Static regions for health policy analysis

1. Static regions for health policy analysis Health Policy Commission Discussion document September 20, 2013

2. Objectives • Review example geographic regions in use in Massachusetts • Describe Health Policy Commission draft approach to static geographic regions • Discuss key decision points in analytic model • Receive Health Planning Council feedback on draft approach

3. Two types of geographic definitions are useful in our policy analyses Static geographic regions Dynamic service areas for market analysis A B • Regions to be used for drilling down a level deeper than statewide figures • Statically defined and changed infrequently to allow measurement of trend over time • Should be based on existing region definitions or should provide an easy crosswalk to support analysis linking data with other sources (including national datasets - census, etc) • Service area defined with the hospital at the center • Definition based on a consistent rule, but actual geographic boundaries of service areas may vary over time based on market shifts • Should align with ‘real’ market function • FOCUS FOR TODAY

4. A Goals for static region definition • Definitions of health care service regions will be used across: • Cost Trends reports and analyses • Assessments of geographic access/disparities • Health resource planning analysis • Policy development – DoN and investments Effective region definitions will be… Meaningful • Reflect population distribution and travel patterns • Incorporate market-oriented understanding of delivery system and referral patterns Understandable • Anchor in familiar concepts (e.g. cities or political boundaries) • Develop through defensible and easily communicated methodology • Use existing region definitions where possible Usable • Set up crosswalks for linking to major data sources (e.g. zip codes for linking to APCD, census data, HSAs) • If regions include multiple levels, build hierarchically to enable effective roll-ups and drill-downs Stable / Rigid • Keep regions consistent over time to allow measurement of trend • Define regions based on data which will not change significantly from year-to-year, so that regions remain meaningful

5. NOT EXHAUSTIVE A Design questions for static regions How many levels of regions should there be? • Single set of regions (e.g. at tertiary care level) • Two sets of regions (e.g. secondary and tertiary care) • Three sets of regions (e.g. to add primary care practice regions) Question Options How should size of regions (and therefore number of regions) be determined? • Based on market / competition (e.g. at least 2 hospitals per region) • Based on geographic access (e.g. no more than 45 mins travel time between 2 points in region) • Based on existing patterns of use (e.g. areas built around how far patients currently go for care) Should we use an existing region definition or develop a new one? • Select region definitions from a Massachusetts agency • Select region definitions from academic literature, a nonprofit, or federal agency • Develop a new region definition How often should region definitions be refreshed? • Every decade • Every 5 years • Every 3 years • Annually

6. A Example of regional definitions currently in use in Massachusetts Organization Region definition Description Dartmouth Atlas • 3 hospital referral regions • 64 hospital service areas • 105 primary care service areas • Based on Medicare patients • HRR: Cardiovascular surgery and neurosurgery • HSA: All inpatient admissions • PCSA: Primary care services Health Planning Council (Freedman draft) • 4 tertiary regions • 16 secondary regions • 122 primary regions • To be used for resource planning • Based on similar criteria to Dartmouth Atlas • Consistent with patient access and referral patterns EOHHS • 6 EOHHS regions • Used for reporting on health indicators • Regions include: Western Mass, Central Mass, Boston, Metro West, Northeast, Southeast DPH • 5 regions for emergency medical services • Based on location of trauma centers and geographic proximity / time to reach emergency services DOI • 7 rating regions • Regions defined for area rate adjustments Network adequacy stds • Highly varied • Varied by payer and services Dartmouth Atlas offers the greatest ability to link to existing studies and national benchmarks, but is especially outdated at the secondary care level (HSAs)

7. EOHHS publications use 6 regions, 14 counties, and 351 cities/towns EOHHS regions Counties (alphabetical) Cities/towns Western Mass Barnstable Berkshire Bristol Central Mass Dukes Essex Northeast Franklin Hampden Hampshire Metro West Middlesex Nantucket Southeast Norfolk Plymouth Boston Region Suffolk Worcester SOURCE: Massachusetts EOHHS/DPH

8. Emergency Medical Service regions SOURCE: Massachusetts EOHHS

9. Division of Insurance rating regions SOURCE: Division of Insurance

10. Map of Massachusetts SOURCE: Division of Insurance

11. Health Planning Council draft regions (May 3) SOURCE: Freedman Analytic Plan/Health Planning Council

12. Health Planning Council draft - Secondary Service Market (SSM) - 16 SOURCE: Freedman Analytic Plan/Health Planning Council

