Patient Classification beyond the hospital

1. Patient Classificationbeyond the hospital Stephen Sutch, MAppSc, BSc steve@sutchconsulting.com

3. Overview Introduction Payment systems for primary, ambulatory (and social) care Casemix Development � Need : Resource Morbidity Primary/Population care classification systems Data issues Purpose and use of classifications Lessons and Conclusions

4. Introduction Casemix classification for Hospital activity is now spreading world wide. direct payment or budgeting Only covers around 10% of the population (up to 70% of healthcare expenditure). Unlike secondary and acute care less international commonality and development of classifications Cultural differences, mixed public/private economies, paucity of data, multiple interactions with clients, customers and citizens. Utilise primary and secondary care data the classification of individuals within populations Recognise individuals with multiple health needs and morbidities Casemix classification for Hospital activity is now spreading world wide and used for direct payment or for budgeting. However this only covers around 10% of the population (but in excess of 70% of healthcare expenditure). Unlike secondary and acute care there is less international commonality and development of classifications for health care services provided outside the hospital setting. This appears to be determined by a number of factors, including the effects of cultural differences, greater involvement of private providers, paucity of data and the difficultly in summarising multiple interactions with clients, customers and citizens. This paper will seek to discuss a number of the issues related to classifying patients beyond hospital care, and will illustrate utilising primary and secondary care data the classification of individuals within populations. In particular it will highlight the need to recognise individual with multiple health needs and morbidities. Casemix classification for Hospital activity is now spreading world wide and used for direct payment or for budgeting. However this only covers around 10% of the population (but in excess of 70% of healthcare expenditure). Unlike secondary and acute care there is less international commonality and development of classifications for health care services provided outside the hospital setting. This appears to be determined by a number of factors, including the effects of cultural differences, greater involvement of private providers, paucity of data and the difficultly in summarising multiple interactions with clients, customers and citizens. This paper will seek to discuss a number of the issues related to classifying patients beyond hospital care, and will illustrate utilising primary and secondary care data the classification of individuals within populations. In particular it will highlight the need to recognise individual with multiple health needs and morbidities.

5. Expenditure across Health Sectors

6. Resource use across the population

7. Interest in risk adjustment is increasing globally Population health care needs are rising, resource availability is not; focusing on �higher risk� patients makes sense. Data systems and data collection are improving Integrated Care - integrating primary, secondary, and community care. Increased Policy towards equitable delivery of health care

8. Commissioning Risk

9. Casemix Development Purpose Iso Resource Iso Need Iso Outcome Need + Resource = Outcome L. Iezzoni / M. Hornbrook

10. Need & Resource Need At Risk of disease Presentation of symptoms Confirmed Disease Continued Consequences Resource Prevention and Health Promotion Investigation and Diagnosis Clinical Management Continuing Care

11. Data Data - Cost / Scarcity Prescribing, service and/or morbidity data Activity Definition Contact / Disease or Need Episode Time period Record Linkage Alternative Settings Changes in clinical practice

12. Co-morbidity is the norm

13. Co-Morbidity associated with healthcare spending Bottom line: people with chronic conditions (particularly multiple chronic conditions) account for a large proportion of health care costsBottom line: people with chronic conditions (particularly multiple chronic conditions) account for a large proportion of health care costs

14. Primary Care/Diagnosis Groupings Adjusted Clinical Groups (ACG) Originally named �Ambulatory Care Groups� Diagnostic Cost Groups (DCGs) HCC 116 Hierarchical Condition Categories, 784 DxGroups Clinical Risk Groupings (CRG) 1083 CRGs, ACRGs (agg CRGs, 370, 131, 34) International Classification of Primary Care ICPC-2 (Encounters) READ, Snomed-CT http://www.veriskhealthcare.com/ http://www.acg.jhsph.edu/ http://solutions.3m.com/ AAC � Australian Ambulatory Classification APAC � Australian Paediatric Ambulatory Classification VACS � Victorian Ambulatory Classification DPG � Day Procedure Groups ACCS � Alberta Ambulatory Care Classification System (based on DPG) Ambulatory Visit Groups (AVG) Ambulatory Patient Groups (APG) Australian Ambulatory Classification (AAC, APAC, VACS) Canadian Comprehensive Ambulatory Classification System (CACS) , DPG, ACCS UK Outpatient HRGs http://www.veriskhealthcare.com/ http://www.acg.jhsph.edu/ http://solutions.3m.com/ AAC � Australian Ambulatory Classification APAC � Australian Paediatric Ambulatory Classification VACS � Victorian Ambulatory Classification DPG � Day Procedure Groups ACCS � Alberta Ambulatory Care Classification System (based on DPG) Ambulatory Visit Groups (AVG) Ambulatory Patient Groups (APG) Australian Ambulatory Classification (AAC, APAC, VACS) Canadian Comprehensive Ambulatory Classification System (CACS) , DPG, ACCS UK Outpatient HRGs

