Measuring the Quality of Pennsylvania’s Commercial HMOs

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Measuring the Quality of Pennsylvanias
Commercial HMOs

• Joe Martin
• Director of Communications and Education
• Pennsylvania Health Care Cost Containment Council

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Knowledge is two kinds
We know a subject ourselves, or we know where
we can find information upon it.
Samuel Johnson Author (1709-1784)
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Wall Street Journal

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

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Commercial HMO Report

• Combines clinical outcomes, prevention measures
  and member satisfaction information

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Why is Pennsylvanias HMO Report unique?

• Linked hospitalization data to health plan data
  using
• NCQA data
• Clinical data
• Established collaborative relationship with
  health plans which participated in data
  verification.
• Analyzed preventive measures (HEDIS) against
  outcomes (hospitalization rates) to test for
  statistical significance.

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PA HMO Enrollment
Enrollment growth in the early 1990s tapered
off beginning in 1998.
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Why Look at HMOs

• 2001
• Fourth highest state HMO enrollment
  approximately 4 million
• Strong managed care penetration in PA
  approximately 35
• Gatekeeper managed care plans emphasize
  preventive care activities
• Source is Henry J. Kaiser Family Foundation
  State Health Facts Online

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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

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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

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Hemoglobin A1c Blood Tests for Members with
Diabetes
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Ambulatory Sensitive Conditions

• Ear, Nose and Throat Infections
• Pediatric or Adult
• High Blood Pressure
• Gastrointestinal Infections
• Kidney/Urinary Tract Infections
• Hospitalization Rates

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Gastrointestinal Infections(Per 10,000)
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Preventive Care Measures

• COPD
• Asthma
• Diabetes
• Mental Health
• Heart Attack

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Surgical Procedures

• Hysterectomy
• Breast Cancer
• Neck and Back
• Prostatectomy

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Neck and Back Procedures
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Selection of Clinical Conditions

• Degree of manageability by an HMO
• Preventing Hospitalization
• Managing On-Going Illness
• Appropriateness of Surgical Procedures
• Significant risk and cost factors
• Health issues important to purchasers and
  consumers

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Clinical Outcome Measures

• Outcome measures reviewed included
• Readmission Rates
• In-hospital Mortality
• Complication Rates
• Length of Stay

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Member Satisfaction

• Getting Needed Care
• Getting a Referral to a Specialist
• Customer Service
• Overall Rating
• Accreditation Status

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Report Highlights

• 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.

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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.

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Report Highlights

• Surgical Procedures
• Complications After Surgery More Likely for HMO
  Members than those in fee-for-service plans

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Report Highlights

• Surgical Procedures
• Reconstruction Surgery There continues to be
  significant variation in breast reconstruction
  surgery following mastectomy among the HMOs

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Report Highlights

• Studies have cited the following possible reasons
  for such differences
• Variation in preoperative counseling
• Surgeon preferences
• Availability of trained surgeons
• Patient preferences
• Practice patterns

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Report Highlights

• Surgical Procedures
• 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

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Report Highlights

• Surgical Procedures
• 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)

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Report Highlights

• 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.

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Disease Management

• Value to the benefits purchaser
• Helps control costs associated with chronic
  diseases
• Increases employee productivity
• Fewer days of lost work time

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Conclusions

• Wide variations in rates and preventive care
  measures suggest an uneven approach to disease
  management.
• PHC4s 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.

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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
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HMO Report Distribution

• 1998 HMO Report  3,000
• 1999 HMO Report  8,000
• 2000 HMO Report  7,500
• 2001 HMO Report  23,800

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HMO Report Web Downloads

• HMO 2001 Data 14,605 
• - Released March 2003
• HMO 2000 Data 130,569

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The Web - WWW.PHC4.Org
Easy Access to PHC4s Free Public Reports
Downloadable PDF Files

• New Interactive Databases

• New Purchaser Section

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• Create Your Own Reports on the Web

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For more information on PHC4

• 225 Market Street, Suite 400
• Harrisburg, PA 17101
• [phone]
• www.phc4.org