13. Dartmouth Atlas region structure • Hospital service areas (HSAs) • 64 in MA (plus 2 RI HSAs overlapping MA) • Local health care markets for hospital care • Based on assigning ZIP codes to hospital area where the greatest proportion of zip code’s Medicare residents were hospitalized (adjusted to ensure contiguity) • Hospital referral regions (HRRs) • 3 in MA (Boston, Worcester, Springfield) • Regional health care markets for tertiary medical care that generally requires the services of a major referral center • Based on where patients were referred for major cardiovascular surgical procedures and for neurosurgery • Each HRR has at least one city where both major cardiovascular surgical procedures and neurosurgery are performed • Primary care service areas (PCSAs) • 104 in MA (plus 3 RI PCSAs overlapping MA) • Reflect Medicare patient travel to primary care providers • Each includes a ZIP code area with 1+ PCPs and any contiguous ZIP code areas whose Medicare populations seek the plurality of their primary care from those providers. SOURCE: Dartmouth Atlas web site

14. A The Health Policy Commission is exploring an approach based on a three-level hierarchy Primary Secondary Tertiary/Quaternary • Proposed approach • Use 108 Dartmouth Atlas PCSAs • Proposed approach • ~10-20 regions, built as roll-up of 64 Dartmouth Atlas HSAs to allow use of nationally reported data • Roll up based on “Dartmouth-like” logic, including e.g.: • Merge small HSAs based on where residents of those HSAs are sent for IP stays • Ensure regions ‘balanced’ in size (e.g. no region > 30% of total MA discharges) • Proposed approach • Use 3 Dartmouth Atlas HRRs for alignment with Medicare and other national analyses • Example analytical uses • Monitoring access to primary care • Example analytical uses • Regional segmentation for descriptive statistics (e.g. health status, TME growth) • Regional variation in prices and provider input costs • Ongoing description of competitive landscape • Example analytical uses • Comparisons of Massachusetts regions to national data on cost, service intensity, health status • Analysis of specialized services (e.g. neurosurgery, CV surgery)

15. Region sets modeled/reviewed Principles for modeling scenario Access-based secondary regions • Merge Dartmouth HSAs to obtain 10-20 regions for which all residents are within 15 mi or 30 min travel time of an “anchor” hospital offering secondary services • Constrained to roll up to Dartmouth HRRs 1 • In addition to map outlining region boundaries, summary outputs for each region should include: • Population of region • Maximum travel time to center of region from any point in region • Provider landscape: • # of hospitals and inpatient beds • # of physicians • # of mental health providers and IP facilities • # of SNFs Service-based secondary regions • Merge Dartmouth HSAs to obtain regions which contain at least 2 providers of: • Labor and delivery • Inpatient surgical services • Inpatient mental health services • SNFs and home health care services • Constrained to roll up to Dartmouth HRRs 2 Adapted Health Planning Council regions • Draft regions defined by Health Planning Council, adjusted to roll up to Dartmouth HRRs 3 Health Planning Council regions • Draft regions as defined by Health Planning Council team, based on following principles: • At least two Community Hospitals • Either 20 or 45 minute driving time (density) from Market center • Organized along major traffic routes • Not contradictory to Dartmouth Atlas HSAs • May require sub-division for ED 4

16. Next steps • Develop secondary regions • Aim to meet following principles: • ~10-20 regions • At least 2 hospitals per region • Regions should be defined by roll-up of Dartmouth Atlas HSAs to allow use of nationally reported data • Regions should be ‘balanced’ in size (e.g. no region > 30% of total MA discharges) • Need to define logic for merging: • Merge a small HSA into a larger HAS only if at least X% of discharges sent to larger HAS • Any HSA which sends at least Y% of its residents’ discharges to hospitals contained within its region should not be merged • ‘Greedy merge’ (merge into HSA receiving largest % of discharges from the smaller HAS) vs. ‘Merge for ‘balance’ (merge into smallest HSA receiving at least X% of discharges) • Model several options based on various thresholds • Review with Health Planning Council, CHIA, AGO, DPH, and other agencies doing geographic breakdowns of health care analysis • Review Regions and Descriptive Statistics at September Health Planning Council meeting • Discussion with other agencies in parallel • Use regional cuts for APCD analyses in December cost trends report from Health Policy Commission