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

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Presentation on theme: "Measuring the Quality of Pennsylvania’s Commercial HMOs Joe Martin Director of Communications and Education Pennsylvania Health Care Cost Containment Council."— Presentation transcript:

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

2 Pennsylvania Health Care Cost Containment Council (PHC4)

3 “Knowledge is two kinds:” “We know a subject ourselves, or we know where we can find information upon it.” Samuel Johnson – Author (1709-1784)

4 Pennsylvania Health Care Cost Containment Council (PHC4) Wall Street Journal  Due to the Council, Pennsylvanians can get far more information about their hospitals than can most Americans.

5 Pennsylvania Health Care Cost Containment Council (PHC4) Commercial HMO Report  Combines clinical outcomes, prevention measures and member satisfaction information

6 Pennsylvania Health Care Cost Containment Council (PHC4) Why is Pennsylvania’s HMO Report unique? Linked hospitalization data to health plan data using: Linked hospitalization data to health plan data using: NCQA data NCQA data Clinical data Clinical data Established collaborative relationship with health plans which participated in data verification. Established collaborative relationship with health plans which participated in data verification. Analyzed preventive measures (HEDIS) against outcomes (hospitalization rates) to test for statistical significance. Analyzed preventive measures (HEDIS) against outcomes (hospitalization rates) to test for statistical significance.

7 Pennsylvania Health Care Cost Containment Council (PHC4) PA HMO Enrollment Enrollment growth in the early 1990’s tapered off beginning in 1998. Enrollment growth in the early 1990’s tapered off beginning in 1998.

8 Pennsylvania Health Care Cost Containment Council (PHC4) Why Look at HMOs 2001 Fourth highest state HMO enrollment – approximately 4 million * Fourth highest state HMO enrollment – approximately 4 million * Strong managed care penetration in PA – approximately 35% * Strong managed care penetration in PA – approximately 35% * Gatekeeper managed care plans emphasize preventive care activities Gatekeeper managed care plans emphasize preventive care activities * Source is Henry J. Kaiser Family Foundation State Health Facts Online

9 Pennsylvania Health Care Cost Containment Council (PHC4) HMO Report: HEDIS Measures - Childhood Immunizations - Timely Prenatal Care - Beta Blockers after Heart Attack - Mental Health Services - Antidepressant Medication Management - Control of High Blood Pressure - Appropriate Medication, Members with Asthma

10 Pennsylvania Health Care Cost Containment Council (PHC4) HMO Report: HEDIS Measures Diabetes - Hemoglobin A1c Levels - Hemoglobin A1c Tests - Eye Exam - Monitor for Kidney Disease - Control Bad Cholesterol Screenings - Breast Cancer - Cervical Cancer - Cholesterol Post Acute Cardio Events - Bad Cholesterol Controlled Post Acute Cardio Events

11 Pennsylvania Health Care Cost Containment Council (PHC4) Hemoglobin A1c Blood Tests for Members with Diabetes

12 Pennsylvania Health Care Cost Containment Council (PHC4) Ambulatory Sensitive Conditions Ear, Nose and Throat Infections Ear, Nose and Throat Infections Pediatric or Adult Pediatric or Adult High Blood Pressure High Blood Pressure Gastrointestinal Infections Gastrointestinal Infections Kidney/Urinary Tract Infections Kidney/Urinary Tract Infections Hospitalization Rates Hospitalization Rates

13 Pennsylvania Health Care Cost Containment Council (PHC4) Gastrointestinal Infections (Per 10,000)

14 Pennsylvania Health Care Cost Containment Council (PHC4) Preventive Care Measures COPD COPD Asthma Asthma Diabetes Diabetes Mental Health Mental Health Heart Attack Heart Attack

15 Pennsylvania Health Care Cost Containment Council (PHC4)

16 Surgical Procedures Hysterectomy Hysterectomy Breast Cancer Breast Cancer Neck and Back Neck and Back Prostatectomy Prostatectomy

17 Pennsylvania Health Care Cost Containment Council (PHC4) Neck and Back Procedures

18 Pennsylvania Health Care Cost Containment Council (PHC4) Selection of Clinical Conditions Degree of manageability by an HMO Degree of manageability by an HMO Preventing Hospitalization Preventing Hospitalization Managing On-Going Illness Managing On-Going Illness Appropriateness of Surgical Procedures Appropriateness of Surgical Procedures Significant risk and cost factors Significant risk and cost factors Health issues important to purchasers and consumers Health issues important to purchasers and consumers

19 Pennsylvania Health Care Cost Containment Council (PHC4) Clinical Outcome Measures Outcome measures reviewed included: Outcome measures reviewed included: Readmission Rates Readmission Rates In-hospital Mortality In-hospital Mortality Complication Rates Complication Rates Length of Stay Length of Stay

20 Pennsylvania Health Care Cost Containment Council (PHC4) Member Satisfaction Getting Needed Care Getting Needed Care Getting a Referral to a Specialist Getting a Referral to a Specialist Customer Service Customer Service Overall Rating Overall Rating Accreditation Status Accreditation Status

21 Pennsylvania Health Care Cost Containment Council (PHC4) Report Highlights For the fourth consecutive year, Pennsylvania HMOs achieved higher member satisfaction rates than the national average. For the fourth consecutive year, Pennsylvania HMOs achieved higher member satisfaction rates than the national average. 86% of members reported no problems in receiving care they felt they needed. 86% of members reported no problems in receiving care they felt they needed.