15. Population Classifications Health Need or Insured �liability� Health Benefit Groups (HBG), Programme Budgetting/ PARR - UK Typology of Aged with Illustrations (TAI) - Japan Principal Inpatient Diagnosis Cost Groups (PIP-DCG � Medicare/MCOs) - USA Burden-of-disease groupings (WHO developing countries) HBG � UK TAI � Japan, application of ICF using illustartions MCO � Managed Care OrganisationsHBG � UK TAI � Japan, application of ICF using illustartions MCO � Managed Care Organisations

16. The Johns Hopkins ACG System Diagnosis (ICD) based: ADGs classify diagnoses into a limited number of clinically meaningful, but not disease-specific, morbidity groups. (e.g. �chronic unstable�) EDCs classify diagnoses based on specific diseases. Disease markers and can be used to determine disease prevalence (e.g. Type I Diabetes, w/o complications). ACGs (Adjusted Clinical Groups) a single, mutually exclusive actuarial cell based on overall disease burden. (e.g. 6-9 ADG Combinations, Age >34, 2 major ADGs). Pharmacy based (NDC/ATC): Rx-MG pharmacy risk markers, Rx-Morbidity Groups � Aggregated Diagnosis Groups (ADGs, the 32 morbidity markers); � Adjusted Clinical Groups (ACGs, the actuarial cells); � Expanded Diagnosis Clusters (EDCs, disease clusters); � Concurrent weights for each ACG category based on national reference data; � Resource Utilization Bands (ACGs collapsed into 6 categories from very low to very high resource use). � Aggregated Diagnosis Groups (ADGs, the 32 morbidity markers); � Adjusted Clinical Groups (ACGs, the actuarial cells); � Expanded Diagnosis Clusters (EDCs, disease clusters); � Concurrent weights for each ACG category based on national reference data; � Resource Utilization Bands (ACGs collapsed into 6 categories from very low to very high resource use).

17. Risk measurement pyramid

18. Purpose and use of classifications Case finding, high-risk, high-use patients Calculate adjusted budgets and/or payment systems Population and resource utilisation Patient access Resource allocation for regions Measurement of provider efficiency Enable quality of care based adjustments Financing, Payment, Planning Morbidity-adjusted capitation Allocation of budgets Forecasting healthcare spending Provider Performance Assessment Profiling high outliers as potentials for fraud/abuse audit Profiling low outliers to review access issues Pay-for-Performance Care Management Identification of high risk patient for case management Identifying need for tailored program in population subgroups Quality Assurance Intervention Assessment Monitoring outcomes Research Surveillance for changes in morbidity patterns Financing, Payment, Planning Morbidity-adjusted capitation Allocation of budgets Forecasting healthcare spending Provider Performance Assessment Profiling high outliers as potentials for fraud/abuse audit Profiling low outliers to review access issues Pay-for-Performance Care Management Identification of high risk patient for case management Identifying need for tailored program in population subgroups Quality Assurance Intervention Assessment Monitoring outcomes Research Surveillance for changes in morbidity patterns

19. What Can Be Achieved with Case Mix Adjustment Equity and fairness Identify patients most in need of health care resources To facilitate providers who specialise in treating patients with higher than average illness burden Create incentives to encourage providers to match services to needs (appropriateness) Ensure appropriate comparisons for research and performance assessment To protect plans/or providers that are selected by a costlier than average group of enrollees. To deter plans or providers from selecting or marketing to healthier enrollees. To facilitate plan/or providers attempts to specialize in treating people with certain illness or conditions, particularly as Medicaid and Medicare move to managed care. To protect plans/or providers that are selected by a costlier than average group of enrollees. To deter plans or providers from selecting or marketing to healthier enrollees. To facilitate plan/or providers attempts to specialize in treating people with certain illness or conditions, particularly as Medicaid and Medicare move to managed care.

