Update on State APCD Public Reporting and Measurement

1. Update on State APCD Public Reporting and Measurement Barbara Rudolph, PhD, MSSW NAHDO Consultant

2. Project Aims Related to APCD Public Reporting • To enhance the value of statewide APCDs by cataloging measures and reporting practices • To develop and disseminate APCD reporting guidance with considerations for state APCD systems • To facilitate APCD planning and reporting activities across states thus reducing duplicative planning efforts

3. Information Gathering • Review APCD Council site • Review individual state APCD websites • General Web Search • Conference calls with State Work Group • Review of Reporting and Measures Table by workgroup

4. Findings: APCD Reports and Websites States with Public Reports • Maryland • New Hampshire • Utah • Vermont • Colorado (Planned) States with Websites • Maine • New Hampshire • Massachusetts • Washington • Colorado (Planned)

5. Measurement Scope of Measurement

6. Utilization Measures Covered by all APCDs—using different types of measures • Global—overall utilization, payer groups, health planning areas, service lines • Provider specific—Utilization of inpatient, outpatient, ED, observation, specialty, primary care, chiropractic, osteopathic, dental, pharmacy, imaging • Payer type—Utilization by Medicaid, SCHIP, CHIP, Medicare, Medicare Part D, Private payer, Employer • Procedures/Conditions—Number of high cost procedures and conditions, knee, lumbar, mental health, screenings (cholesterol, diabetes, kidney disease), prescriptions for specific conditions

7. Cost of Care Measures Most APCD’s address cost—(using different measures) • Cost to Payer—PMPM costs, high cost area, profile reports on medical, dental, pharmacy costs by payer, high cost distribution by plan product type, plan payments, plan costs by procedure, plan costs by health service area, aggregated costs for commercial population, payments per day and per day’s supply by major therapeutic categories of drugs • Cost to Patient—Total out-of-pocket cost, co-pays, co-insurance, deductible amounts, cost to uninsured vs insured, costs by procedure and by provider • Provider Cost—by specialty, standardized pricing, compared for units of service and mix of service • Cost by Procedure/Condition—measures for preventive health, ED Visit, radiology, common surgical procedures, maternity measures, CRG, Diagnosis, chronic conditions, pharmacy costs • Episode Cost—Burden of illness by CRG, diabetes, asthma depression

8. Quality and Reporting Measures Some APCD’s are reporting limited quality measures: • Use of tools like MONAHRQ for reporting quality measures • Use of NCQA (HEDIS) measures—for mental health and substance abuse, medical groups, hospitals • Use of some process measures for medical groups (LDL_C, HbA1C, eye exams, ) • Use of CMS measures for hospital care • Use of HCAPHS patient experience of care • Re-admission rates (both cost and quality)

9. Efficiency Measures Measures thought to address efficiency include: • Admission rates for ambulatory sensitive conditions • Rates for potentially avoidable ED visits • Costs per procedure by provider • Length of Stay • 30-day Readmission Rates • Variation in rates of imaging • Pharmacy payments by hospital service area presented as PMPM; payments per day’s supply by major therapeutic categories of drugs by HAS • Provider’s costs to others of the same specialty—costs by mix of ETG’s using standardized pricing

10. Population Health Measures • Prevalence of key chronic conditions • Admission rates for ambulatory care sensitive conditions • Geographic variations in utilization, cost and care • High Cost areas for Medicaid and Commercial populations • Trends in healthcare costs • Overall measures such as PMPM by geography • Percentage of total health care costs of the top five chronic conditions • Asthma billed medical costs and amounts paid by age group • Health screenings for chronic conditions in small areas • Variation in imaging rates across geography • Key contributors driving pharmacy payments • Provider access measures

11. State APCD Public Reports and Measure Types Draft Table

12. Observations on Reporting and Measurement

13. Observations on Reporting • APCD’s that are most developed in terms of public reporting are those that have had APCD systems longer… • New APCD’s have public plans for reporting, but because of data lag they are not yet reporting • States with mandatory reporting tend to do more public reporting • Voluntary collections are less likely to report publicly and those that do are more likely to use measures that do not distinguish between providers (e.g., process measures with 99% compliance) • Wide variation in number of reports and, whether or not there is a “choice” website for the public, and utility of reporting

14. Observations on Measurement • Large range of measures in use—when you see one of a kind measures—it is likely due to particular stakeholders • Population health measures are plentiful; mainly utilizing geographic variation to examine prevalence of disease, access to care • Certain types of measures are more expensive to produce—require risk adjustment or diagnostic/episodic groupers ; episode measurement very limited—due to complexity of decision rules, software, provider push back and other factors • Quality measures are also limited given the availability of hundreds of endorsed measures—likely due to a focus on costs by stakeholders • Some quality measures in use have little or no variation across providers—and therefore, very little utility • Because of limitation on quality measures and episode measures—efficiency measures are also lean. No composite measures of efficiency in use. • At this time, it would be very difficult to create benchmarks or to do regional/national analyses given the lack of consistency in measures used by APCDs

15. Next Steps: Crossing Boundaries • Transparency boundaries for voluntary collections • Complex analytic boundaries for established APCDs • Standardization Boundaries for all!

16. How we plan to help… • Provide a guidance document • Provide a completed Table of Measures • Provide a Knowledge Base Tool (when funding is available)