HCCI and the Florida Transparency Initiative Health Care Cost Institute (HCCI) December 2017

1. HCCI and the Florida Transparency InitiativeHealth Care Cost Institute (HCCI)December 2017

2. Outline • HCCI Overview • HCCI Research • FL Specific Data Findings • National Guroo • FL Transparency Initiative • Pre-Rule Site • Post-Rule Site • Requesting Care Bundle Details

3. Why was HCCI founded? • Any informed debate about health care reform relies on access to data from commercial payers • Prior to HCCI’s formation: • Access to payer data was piecemeal with researchers primarily relying on Medicare data for research and analysis • There was little to no transparency in health care pricing/prices • HCCI was founded to: • Promote independent, nonpartisan research and analyses on the causes of the rise in U.S. health spending • Inform the public policy process and assist in developing new solutions to long-term problems confronting the health care system

4. HCCI Data Holdings Current Future • Commercial Claims • Years 2008-2015 • ~50 million individuals per year • Employer-sponsored, individual and Medicare Advantage (Part C) • All 50 states and D.C. • Updated annually • De-identified, HIPAA and anti-trust compliant • Medicare fee-for-service claims (via the Qualified Entity Program) • Years 2012-2015 • Parts A & B (100%) • Part D (~40%) • Additional years of current contributors’ data • 2016 data is currently being constructed and is expected to be available in January 2018 • 2016 Medicare claims will be available in February 2018 • Administrative data from additional payers • State APCDs • Medicaid and CHIP

5. Using HCCI’s Data HCCI reports and issue briefs are free and available online August 31, 2017

6. Academic Research • HCCI’s current academic partners include: • HCCI has also facilitated data access and research support through external funding partnerships:

7. Florida Specific Data • What can HCCI’s claim data tell us about spending and utilization in Florida? • HCCI data include 3 million covered employer sponsored insurance lives in Florida (38% of total) • HCCI data include approximately 27% of the national ESI population

8. ESI Per Capita Spending in Florida FL – National Spending Difference in 2015 • Florida has slightly above average health care spending for commercially insured • From 2012-2015, health care spending in FL averaged 3% more than national spending, but varied by service • Outpatient spending lower than national average

9. ESI Per Capita Spending Trends • Per capita spending growth in FL was consistent with national trend • From 2012 to 2015, US total spending rates increased by 10%, FL increased 9% • But trends for FL and US varied when comparing service categories • FL saw greater inpatient spending growth and lower physician spending growth Change in per capita Spending since 2012

10. Health Care Price Variation • Trends in per capita spending are influenced by many factors including the underlying population, prices, and utilization • Research has shown substantial geographic variation in commercial spending, driven largely by differences in price rather than utilization • IOM 2013, Cooper et al 2016 • HCCI’s Healthy Marketplace Index (HMI) reports price indices for 3 service categories at the local level • Indices allow users to compare a common weighted average price across geographic areas and over time (2012-2014) • FL CBSAs: Cape Coral-Fort Myers, Deltona-Daytona Beach-Ormond Beach, Jacksonville, Lakeland-Winter Haven, Miami-Fort Lauderdale-West Palm Beach, North Port-Sarasota-Bradenton, Orlando-Kissimmee-Sanford, Palm Bay-Melbourne-Titusville, Tampa-St. Petersburg-Clearwater

11. Healthy Marketplace Index (HMI) • Healthy Marketplace Index (funded by Robert Wood Johnson Foundation) developed measures of the economic performance of health care markets across the country: price, productivity, and competition • Future work on high spenders will investigate differences in demographics and types of health care expenditures between persistent vs. new high spenders • Measures were presented in a series of issue briefs and interactive mapping tool on the HCCI website

12. Florida Health Care Price Variation - Inpatient 2014 Inpatient Price Indices • Inpatient prices varied widely across the Florida CBSAs, but price increases within CBSAs were similar to the national growth rates • Lakeland has the lowest average inpatient prices (9% below the national average), while Orlando had the highest (21% higher) • 7 of the 9 Florida CBSAs had inpatient growth rates between 8-15%, generally aligning with the national inpatient growth rate of 11%

13. Florida Health Care Price Variation - Outpatient • Outpatient prices grew faster than national rate • In 7 of the 9 CBSAs studied, outpatient price levels rose at the same or higher rate compared to the national growth level of 14% • Largest increase was in Tampa - outpatient prices went from 9% below to 14% above the national average between 2012 and 2014 2012 2014

14. Florida Health Care Price Variation – Professional Services 2014 Professional Services Price Indices • Professional services prices were well below the national average in all FL CBSAs • Ranging from 0% to 12% below average in 2014 • No CBSA had a growth rate higher than 7%, and 6 of the 9 CBSA’s had growth rates ≤ 1%

15. Procedure Spending - FL • HMI reported demographically adjusted spending per 1000 people for 3 knee procedures • Generally, FL had average to below average spending on Knee Injections and consistently below average spending on ACL Repairs • Wide variation across FL CBSAs for spending on Knee Replacements • Spending in Miami was less than 1/3rd the national average, while spending in Fort Meyers was 50% greater Spending per 1000 people by CBSA Knee Replacements ACL Repairs Knee Injections

