missing from the summary of utilization of mental health and substance use

services.

Dividing the Remaining Population into Population Segments based on Utilization

People in these four populations do not have any of the health conditions that would have

assigned them to any of the population segments discussed above. In 2013/14, 40% of the BC

population were identified in one or more of the population segments described above, leaving

60% to be separated into the four population segments based on age and the dollar value of

publicly funded health care services used.

New to 6: Replacing the former Broad Depression Registry with the new Episodic

Depression Registry has moved many BC residents who were in the Low Chronic Conditions

population (PS05) in Matrix 5.0, to the ‘remainder’ population divided between healthy, major

conditions and non-user populations in Matrix 6.

Figure 13: Allocation of the BC Population by Population Segments, 2013/14

5 2013/14 General Medical Services (GMS) Contract Quality And Outcomes Framework (QOF), p. 20,

National Health Service, England, March 2013. The NHS considered mental health conditions to be in remission if, in a 5 year period, the person did not have a hospitalization, have an antipsychotic medication, or have contact with a community mental health centre.


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PS03 Adult Major Conditions Age 18+ Major or Significant Time-limited Health Needs: Adults Broad Category: Getting Healthy

Detailed definition: BC residents who are 18 years old or older with major health conditions that

were not identified in other population segments. They are identified as having a major condition

if they were hospitalized in the year as an inpatient or day surgery patient, or used more than

$1,500 of physician services (including family physicians, specialists, lab, diagnostics), or used

more than $1,000 of prescription drugs dispensed from a community pharmacy (PharmaNet

claimed amount which includes both government paid and out-of-pocket / extended benefits

prescription drugs dispensed from a community pharmacy), or died during the year.

PS04 Child and Youth Major Conditions Major or Significant Time-limited Health Needs: Children and Youth < 18 years Broad Category: Getting Healthy

Detailed definition: For BC residents under 18 years of age with the same definition as PS03

Adult group.

“Healthy” newborns are excluded from this group and assigned to the PS08 Maternity & Healthy

Newborn population segment. The newborns in PS04 Child and Youth Major Health Conditions

population segment are defined as newborns hospitalized with any hospital case mix group

other than singleton vaginal delivery (CMG576) or normal newborns in multiple or caesarean

delivery (CMG 577), or newborns who had atypical length of stay in a hospital, or newborns who

used any of the 16 flagged interventions (Cardioversion; Cell saver; Chemotherapy; Dialysis;

Feeding tubes (PEG); Heart resuscitation; Invasive ventilation greater than or equal to 96 hours;

Invasive ventilation less than 96 hours; Paracentesis; Parenteral nutrition; Pleurocentesis;

Radiotherapy; Tracheostomy; Vascular access device; Non-invasive biopsy; Per orifice

endoscopy), or newborns who were hospitalized one day or more in a special care unit.

It is recognized that the current population segment definitions do not adequately identify

children and youth with chronic conditions. The Health System Matrix team is working with

groups such as Child Health BC to develop better ways of identifying chronic conditions for

children and youth.

PS02 Healthy & Low User Healthy / Minor Episodic Health Needs Broad Category: Staying Healthy

BC residents of any age who were ‘low users’ of publicly funded services, and did not have any

health conditions that were identified in other population segments. The term ‘low user’ was

arbitrarily determined, defined as using only a limited dollar value of physician services

(including specialists, labs, and diagnostics) and/or a limited dollar value of prescription drugs

from community pharmacies, and they were alive at the end of the year.

Detailed definition: This population is comprised of all BC residents who annually used less than

$1,500 of physician services and less than $1,000 of prescription drugs dispensed from a

community pharmacy (PharmaNet expenditures which includes both government paid and out-

of-pocket / extended benefits prescription drugs), did not use any other health care services

tracked in the Health System Matrix, and were alive at the end of the year.


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PS01 Non User Healthy Non-Users Broad Category: Staying Healthy

BC residents of any age who used none of the health care services in the year which were

tracked in the Health System Matrix, and did not have any health conditions which would assign

a person to a higher priority population segment.