20. Capitation Budgets and Casemix Adjustment

21. Distribution of Resource Utilisation across PC Centres

22. Risk-Adjusted Profiles Across Torbay

23. Risk-Adjusted Profiles Across Torbay cont. Relative Cost : Actual / Average Illness Burden: Expected / Average Efficiency: Actual / Expected Relative Cost : Actual / Average Illness Burden: Expected / Average Efficiency: Actual / Expected Relative Cost : Actual / Average Illness Burden: Expected / Average Efficiency: Actual / Expected Relative Cost : Actual / Average Illness Burden: Expected / Average Efficiency: Actual / Expected Relative Cost : Actual / Average Illness Burden: Expected / Average Efficiency: Actual / ExpectedRelative Cost : Actual / Average Illness Burden: Expected / Average Efficiency: Actual / Expected Relative Cost : Actual / Average Illness Burden: Expected / Average Efficiency: Actual / Expected Relative Cost : Actual / Average Illness Burden: Expected / Average Efficiency: Actual / Expected Relative Cost : Actual / Average Illness Burden: Expected / Average Efficiency: Actual / Expected Relative Cost : Actual / Average Illness Burden: Expected / Average Efficiency: Actual / Expected

24. Patient risk information in support of community matrons / case managers

25. The Problem (1) Cost of data collection very high relative to the cost of the activities being measured, important to utilise existing data collections The episode or period of care to be measured (e.g. hospital care episode, disease episode, need based record, annual care record) unique patient identification, tracking between events, different provider organisations and different commissioning agencies There are a number of issues to be addressed to classify a population with respect to healthcare needs and interventions. The cost of data collection can be very high relative to the cost of the activities being measured, and it becomes important to utilise existing data collections. The episode or period of care to be measured (e.g. hospital care episode, disease episode, need based record, annual care record) highlights the need to have unique patient numbers to allow tracking between events, different provider organisations and different commissioning agencies. This is also being highlighted with the increased policy recognition of individuals with chronic health needs. The Pathway approach to health care provision is often referenced but does appear to often present a model of health care from a particular disease or treatment perspective (vertical v. horizontal approach). The recognition of multiple-morbidity has been realised to an extent within hospital casemix classification systems, and in population classifications such as the ACG and DxCG systems.There are a number of issues to be addressed to classify a population with respect to healthcare needs and interventions. The cost of data collection can be very high relative to the cost of the activities being measured, and it becomes important to utilise existing data collections. The episode or period of care to be measured (e.g. hospital care episode, disease episode, need based record, annual care record) highlights the need to have unique patient numbers to allow tracking between events, different provider organisations and different commissioning agencies. This is also being highlighted with the increased policy recognition of individuals with chronic health needs. The Pathway approach to health care provision is often referenced but does appear to often present a model of health care from a particular disease or treatment perspective (vertical v. horizontal approach). The recognition of multiple-morbidity has been realised to an extent within hospital casemix classification systems, and in population classifications such as the ACG and DxCG systems.

26. The Problem (2) Increased policy recognition of individuals with chronic health needs The Pathway approach to health care provision presents a model of health care from a particular disease or treatment perspective vertical v. horizontal approach Recognition of multiple-morbidity has been realised within hospital casemix classification systems, in population classifications such as the ACG and DxCG systems. There are a number of issues to be addressed to classify a population with respect to healthcare needs and interventions. The cost of data collection can be very high relative to the cost of the activities being measured, and it becomes important to utilise existing data collections. The episode or period of care to be measured (e.g. hospital care episode, disease episode, need based record, annual care record) highlights the need to have unique patient numbers to allow tracking between events, different provider organisations and different commissioning agencies. This is also being highlighted with the increased policy recognition of individuals with chronic health needs. The Pathway approach to health care provision is often referenced but does appear to often present a model of health care from a particular disease or treatment perspective (vertical v. horizontal approach). The recognition of multiple-morbidity has been realised to an extent within hospital casemix classification systems, and in population classifications such as the ACG and DxCG systems.There are a number of issues to be addressed to classify a population with respect to healthcare needs and interventions. The cost of data collection can be very high relative to the cost of the activities being measured, and it becomes important to utilise existing data collections. The episode or period of care to be measured (e.g. hospital care episode, disease episode, need based record, annual care record) highlights the need to have unique patient numbers to allow tracking between events, different provider organisations and different commissioning agencies. This is also being highlighted with the increased policy recognition of individuals with chronic health needs. The Pathway approach to health care provision is often referenced but does appear to often present a model of health care from a particular disease or treatment perspective (vertical v. horizontal approach). The recognition of multiple-morbidity has been realised to an extent within hospital casemix classification systems, and in population classifications such as the ACG and DxCG systems.