16. Procedure Specific Utilization - FL • HMI reported demographically adjusted utilization rates per 1,000 people for the same 3 procedures • Similar to spending, most FL CBSA Knee Injection utilization rates were around or below the national average and were below to substantially below for ACL Repairs • There was more variation for Knee Replacement utilization with Fort Meyers again having the highest use rate and Miami the lowest Utilization Rates per 1,000 people by CBSA Knee Replacements ACL Repairs Knee Injections

17. Procedure Specific Price Index - FL • HMI reports a price index with 1.00 being the national average • Consistently below average Knee Injection prices also helped lead to below average Knee Injection spending across FL CBSAs • Lakeland -> slightly above average utilization, but below average prices • Outside of average prices in Fort Meyers, FL had below average ACL Repair prices • Palm Bay had the highest Knee Replacement prices of FL CBSAs, potentially explaining their above average spending with below average utilization Price Indices by CBSA Knee Replacements Knee Injections ACL Repairs

18. Medicare FFS Spending Trends • Total Medicare spending per capita in FL grew slower than the national rate between 2008 and 2015 • Home Health spending had notable decline in FL Outpatient Florida National E&M Hospice Total SNF Home Health Inpatient

19. Medicare vs ESI spending • Very different patterns of geographic variation in spending per capita • Low cost Medicare states don’t necessarily have low costs in the ESI population • Florida has average spending on commercially insured, but very high Medicare spending Medicare FFS Spending per capita Commercially Insured Spending per capita

20. HCCI Transparency Initiative: Guroo • Guroo launched February 2015 • Number of Care Bundles: Initially – 78; Currently – 295 • Geographical Searches • National, State, Local (town/city/ZIP) • Updated March 2016 to include: • Additional content, Quality metrics (6 total: High Blood pressure (2), Diabetes (2), Asthma, Readmission), Body image search

21. Florida Transparency Initiative • Began taking in FL Medicaid Data July 1, 2017 • Pre-Rule site launch November 28, 2017 • Co-branded, MSA level site • Post-Rule site launch (4 – 6 weeks after the Rule is finalized) • Displays HCCI’s United, Aetna, and Humana data at the facility level • Onboard FL Blues and Avmed in year 1 of the contract (timing contingent upon Rule being finalized); this data will be displayed after the 2nd refresh (TBD) • With FL Blues, Avmed, United, Aetna, and Humana HCCI will hold ~ 90% of the commercially insured data in FL • Other payers’ data will be displayed after the 3rd refresh (TBD)

22. Pre-Rule MSA Site • The Pre-Rule site shows progress on the initiative • Facility-level pricing cannot be displayed until the Rule is finalized • Platform is National Guroo • Co-branded site (FL logo and content) • FL data is the same as for National Guroo

23. Pre-Rule MSA Site Data • Data from Aetna, Humana, and United • Based on about 758 million claims • 24 month data period: 7/1/2013 – 6/30/2015 • Estimates trended to and considered valid through July 1, 2017 • Data will be refreshed March 2018 • 295 Care Bundles

24. Accessing the Pre-Rule MSA Site • You can access the site 3 different ways: • From Florida Health Finder - Access the site by clicking on the FloridaHealthPriceFinder link in the middle of the home page(http://www.floridahealthfinder.gov/index.html) • From guroo.com – Change your location to a Florida city • From the new URL designated by Florida https://pricing.floridahealthfinder.gov

25. Website Demo

26. Post-Rule Site • Data from Aetna, Humana, and United • Based on about 58.8 million claims • 24 Month Data Period: 7/1/2014 – 6/30/2016 • Membersmust have a Florida zip code • Providersmust have evidence of a Florida zip code • Note: There are no reliable indicators for whether or not a provider zip code represents a billing or servicing location. Logic is applied to estimate provider servicing zip code. Providers must have both member zip codes in Florida and also a provider zip code in Florida from at least one payer. • 295 Care Bundles

27. Data Scrubbing • Data Trended to 7/1/2018 • Trend assumption rates vary by Inpatient, Outpatient & Physician • Claims which cannot accurately estimate costs are removed • Examples: Low outliers, Providers missing an NPI number • Historical costs for the facility component of a surgery are aggregated by case

28. Masking Rules • Code level estimates are calculated by provider/payer • Provider - at least 5 “clean/scrubbed” claims per code and payer over the 24 month data period • Code level estimates are calculated by county/state/provider (all payers) • 2 Payers • 2 Providers per payer for non-identifiable providers • 1 Provider per payer for identifiable providers • Rollup Care Bundles • Subtotals by code (code level estimate X volume of service) • Subtotals by care bundle step • Totals by care bundle

29. Care Bundle Estimates • National • National level price estimates are sourced from Guroo.com • County • County is based on provider zip code • Zip codes which cross county lines are mapped to the county of majority residence • Facility Providers • Providers and Provider Type of Hospital vs ASC defined by AHCA • Care bundles with a primary step performed at a facility are reported at a facility level • Costs for supporting steps are calculated at either the county or state level

30. Requesting Care Bundle Details • To request the Care Bundle details, please send an email to: carebundledownloadfl@guroo.com • Individuals will need to sign a Request Form and acknowledge the Care Bundle License • The license will be sent along with the Request Form • Usage Requirements • Entity/Individual will use the Care Bundle Details document solely to further the purpose of, and in a manner consistent with, Florida’s Act Relating to Transparency in Health Care (2016 FL House Bill 1175) and the regulations that may bepromulgated thereunder

31. Example of Care Bundle Details Knee Replacement

32. Questions?