Assignment to a Unique Population Segment each Year

People with multiple conditions can ‘qualify’ for multiple population segments each year. For

analysis that requires a ‘unique’ assignment to a single population segment, the Health System

Matrix uses the following hierarchy to assign each BC resident to the population segment that

represents their highest need for health care in the year. This priority order was established by

consensus.

PS14 End of Life

PS13 Frail in Care (In Residential Care)

PS12 Cancer

PS11 Frail High Complex Chronic Conditions (with HCC)

PS10 High Complex Chronic Conditions (without HCC)

PS09 Frail in the Community (with HCC)

PS08 Maternity & Healthy Newborns

PS07 Mental Health & Substance Use

PS06 Medium Complex Chronic Conditions

PS05 Low Complex Chronic Conditions

PS04 Child and Youth Major

PS03 Adult Major Age 18+

PS02 Healthy & Low User

PS01 Non User

The following table compares the ‘overlapping’ population segments which counts all people

who met the definition for the segment, with the count of people ‘uniquely assigned’ to the

segment. Because people with multiple conditions are counted multiple times in the table, the

user needs to understand which cells can be summed, and which cannot. By definition, there is

never an overlap between High, Medium and Low Complex Chronic Conditions (PS11, PS10,

PS06 and PS05), and between Major Conditions, Healthy & Low Users, and Non-Users (PS04,

PS03, PS02 and PS01)

In the table, the ‘overlapping’ population segments are shown in the columns:

The last row in each column shows the total number of people who qualified for that

population segment, while the yellow cell shows the final number ‘uniquely assigned’ to

the population segment. For example, of the 39,640 BC residents who met the definition

for PS13 Frail in Care (in Residential Care), 36,950 were uniquely assigned to that

population segment because it represented their highest need for care in the year.

The pink cells in the column above the yellow cells show the ‘unique’ count of people

who were assigned to a higher priority population segment, and are therefore summable.

For PS13, 7% were uniquely assigned to a ‘higher’ population segment: 2,690 people to

PS14 End of Life.

The light gray cells in the column below the yellow cells show the number of people in

the segment that also had any ‘lower’ priority condition(s). The counts in the light gray

cells cannot be summed, because people with multiple conditions will be counted in

multiple segments. For example, continuing in the PS13 column, 25,090 people also met

the criteria for PS10 High Complex Chronic Conditions (without HCC), and 2,620 met

the criteria for PS07 Severe Mental Health and Substance Use. These cannot be


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summed, because people meeting both criteria are already counted in both PS13 and

PS07. From our definition of the population segments we know the 400 who also met

the criteria for PS02 Healthy & Low Users (low use of only physician and community

pharmacy health care services in the year) must be in private residential care because

they did not use any publicly funded residential care.

Figure 14: Unique versus Overlapping Population Segments: Counts of BC Residents

The table shows the importance of creating separate population groups for either frailty or high

complex chronic conditions or both. For service planning purposes, it is important to know that

of the 58,240 people who receive supports for daily living, 21,470 are uniquely assigned to

PS09 because they do not have dementia, Alzheimer’s, heart failure or other high complex

chronic conditions, while 27,060 are assigned to PS10 because they do have one or more of

these conditions.

Figure 15: Unique versus Overlapping Population Segments: Distribution of BC Residents


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SERVICE LINES

The Health System Matrix Services presents a view of how publicly funded services are used

across the BC health system. To do that, the underlying database brings together information

from the separate administrative databases for physician and hospital care, community

services, and prescription drugs, and summarizes fiscal year utilization by specific service lines.

SL01 – Primary Health Care

SL02 – Obstetrics

SL03 – Gynaecology, excluding Oncology

SL04 – Mental Health & Substance Use

SL05 – Medical Specialists

SL06 – Oncology

SL07 – Emergency Dept.