22 Pennsylvania Health Care Cost Containment Council (PHC4) Report Highlights For the second consecutive year, Pennsylvania HMOs improved their results in all 15 preventive care measures in the report and outperformed their national counterparts in these categories. For the second consecutive year, Pennsylvania HMOs improved their results in all 15 preventive care measures in the report and outperformed their national counterparts in these categories.

23 Pennsylvania Health Care Cost Containment Council (PHC4) Report Highlights Surgical Procedures Complications After Surgery – More Likely for HMO Members than those in fee-for-service plans Complications After Surgery – More Likely for HMO Members than those in fee-for-service plans

24 Pennsylvania Health Care Cost Containment Council (PHC4) Report Highlights Surgical Procedures Reconstruction Surgery – There continues to be significant variation in breast reconstruction surgery following mastectomy among the HMOs Reconstruction Surgery – There continues to be significant variation in breast reconstruction surgery following mastectomy among the HMOs

25 Pennsylvania Health Care Cost Containment Council (PHC4) Report Highlights Studies have cited the following possible reasons for such differences: 1) Variation in preoperative counseling 2) Surgeon preferences 3) Availability of trained surgeons 4) Patient preferences 5) Practice patterns

26 Pennsylvania Health Care Cost Containment Council (PHC4) Report Highlights Surgical Procedures Hysterectomy Between 1998 – 2001 Hysterectomy Between 1998 – 2001 Procedure rate for all hysterectomies increased from 42.7 to 55.8 per 10,000 female members Complications rates for both abdominal and vaginal hysterectomies decreased

27 Pennsylvania Health Care Cost Containment Council (PHC4) Report Highlights Surgical Procedures Hysterectomy 2001 Hysterectomy 2001 Abdominal procedure* more likely than vaginal procedure for HMO Members than for those in fee-for service plans (*higher length of stay and complication rate)

28 Pennsylvania Health Care Cost Containment Council (PHC4) Report Highlights The study statistically shows a correlation between well-controlled blood pressure levels and lower hospitalization rates. The study statistically shows a correlation between well-controlled blood pressure levels and lower hospitalization rates. Overall hospitalization rates for diabetes decreased which may also suggest that HMO prevention measures are having a positive effect. Overall hospitalization rates for diabetes decreased which may also suggest that HMO prevention measures are having a positive effect.

29 Pennsylvania Health Care Cost Containment Council (PHC4) Disease Management Value to the benefits purchaser: Helps control costs associated with chronic diseases Increases employee productivity Fewer days of lost work time

30 Pennsylvania Health Care Cost Containment Council (PHC4)

31 Conclusions Wide variations in rates and preventive care measures suggest an uneven approach to disease management. Wide variations in rates and preventive care measures suggest an uneven approach to disease management. PHC4’s data shows that better preventive and primary care helps patients avoid unnecessary trips to the hospital. PHC4’s data shows that better preventive and primary care helps patients avoid unnecessary trips to the hospital. The cost implications could have a major impact on the health care delivery system. The cost implications could have a major impact on the health care delivery system.

32 Pennsylvania Health Care Cost Containment Council (PHC4)

33 “We want to use indicators that are fairly well accepted.” Among those sources are statistics gathered by Pennsylvania Health Care Cost Containment Council, a state agency that collects and analyzes information related to the performance of hospitals in the state. Sept. 13, 2002

34 Pennsylvania Health Care Cost Containment Council (PHC4)

35 HMO Report Distribution 1998 HMO Report: 3,000 1999 HMO Report: 8,000 2000 HMO Report: 7,500 2001 HMO Report: 23,800

36 Pennsylvania Health Care Cost Containment Council (PHC4) HMO Report Web Downloads HMO 2001 Data = 14,605 HMO 2001 Data = 14,605 - Released March 2003 HMO 2000 Data = 130,569

37 Pennsylvania Health Care Cost Containment Council (PHC4) The Web - WWW.PHC4.Org New Interactive Databases Easy Access to PHC4’s Free Public Reports Downloadable PDF Files New Purchaser Section New Purchaser Section

38 Pennsylvania Health Care Cost Containment Council (PHC4) Create Your Own Reports on the Web

39 Pennsylvania Health Care Cost Containment Council (PHC4) For more information on PHC4: 225 Market Street, Suite 400 Harrisburg, PA 17101 (717) 232-6787 www.phc4.org


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