27. Discussion Existing data sources exist to review the classification of the individual survey data, morbidity/findings, pharmacy use (prescriptions). Exploitation of these data can prove to be cost effective. Where family doctor data exists, need to increase the quality and consistency of recording For example the use of prescribing data can increase the recognition of particular diseases in data not registered in clinical findings. Existing data sources exist to review the classification of the individual, such as survey data, health morbidity findings and pharmacy use (prescriptions). The exploitation of these data can prove to be cost effective. Where family doctor data exists, there is a need to increase the quality and consistency of recording. For example the use of prescribing data can increase the recognition of particular diseases in data not registered in clinical findings. Whilst there has been work undertaken in the WHO to classify function (ICF) there is little evidence that this system is being implemented, except in areas of rehabilitation services. Again whilst initially hospital focused these systems are being adapted to include hospital-at-home. The medical design of many systems does present a problem with the recognition of social service interventions; however a greater problem exists where the responsibility for care to an individual exists across multiple agencies and government departments. The introduction of direct payments to individuals is a policy area particularly prevalent in northern Europe which forces the need to integrate funding across multiple providers and agencies to recognise the needs of an individual. It also requires a single point for coordinating care and information for an individual.Existing data sources exist to review the classification of the individual, such as survey data, health morbidity findings and pharmacy use (prescriptions). The exploitation of these data can prove to be cost effective. Where family doctor data exists, there is a need to increase the quality and consistency of recording. For example the use of prescribing data can increase the recognition of particular diseases in data not registered in clinical findings. Whilst there has been work undertaken in the WHO to classify function (ICF) there is little evidence that this system is being implemented, except in areas of rehabilitation services. Again whilst initially hospital focused these systems are being adapted to include hospital-at-home. The medical design of many systems does present a problem with the recognition of social service interventions; however a greater problem exists where the responsibility for care to an individual exists across multiple agencies and government departments. The introduction of direct payments to individuals is a policy area particularly prevalent in northern Europe which forces the need to integrate funding across multiple providers and agencies to recognise the needs of an individual. It also requires a single point for coordinating care and information for an individual.

28. Cardiovascular Distribution

29. GP diagnosisCoding and Drug prescribing with the exception of congestive heart failure, many chronic diseases have lower treatment prevalence for the PCT compared to the US (absence of diagnosis coding by GP is a possible explanation for this finding) diseases with a lower diagnosis rate for the PCT compared to the US : hypertension, hyperlipidemia, congestive heart failure diseases with a higher diagnosis rate for the PCT compared to the US : depression, asthma special case for diabetes: similar diagnosis rates for the PCT and the US, but lower prescribing rate for PCT with the exception of congestive heart failure, many chronic diseases have lower treatment prevalence for the PCT compared to the US (absence of diagnosis coding by GP is a possible explanation for this finding) diseases with a lower diagnosis rate for the PCT compared to the US : hypertension, hyperlipidemia, congestive heart failure diseases with a higher diagnosis rate for the PCT compared to the US : depression, asthma special case for diabetes: similar diagnosis rates for the PCT and the US, but lower prescribing rate for PCT

30. Sometimes Headlines can help

31. Discussion (2) Medical orientation of data, a problem with the recognition of social service interventions A greater problem exists where the responsibility for care to an individual exists across multiple agencies and government departments The introduction of direct payments to individuals is a policy area particularly prevalent in northern Europe which forces the need to integrate funding across multiple providers and agencies to recognise the needs of an individual It also requires a single point for coordinating care and information for an individual.