SL08 – In Hospital Medical

SL09 – Ambulatory Surgical

SL10 – Inpatient Elective Surgical

SL11 – Transplant Surgery

SL12 – IP Trauma and Emergency Surgery

SL13 – Palliative Care

SL14 – Pathology/Laboratory

SL15 – Diagnostics

SL16 – Ambulatory Support Therapies

SL17 – Pharmaceuticals

SL18 – Anaesthesia

SL19 – Hospital Outpatients

SL20 – Physical Medicine and Rehabilitation

SL22 – Community Supports for Daily Living

SL24 – Residential Care

SL25 – Paediatrics

SL30 – Surgeons

SL99 – Other Physicians

Missing from matrix

Healthy living (Population Health)

Environmental Health

Health Emergency Management

Community Mental Health

Emergency Transport

Services not reported to the Ministry’s

administrative databases

The service line categories are based on services of interest and data availability. Not all

publicly funded health care services appear in the Matrix. For a further discussion of the

missing services, please see section Behind the Numbers – Data Sources, Inclusions and

Exclusions.

New to 6: Hospital workload is counted in the year in which the hospital days occurred.

This is a very different approach than used in all other analysis of hospital care.

Former versions of the Matrix (and most analysis of hospital care in Canada) count hospital

inpatient and day procedure cases, days and dollars (based on resource intensity weights)

following a standard analysis practice which allocates all workload to the year of discharge. For

the Matrix which summarizes health care utilization by BC resident, this presented a problem in

analyzing services for people whose hospitalization spanned the March 31 to April 1 cut-off

between two fiscal years; their physician costs were counted accurately in both fiscal years, but

their entire hospitalization was attributed to the year of discharge.

For hospitalizations which span two fiscal years, the Matrix 6 has split the hospitalization the

fiscal year they occurred, based on admit and discharge dates. The matrix database uses the

label ‘adjusted’ to differentiate from the standard ‘DAD FY’ count of days). To make the split, a

number of assumptions were made. 1) Any intensive care unit (ICU) days were assumed to

occur at the start of the hospitalization. 2) Any alternate level of care (ALC) days were assumed

to occur at the end of the hospitalization. 3) Resource Intensity weights (used to estimate costs)

were divided between two fiscal years in the same proportion as hospital days.


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Figure 16: Counting Hospitalizations in year of care

New to 6: SL01 Primary Health Care: Professional Home Nursing. In Matrix 6 rehabilitation

services provided by the health authorities have been separated, and moved to SL20.

New to 6: SL02 Obstetrics: Matrix 6 excludes abortions.

New to 6: SL20 Rehabilitation: Now includes rehabilitation services (physiotherapy,

occupational therapy) provided by the health authorities.

New to 6: SL22 Community Supports for Daily Living: Case Management has been added

to the service line.

New to 6: Methodology has been revised for estimating unit costs for hospital care for the

home and community care services provided by the health authorities

New to 6: SL07: The dollar value of physician costs of emergency department visits have

been estimated for APP ED shadow billings and NACRS ED visits, based on the average dollar

billings by 3 levels of care and 3 times of day recorded in MSP ED physician billings.

The major administrative databases held by the Ministry contain patient level records of

physician care (mostly Fee for Service billings), hospital inpatient care and day procedures,

emergency department visits, prescription drugs dispensed in community pharmacies, and

services provided in the community to support activities of daily living. Because data are

housed in separate databases, there has been a tendency to do analysis in the silos. Even

though the Ministry databases can be linked, the different data structures make it challenging to

work with more than one database at a time. One of the goals of the Matrix approach was to

encourage analysis across the health care system, and therefore across the databases. The

Matrix project accomplished this by summarizing service utilization by service lines, rather than

databases. In this way, the Matrix shows the entire cost of care from physicians, hospitals,

publicly funded prescription drugs and services provided in the community. The following table

outlines how service lines are built from data from each database.


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Figure 16: Crosswalk between Databases and Service Lines

Originating Database

Service Lines Physician Care

Medical Services Plan (1)

Hospital Care Discharge Abstract

Database (2)

Prescription Drugs PharmaCare (3)

Home and Community Care

(4)

