Challenges in Coordination of Health Care Services

1. Challenges in Coordination of Health Care Services Stacey EcclestonDivision of Health Care Finance and Policy June 30, 2011

2. Overview • Describe factors associated with 3 indicators that suggest the need for improved care coordination • Preventable hospitalizations • Potentially preventable re-admissions • Avoidable emergency department (ED) visits • Assess potential savings associated with each of the 3 areas • Provide results of recent community health center efforts aimed at reducing avoidable ED visits

3. Why analyze preventable hospitalizations and readmissions and avoidable ED visits? • Avoidable ED use, preventable hospitalizations, and potentially preventable readmissions may be an indicator of barriers to accessing appropriate primary care. • Differences in these indicators by geographic area and/or socio-economic factors inform us about needs for better care coordination that may exist for certain populations. • Avoidable ED visits and preventable hospitalizations and readmissions lead to excess costs and present an opportunity for savings. • Greater emphasis on primary care, patient-centered models, and patient education may help reduce avoidable ED visits and preventable hospitalizations and readmissions , and may help to mitigate cost growth over time.

4. Definitions, data sources, and methods • Preventable hospitalizations (PHs) are the inpatient treatment of conditions for which outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease. Data/Method:AHRQ “Prevention Quality Indicators”. • Potentially preventable re-admissions (PPR): A subsequent hospitalization within 30 days that is determined to be clinically related to the initial hospitalization. Data/Method: 3M PPR methodology. • Avoidable emergency department (ED) visits:ED visit that is not urgent, urgent but primary care treatable, or urgent but preventable condition. Data/Method: Avoidable categories are based on the Billings algorithm as published by AHRQ as modified by DHCFP. • All 3 measures use DHCFP Hospital Discharge Databases for FY2009

5. Estimated costs associated with potentially preventable events was nearly $2 billion* in FY2009 *Much of the estimated costs could be realized in system savings

6. 12% of adult inpatient admissions in MA were potentially preventable in FY09 ($719M)Preventable and Non-Preventable Inpatient Admissions for MA residents age 18+, FY09 Adult Inpatient Hospitalizations: 697,607 Non-PHs: 87.7% of inpatient hospitalizations $7.2B PHs: 12.3% of inpatient hospitalizations $719M *Non-Preventable Hospitalizations (Non-PHs) are inpatient hospitalizations that are for conditions that are not considered ambulatory care sensitive. **Adult inpatient population is defined as those age 18+ (this group represents 85% of total inpatient hospitalizations for all ages).

7. Congestive heart failure and bacterial pneumonia are most common PHs in FY09 Percent of Total PHs by Condition, FY09 Total Preventable Hospitalizations: 85,579 Acute conditions Chronic conditions

8. Massachusetts PH rates are lower than the nation for 9 of 12 conditions in FY09 Risk Adjusted Admission Rates per 100,000 Population for Individual PH Conditions, FY09; MA and U.S. Data for U.S. rates are from National Healthcare Quality Report AHRQ Prevention Quality Indicators applied to the 2007 HCUP State Inpatient Databases, March 2010. U.S. data presented here is available at http://hcupnet.ahrq.gov/. Overall PH rates were not available.

9. 17% of hospitalizations among Medicare patients were considered preventable in FY09 PH Admissions as a Percentage of Total Hospitalizations by Payer Type *All other payer includes: Worker’s compensation, other government payer, auto insurance, and missing or invalid payer data

10. Potentially preventable readmissions (PPR), FY2009 • There were 54,179 readmission chains out of the 610,779 hospital admissions determined to be at risk for readmission • Statewide PPR rate = 8.9% • The PPR rate for medical conditions was 11.1%, higher than the PPR rate for surgical conditions at 8.0%. • Range across hospitals was 5.6% to 13.9%, but most fell between 8% and 10%. • Estimated costs associated with the PPRs were $704 million in FY2009 • MA hospital readmission rates are higher compared to national rates for heart attack, heart failure, and pneumonia

11. Top PPR service lines *Charges are translated to estimated costs based on a cost to charge ratio of 48.5% for FY2009 Several “service lines” had PPR rates that were above the statewide average rate. The following service lines which had the highest PPR rates accounted for almost $117 million in estimated hospital costs.*

12. Little difference in PPR rates by payer, region, and hospital status • PPR rates were similar across admissions by various payers (somewhat lower for Medicare and Medicaid compared to commercial payers). • There were no appreciable differences in PPR rates across the statewide EMS regions (rates ranged from 8.4% to 10.0%) - Lowest for Boston metro area and highest for Western EMS. • The average PPR rate for teaching hospitals was marginally lower (8.6%) than the average PPR rate for community hospitals (9.0%). • The average PPR rate for Disproportionate Share Hospitals (DSHs) was marginally lower (8.6%) than the average PPR rate for non-DSHs (9.0%).