32. Problems & Challenges Healthcare System Scope of non secondary care Inter-agency working Cultural differences between and within Countries Patient Identification Environmental/Social Factors ADL, Living alone, Rurality, Individual and community deprivation

33. Lessons Do not wait for it to be 100%, implementation leads to increased recording Watch for policy changes leading to recording changes E.g. QOF, ?Ca referrals Recording of what is relevant to the individual now, despite the diagnoses being made years before Fee For Service without checks on population view will lead to increased provision in traditional areas (Efficiency � Technical v Allocative) Start in Silos, but look across or leads to an effective barrier to integrated care Take a patient eye view of the healthcare system Integrated Health Care

34. Conclusions (1) International trend towards casemix based payments systems for admissions to hospital. Systems to contain costs, provide a transparent or simplified basis for reimbursement, equality of payment to competing providers. This move away from global budgets is also now extending to ambulatory services, but being retained for essential and national services There are an increasing number of initiatives to introduce patient level information for budgets based on population need Important to recognise need as distinct from utilisation There is an international trend towards the use of casemix based payments systems for admissions to hospital. These systems are brought in to contain costs, provide a transparent or simplified basis for reimbursement and give equality of payment to competing providers. This move away from global budgets is also now extending to ambulatory services, but being retained for essential and national services. There are an increasing number of initiatives to introduce patient level information to reimburse or budget based on needs of the population. In primary, community and social care, the international trend shows greater autonomy with systems being heavily regulated under central government, with increased policies to support client/patient choice. There is increasing information collection regarding the comprehensive health and social status of populations, and the recording to support regulation of the providers of services to patients and clients in their own homes. There increased discussion over measuring outcomes and also utilising pathways of care, however with increased recognition of the issue of individuals with multiple-morbidity it is essential for the activities and needs of individuals to be recorded to ensure adequate and alternative provision can be considered.There is an international trend towards the use of casemix based payments systems for admissions to hospital. These systems are brought in to contain costs, provide a transparent or simplified basis for reimbursement and give equality of payment to competing providers. This move away from global budgets is also now extending to ambulatory services, but being retained for essential and national services. There are an increasing number of initiatives to introduce patient level information to reimburse or budget based on needs of the population. In primary, community and social care, the international trend shows greater autonomy with systems being heavily regulated under central government, with increased policies to support client/patient choice. There is increasing information collection regarding the comprehensive health and social status of populations, and the recording to support regulation of the providers of services to patients and clients in their own homes. There increased discussion over measuring outcomes and also utilising pathways of care, however with increased recognition of the issue of individuals with multiple-morbidity it is essential for the activities and needs of individuals to be recorded to ensure adequate and alternative provision can be considered.

35. Conclusions (2) Primary, community and social care, the international trend shows increased regulation (supporting quality), with increased policies to support client/patient choice Increasing information collection, need for standards Increased policy discussion over measuring outcomes and pathways of care, need to avoid bias recording A need to look at both sides of the health equation, Health Resource and Health Need Recognising the Morbidity burden of the individual is important, with next step to recognise social care needs There is an international trend towards the use of casemix based payments systems for admissions to hospital. These systems are brought in to contain costs, provide a transparent or simplified basis for reimbursement and give equality of payment to competing providers. This move away from global budgets is also now extending to ambulatory services, but being retained for essential and national services. There are an increasing number of initiatives to introduce patient level information to reimburse or budget based on needs of the population. In primary, community and social care, the international trend shows greater autonomy with systems being heavily regulated under central government, with increased policies to support client/patient choice. There is increasing information collection regarding the comprehensive health and social status of populations, and the recording to support regulation of the providers of services to patients and clients in their own homes. There increased discussion over measuring outcomes and also utilising pathways of care, however with increased recognition of the issue of individuals with multiple-morbidity it is essential for the activities and needs of individuals to be recorded to ensure adequate and alternative provision can be considered.There is an international trend towards the use of casemix based payments systems for admissions to hospital. These systems are brought in to contain costs, provide a transparent or simplified basis for reimbursement and give equality of payment to competing providers. This move away from global budgets is also now extending to ambulatory services, but being retained for essential and national services. There are an increasing number of initiatives to introduce patient level information to reimburse or budget based on needs of the population. In primary, community and social care, the international trend shows greater autonomy with systems being heavily regulated under central government, with increased policies to support client/patient choice. There is increasing information collection regarding the comprehensive health and social status of populations, and the recording to support regulation of the providers of services to patients and clients in their own homes. There increased discussion over measuring outcomes and also utilising pathways of care, however with increased recognition of the issue of individuals with multiple-morbidity it is essential for the activities and needs of individuals to be recorded to ensure adequate and alternative provision can be considered.

36. Thank You! steve@sutchconsulting.com