SL01 – Primary Health Care GP & Family Physicians

Professional Home

Care Nursing SL02 – Obstetrics GP and Specialists Inpatient


GP and Specialists Inpatient & Day

Procedures

SL04 - Mental Health & Substance Use

GP and Specialists Inpatient & Day

Procedures PharmaCare Plan G

SL05 – Medical Specialists Specialists

SL06 – Oncology GP and Specialists Inpatient & Day

Procedures

SL07 – Emergency Dept. (5) GP and Specialists ED visits in NACRS

SL08 – In Hospital Medical Inpatient

SL09 – Ambulatory Surgical Day Procedures SL10 – Inpatient Elective

Surgical Inpatient

SL11 – Transplant Surgery & aftercare

Specialists Inpatient


Inpatient

SL13 – Palliative Care Inpatient PharmaCare Plan P

SL14 – Pathology / Laboratory Specialists

SL15 – Diagnostics Specialists SL16 – Ambulatory Support

Therapies (Dialysis) GP and Specialists Day Procedures

SL17 – Pharmaceuticals PharmaCare, PharmaNet

SL18 – Anaesthesia GP and Specialists

SL19 – Hospital Outpatients GP and Specialists


GP and Specialists Inpatient Community Rehab


Home Support, Assisted Living,

Adult Day Program Case Management

SL24 – Residential Care Physician visits to

RC PharmaCare Plan B Residential Care

SL25 - Paediatrics GP and Specialists Inpatient

SL30 – Surgeons GP and Specialists

SL99 – Other Physicians GP and Specialists 1) MSP: Paid dollars, and estimated encounter days are mainly based on Fee for Service billings. Any shadow billings from

physicians in Alternate Payment programs have been included; standard fee codes have been used to estimate a dollar value

of these services. Physicians on alternate payment programs who do not submit shadow billings are not included; for example,

excluded APP physicians are psychiatrists, oncologists at the BC Cancer Agency, specialists at Women’s and Children’s

hospital. 2) DAD: Days of care, cases, and resource intensity weights (RIWs) for Inpatient and Day procedure discharges are allocated to

year of discharge. Dollars of hospital care (excluding physician costs) have been estimated from RIWs and estimates of annual

cost per weighted case. 3) PharmaCare: Dollars of publicly funded prescription drugs dispensed in a community pharmacy. Specific plans are used in the

definition of specific service lines. PharmaNet summarizes dollar value of all prescription drugs dispensed in a community

pharmacy regardless of payer. 4) Home and Community Care: Health authorities report publicly funded work load units (hours of home support, days of assisted

living, days of Adult Day Programs, Case Management visits, and days of residential care for short term convalescent patients

and long term permanent RC residents. Dollars of care have been estimated from workload units based on estimated BC level

unit costs for each year. 5) ED visits are compiled from all visits in MSP billings and APP shadow billings, and all other ED visits reported in National

Ambulatory Care Reporting System (NACRS) for the patient, not already counted. Estimated dollars of ED physician care

based on average MSP billings for 3 levels of care and 3 times of day. ED facility costs estimated from HAMIS data.


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Figure 17: Definition of Service Lines

Service Line Type Definition ( to uniquely assign physician services to services lines, assignments were made in the priority order stated)

SL01 – Primary Health Care

SL01 Physicians FFS+

GP and family practice physicians’ services. Identified by speciality code 0, assigned in priority 18. Therefore, does not include services for obstetrics, gynaecology, mental health, oncology, palliative care, rehab, emergency department, and paediatrics and visits to people in residential care which are counted in other service lines.

SL01 Home Nursing

Home Care Nursing: Professional home nursing care provided in the patient’s home by the Health Authority.

SL02 – Obstetrics


Obstetrics Physician: GP and specialist physician services for obstetrics (service codes 13, 42 assigned in priority 2. Includes midwifery services and excludes abortions.

SL02 Hospital Obstetrics Hospital: Inpatient hospital care related to pregnancy and childbirth, including services to healthy newborns. Excludes abortions. Note: Hospital services to unhealthy newborns are in Paediatrics (hospital) service line.



Gynaecology Physician: GP and Specialist Physician care related to gynaecology, excluding oncology. Identified by fee items, assigned in priority 12.

SL03 Hospital Gynaecology Hospital: Inpatient care and day procedures for gynaecology.

SL04 - Mental Health & Substance Use


Physician: GP and specialist physician services for mental health.