13. Nearly 50% of outpatient ED visits in MA were considered preventable or avoidable, FY09 ($571M) Unclassified: 8.0% of ED visits Mental/Substance Abuse: 5.6% of ED visits Emergent: 38.5% of ED visits Preventable/Avoidable: 47.9% of ED visits

14. Categorizing preventable/avoidable ED visits: Definitions and volume by category Preventable or Avoidable Visits 1,152,464 (48% of outpatient ED visits) Non-Emergent (22% of visits) (18% of costs) Non-Emergent: Care was not required within 12 hours (e.g. sore throat) Emergent but Primary Care Treatable (20% of visits) (21% of costs) Urgent but Primary Care Treatable (PCT): The condition could have been treated in a primary care setting (e.g. infant fever) Emergent but Avoidable Condition (6% of visits) (6% of costs) Urgent but Preventable Condition: The urgency of the condition could have been avoided with better primary care (e.g. asthma flare-up).

15. Population adjusted ED visit rate was flat between 2008 to 2010 after increasing 2% per year from 2006 to 2007

16. Preventable/Avoidable ED visits decreased from 2008 to 2009; Significant increase for mental health visits Indexed Trend of Outpatient ED Visits in MA, FY06-FY09 Index: 2006=100

17. 5% of patients are frequent ED users, accounting for 21% of outpatient ED visits in FY09 Frequent users are defined as those patients with 5 or more visits in the fiscal year.

18. Medically underserved populations (MUPs) are consistently associated with higher preventable/avoidable ED visit rates, FY2008 Rate of Preventable/Avoidable ED visits per 1,000 population in designated Medically Underserved Populations (MUPs) (LI) = Low income , (H)= Homeless Population numbers are based on Clarita’s, Inc. annual estimates. *Source: U.S. Census Bureau State and County QuickFactshttp://quickfacts.census.gov/qfd/states/25/2537000.html

19. Commonwealth Care, Medicaid, and uninsured patients had highest proportion of ED visits considered preventable/avoidable Preventable/Avoidable visits as a proportion of the total ED visits for that payer, FY09

20. CMS Emergency Department Diversion Grant Program In 2008, the state received a $4.5 Million grant from CMS to fund an emergency department (ED) diversion program, with the following objectives: • Reduce use of EDs by Medicaid patients for non-emergent conditions • Improve access to urgent care at local CHCs • Improve access to on-going primary care for MassHealth beneficiaries • Educate MassHealth beneficiaries about the appropriate uses of EDs and CHCs • Determine cost savings to the MA health system as a result of diverting non-emergent ED visits to CHCs • Improve collaborative efforts between CHCs and community hospitals

21. Grant program scope and design The ED Diversion Grant Program was administered by Neighborhood Health Plan, and involved 17 CHC participants. The health centers implemented ED diversion initiatives in one or more of the following areas: • Expand hours of operation: Participating CHCs opened evening hours and/ or added Saturday hours • Expand capacity for urgent care and/ or primary care services: CHCs that implemented this type of intervention added additional hours, increased provider capacity during existing hours, or expanded physical space • Create medical home linkages: This type of intervention focused on strengthening the “medical home” concept through implementation of nurse triage systems and/ or care management strategies

22. Participating CHCs and intervention types

23. Most CHCs experienced a decrease in the proportion of ED visits considered non-emergent during grant period

24. Most CHCs experienced a decline in proportion of ambulatory care sensitive (ACS) ED visits during grant period

25. Estimated costs and savings for 22,114 total patient visits during grant period Estimated costs and savings are based on average Medicaid payment of $316 for emergency department visits and an average cost of $126 for a community health center visit in 2008.

26. For more information: www.mass.gov/dhcfp/costtrends