SL04 Hospital Hospital: Inpatient care and day procedures for mental health (Major Clinical Classification 17)

SL04 PharmaCare

PharmaCare Mental Health Plan: Publicly funded prescription drugs paid under the PharmaCare No-Charge Psychiatric Medication Plan (Plan G)

SL05 – Medical Specialists


Physician Speciality Care: GP and specialist physician services by priority 17. Therefore, services do not include obstetrics, gynaecology, mental health, oncology, palliative care, rehabilitation, paediatrics and surgery which are counted in other service lines.

SL06 – Oncology


Physician: GP and specialist care for the treatment of malignant cancer (based on reported diagnosis code of cancer), assigned in priority 11. Note, does not include services by physicians on salary with the BC Cancer Agency.

SL06 Hospital Hospital: Inpatient and day procedure hospital care for the treatment of cancer based on a most responsible diagnosis of cancer or a chemotherapy/radiotherapy received (excluding skin cancer). Note, radiation and chemotherapy services provided by the BC Cancer Agency are not reported to the Ministry's administrative databases.

SL07 – Emergency Department

SL07 Physicians FFS++

Physician: Services provided by FFS emergency medicine specialists or GP or specialists in the Emergency Department (based on FFS location code and fee-for-service fee items, assigned in priority 5); and ED visits reported in NACRS for facilities which do not report FFS encounters.)

SL07 ED Hosp Cost

For total cost and average costs per user tables only: estimated hospital facility costs of emergency department visits, based on an estimated facility cost for ED visits reported physician encounters (MSP and APP) and ED visits reported in NACRS for facilities which do not report FFS encounters.

SL08 – In Hospital Medical

SL08 Hospital Hospital: Inpatient hospital care for medical patients (i.e. non-surgical patients), excluding obstetrics, gynaecology, mental health, oncology, palliative care, rehab, and paediatrics which are counted in other service lines.

SL09 – Ambulatory Surgical

SL09 Hospital Hospital: Day procedures performed in hospitals. Includes all day procedures, therapeutic and diagnostic, elective and emergency, except those reported in other services lines: renal dialysis (SL16), physician rehab (SL20), oncology (SL06), and gynaecological surgery (SL03). Most day procedures are elective.

SL10 – Inpatient Elective Surgical

SL10 Hospital Hospital: Elective inpatient surgeries.

SL11 – Transplant Surgery and after care


Physician: Specialist care related to transplant surgery and post surgical care identified by fee items or diagnostic codes, assigned in priority 1.

SL11 Hospital Hospital: Inpatient hospital care related to solid organ transplants and post transplant care.


SL12 Hospital Hospital: Inpatient admissions for trauma or emergency surgery (MCC

SL13 – Palliative Care


Physician: Palliative care provided by GP and specialist physicians identified by fee items or diagnostic codes, assigned in priority 9.

SL13 Hospital Hospitalizations for Palliative Care: Inpatient hospital care for patients specifically admitted for palliative care (CMG810). Does not include patients admitted for other treatment and subsequently receive palliative care.

SL13 PharmaCare

PharmaCare: Publicly funded prescription drugs paid under the PharmaCare BC Palliative Care Drug Plan (Plan P)


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Service Line Type Definition ( to uniquely assign physician services to services lines, assignments were made in the priority order stated)

SL14 – Pathology/Laboratory


Laboratory Services: physician services based on FFS billings identified by service codes, assigned in priority 14.

SL15 – Diagnostics


Diagnostic Imaging: physician services based on FFS billings identified by service codes, assigned in priority 15 .

SL16 – Ambulatory Support Therapies (Dialysis)


Physician: Specialist physician services for dialysis and transfusion services identified by service code assigned in priority 7. Note, does not include BC Renal Agency services.

SL16 Hospital Hospital: Inpatient and day procedures cases which had renal dialysis performed in hospital. Note, does not include BC Renal Agency services.

SL17 – Pharmaceuticals

SL17 PharmaCare

PharmaCare: Total publicly funded prescription drugs from community pharmacies, i.e. paid by Ministry under Fair PharmaCare and other PharmaCare plans, except plans counted in other service lines: Mental Health (Plan G, SL07), Palliative Care (Plan P, SL13) and Residential Care (Plan B, SL24). Only publicly funded PharmaCare is included in cost totals. For comparison, the PharmaNet total is also reported in the Total cost and Cost per user tables; PharmaNet includes the total cost of all drugs dispensed in community pharmacies regardless of payer.

SL18 – Anaesthesia


Physician: GP and specialist physician anaesthesiology services (in hospitals and all other locations) .

SL19 – Hospital Outpatients


Physician: GP and Specialist services reported in a hospital Outpatient setting.



Physician: rehabilitation services provided by rehabilitation specialist physicians. Identified by physician speciality, assigned in priority 8.

SL20 Hospital Hospital: Inpatient care for patients admitted for rehabilitation services (CMG 805).

SL20 HCC Community Rehabilitation services (Physiotherapy, Occupational therapy)


SL22 Assisted Living

Assisted Living: publicly funded home support services (support for activities of daily living) provided in assisted living settings.

SL22 Home Support

Home Support: Publicly funded home support services (support for activities of daily living), provided in the home.

SL22 Home Support CSIL

Home Support for Community Services for Independent Living: Public funding to CSIL clients to enable them to arrange their own home support program.

SL22 Adult Day Services

Adult Day Care: Home and Community Care adult day care program provided by health authorities.

SL22 Case Management

Case Management: Health authority case management for home support and assisted living clients.

SL24 – Residential Care


Physician: GP visits to residential care facilities, based on fee items, assigned in priority 10.

SL24 Prescription Drugs

Prescription drugs for permanent residents of RC. Publicly funded prescription drugs to permanent residents of stand alone licensed residential care facilities under PharmaCare Plan B. Plus estimates of prescription drugs used by RC clients in extended care associated with acute care facilities, where the drugs are dispensed from the hospital pharmacy.

SL24 Residential Care

Residential Care: publicly funded residential care including long term and short term (convalescent care, transition care, respite). The residential care days used by all population segments except PS13 and PS14 will be short term RC, by definition. Note: Frail in Care population segment (PS13) includes people in privately funded residential care. Their private days of care are NOT included in this service line.

SL25 - Paediatrics


Physician: services provided by paediatricians identified by most recent physician speciality, assigned in priority 3.

SL25 Hospital Hospital: Inpatient paediatric care (defined by patient service paediatrics) and all inpatient care for 'unhealthy' newborns defined as a newborn hospitalization with any hospital case mix group other than singleton vaginal delivery (CMG576) or normal newborns in multiple or caesarean delivery (CMG 577); or who had an atypical length of stay in hospital; or used any of the 16 flagged interventions; or had 1+ special care unit days.

SL30 – Surgeons


Physicians: surgical services by GP and surgeon specialists, in hospitals, clinics, and offices, identified by service codes, assigned in priority 13. Therefore, does not include services for obstetrics, gynaecology, and oncology which are counted in other service lines.

SL99 – Other Physicians


All Other Physician Services: This is the FFS billings for all other services not included in any other service line, assigned in priority 19.


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ESTIMATING THE PUBLIC EXPENDITURES ON HEALTH CARE IN DOLLARS

Many of the health care services reported in Ministry databases are in terms of units of service,

such as days, hours, visits, or resource intensity weights (used in hospital services). In order to

summarize use of services across the health care system, the Health System Matrix has used a

set of standard unit costs to convert the service units to dollars. The unit costs developed for

the Health System Matrix are BC level values only, intended for analytic purposes of health care

costs, to estimate the relative values of services in a health care bundle across the health care

spectrum. They are not intended to be a measure of the actual cost of providing the service, nor

reflect the variation in the cost of providing services to different populations, or in different

regions, as they do not reflect differences in costs related to the specific delivery / treatment

programs, acuity of patient, regional cost differences, ownership (health authority

owned/operated, not for profit, contracted out, etc.). Very different assumptions were used for

each health care service, and the availability and quality of supporting data varied significantly.

Workload from the Medical Service Plan database (physicians who are remunerated by Fee for

Service) and the PharmaCare / PharmaNet database (prescription drugs dispensed in

community pharmacies) are already measured in dollars. All other services in the Matrix are

reported to the Ministry in terms of workload units. Because the physician and prescription

drugs expenditures include inflation (increases in the fee schedule for physicians, or prices of

drugs over time), it was necessary to determine unit costs for all other services for each fiscal

year. Where available, the unit costs are standard rates used that year or calculated from

administrative data. For others, different approaches were used to determine unit cost time

series. Estimates for hospital costs for inpatient care, day procedure and emergency

department visits include direct and indirect costs, excluding physician costs. (A separate

document is available on the methodology used to estimate unit costs.)

Figure 18: Estimation of Dollar Value of Health Care Services

Administrative database Encounters Dollar value of services

Hospital inpatient care

(Discharge Abstract Database)

Inpatient Total Days by service line

Utilization measures: Cases (discharges),

Acute/rehab days, Intensive Care Unit days, Alternate

level of care days. For hospitalizations spanning two

fiscal years, the utilization has been ‘adjusted’ - split

between the two fiscal years based on dates. ICU

days are assumed to be at the start and ALC days at

the end of the hospitalization, and the hospitalization

counted as a case in both years.

Resource Intensity Weight x BC

average cost per weighted case.

For hospitalizations spanning two

fiscal years, the total cost has

been split between the two fiscal

years in proportion to the days.

Hospital day surgery

(Discharge Abstract Database)

Days based on Cases (discharges) Resource Intensity Weight x

estimated cost per weighted case

Physician care (MSP

Physicians on Fee for Service)

Estimated encounter days based on unique dates of

physician encounters (from fee-for-service billings), by

service line

Actual Billed dollars

Physician care (MSP shadow

billings)

Estimated encounter days based on unique dates of

physician encounters (from shadow billings), by

service line

Estimated dollars based on fee

code

Physician Care in Emergency

Departments

ED visits in Matrix is combination of ED visits from

Fee for Service physicians, MSP ED shadow billings,

and any other ED visit in NACRS facility not already

counted by date.

MSP FFS: actual billed dollars.

MSP shadow billings and NACRS

visits: estimated based on

average MSP billings for 3 levels

of care and 3 time of visit (day,

evening, night).


34

Administrative database Encounters Dollar value of services

Prescription drugs dispensed

from community pharmacy:

Publicly funded (PharmaCare)

No measure of drug encounters Actual paid dollars (This publicly

paid portion of prescription drugs

is included in Matrix total costs.


from community pharmacy:

Total (PharmaNet)

No measure of drug encounters Actual claimed dollars (This total

includes publicly funded and

privately paid, and is not included

in Matrix total costs)


from Hospitals for Residential

Care clients in Extended Care

facilities

(for SL24 residential care, the dollar value of drugs

dispensed for residents of stand-alone facilities is

reported in PharmaCare. Cost of drugs to RC

patients in extended care facilities was estimated to

avoid undercounting the full publicly funded cost of

their care.)

Estimate based on a regression

analysis including the following

characteristics: age, whether the

patient was new or

Community services provided by Health Authority

Home support Hours Hours x estimated unit cost

Assisted living Days Days x estimated unit cost

Adult day program Days Days x estimated unit cost

Residential care Days Days x estimated unit cost

Professional home care Visits Visits x estimated unit cost

Case Management Visits Visits x estimated unit cost

The Health System Matrix 6 summarizes data from 2002/03 to 2013/14. Different unit costs

were used for each year for comparing the cost of different services, and bundles of services in

the year. Since the unit costs reflect very different assumptions of ‘inflation’, for comparisons

over time, users are recommended to focus on the number of encounters, rather than dollars.

Figure 19 Unit Costs used in the Health System Matrix 6


35

BEHIND THE NUMBERS – DATA SOURCES, INCLUSIONS AND EXCLUSIONS

Health System Matrix summarizes almost all patient level data reported to the Ministry of

Health’s administrative databases. Each database contains a summary of the publicly funded

health care encounters, such as diagnosis, intervention or care provided, and limited

anonymized information about the patient (such as age, gender, region where they live). By

looking across the different databases, the Health System Matrix project provides insight into

the health of BC residents and their annual use of selected health care services by specific

services lines, to provide a view of the different bundles of services by different health status

groups.

The term selected services is used intentionally; it is important to state that the Matrix

summaries do not reflect all publicly funded health care services provided in the province. The

BC Government’s Health Expense by Function was an estimated $17.862 billion in 2013/146.

This estimate includes expenditures by the Ministry of Health (Medical Services Plan and

PharmaCare), the health authorities, and payments for healthcare services by the Ministry of

Social Development and the Ministry of Children and Family Development made on behalf of

their clients. The Matrix summarizes approximately $11.164 billion of publicly funded health

care services provided to BC residents or 62% of the total provincial government Health

Function expenditures.

Figure 20: Summary of Publicly Funded Health Care Expenditures in the Health System Matrix, as a share of

Provincial Government Health Expense by Function, 2013/14

The following table outlines the health care services included and missing from the Health

System Matrix work:

6 Source: Health Function Expenditures, BC Government Budget and Fiscal Plan – 2015/16 to 2017/18,

2013/14 Actual, page 120, February 2015.


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Figure 21: Estimate of BC Government Health Function Expenditures Included or Missing from the Health System

Matrix 6, 2013/14


37

BACKGROUND: INTRODUCTION TO THE BRITISH COLUMBIA HEALTH CARE

SYSTEM

British Columbia

Province on the west coast of Canada.

Population 4.6 million (2014, BC Stats, PEOPLE 39)

Large urban population (2.8 million) in the Greater Vancouver area

Ministry of Health

Annual Ministry Budget $16.9 billion7 (Canadian dollars) 2014/15

Sets policy, legislation, strategic direction and planning

Directly funds Physician services, and PharmaCare publicly funded drug

Funding to regional health authorities, approximately $11.5 billion, is mainly ‘global’ funding, not

separated by specific services

The Matrix summarizes approximately $11 billion of publicly funded health care services provided

to BC residents. This represents 61% of the total provincial government Health Function

expenditures of $18.2 billion in 2013/148. Health function expenditures is an estimate of the

expenditures on health care services including payments for healthcare services by the Ministry

of Social Development and the Ministry of Children and Family Development made on behalf of

their clients.

Physician services:

In 2012/13, there were 10,199 physicians in BC, of which 39.8% were paid entirely through Fee

for Service billings, 16.8% were paid entirely through alternative payment programs, and 44.5%

paid through a combination of Fee for Service and alternative payments9.

Prescription drugs dispensed from community pharmacies

PharmaCare program: publicly paid portion of prescription drugs. Largest program is Fair

PharmaCare which covers a formulary of drugs and medical devices, with an income based

threshold for coverage for all ages.

PharmaNet: all community pharmacies are linked electronically through PharmaNet. Therefore

the Ministry has access to all prescription drugs dispensed in community pharmacies, both

publicly and privately paid.

Five Regional Health Authorities provide the following services

Hospital care

Integrated community care services (major services: long term residential care, assisted living,

home support for activities of daily living)

Population health and wellness

Community mental health

The sixth health authority, the Provincial Health Services Authority operates the Women’s and Children’s

hospital, and co-ordinates major provincial services (Cancer Agency, Renal Agency, provincial

ambulance service, etc.)

7 BC Government, Ministry of Health 2014/15 to 2016/17 Service Plan, February 2014, 2014/15 Estimates

of Operating Expenses, page 19. 8 Source: Full Year Forecast 2013/14 Health Function Expenditures, BC Government Budget and Fiscal

Plan - 2014/15 to 2016/17, 2013/14 Revised Financial Forecast (Third Quarterly Report), page 99. 9 Physicians in Canada 2014, Physician payment data table 2.4, Canadian Institute for Health

Information, 2014.


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GLOSSARY

BCCA BC Cancer Agency

CMG+ Case Mix Group Plus: a hospital case mix grouper system used in Canada and

developed by the Canadian Institute for Health Information.

HCC Health authority’s home and community care programs (home support, assisted

living, adult day services, professional home care)

MSP FFS Medical Services Plan physician Fee for Service Billings. FFS physicians are

paid based on the billings they submit for each patient encounter.

PharmaCare Publicly funded prescription drugs dispensed in community pharmacies. Most

BC residents are under the Fair PharmaCare plan which publicly funds all or part

of the cost of eligible prescription drugs and designated medical supplies, based

on family net income. BC Residents may be eligible for other PharmaCare plans.

PharmaNet All prescription drugs dispensed in community pharmacies, regardless of payer.