Measuring the Quality of Pennsylvania’s Commercial HMOs

1. Measuring the Quality of Pennsylvania’s Commercial HMOs Joe Martin Director of Communications and Education Pennsylvania Health Care Cost Containment Council

3. “Knowledge is two kinds:” “We know a subject ourselves, or we know where we can find information upon it.” Samuel Johnson – Author (1709-1784)

4. Wall Street Journal • Due to the Council, Pennsylvanians can get far more information about their hospitals than can most Americans.

5. Commercial HMO Report • Combines clinical outcomes, prevention measures and member satisfaction information

6. Why is Pennsylvania’s HMO Report unique? • Linked hospitalization data to health plan data using: • NCQA data • Clinical data • Established collaborative relationship with health plans which participated in data verification. • Analyzed preventive measures (HEDIS) against outcomes (hospitalization rates) to test for statistical significance.

7. PA HMO Enrollment Enrollment growth in the early 1990’s tapered off beginning in 1998.

8. Why Look at HMOs 2001 • Fourth highest state HMO enrollment – approximately 4 million * • Strong managed care penetration in PA – approximately 35% * • Gatekeeper managed care plans emphasize preventive care activities * Source is Henry J. Kaiser Family Foundation State Health Facts Online

9. HMO Report: HEDIS Measures - Childhood Immunizations - Timely Prenatal Care - Beta Blockers after Heart Attack - Mental Health Services - Antidepressant Medication Management - Control of High Blood Pressure - Appropriate Medication, Members with Asthma

10. HMO Report: HEDIS Measures Diabetes - Hemoglobin A1c Levels - Hemoglobin A1c Tests - Eye Exam - Monitor for Kidney Disease - Control Bad Cholesterol Screenings - Breast Cancer - Cervical Cancer - Cholesterol Post Acute Cardio Events - Bad Cholesterol Controlled Post Acute Cardio Events

11. Hemoglobin A1c Blood Tests for Members with Diabetes

12. Ambulatory Sensitive Conditions • Ear, Nose and Throat Infections • Pediatric or Adult • High Blood Pressure • Gastrointestinal Infections • Kidney/Urinary Tract Infections • Hospitalization Rates

13. Gastrointestinal Infections(Per 10,000)

14. Preventive Care Measures • COPD • Asthma • Diabetes • Mental Health • Heart Attack

16. Surgical Procedures • Hysterectomy • Breast Cancer • Neck and Back • Prostatectomy

17. Neck and Back Procedures

18. Selection of Clinical Conditions • Degree of manageability by an HMO • Preventing Hospitalization • Managing On-Going Illness • Appropriateness of Surgical Procedures • Significant risk and cost factors • Health issues important to purchasers and consumers

19. Clinical Outcome Measures • Outcome measures reviewed included: • Readmission Rates • In-hospital Mortality • Complication Rates • Length of Stay

20. Member Satisfaction • Getting Needed Care • Getting a Referral to a Specialist • Customer Service • Overall Rating • Accreditation Status

21. Report Highlights • For the fourth consecutive year, Pennsylvania HMOs achieved higher member satisfaction rates than the national average. • 86% of members reported no problems in receiving care they felt they needed.

22. Report Highlights • For the second consecutive year, Pennsylvania HMOs improved their results in all 15 preventive care measures in the report and outperformed their national counterparts in these categories.

23. Report Highlights Surgical Procedures • Complications After Surgery – More Likely for HMO Members than those in fee-for-service plans

24. Report Highlights Surgical Procedures • Reconstruction Surgery – There continues to be significant variation in breast reconstruction surgery following mastectomy among the HMOs

25. Report Highlights Studies have cited the following possible reasons for such differences: • Variation in preoperative counseling • Surgeon preferences • Availability of trained surgeons • Patient preferences • Practice patterns

26. Report Highlights Surgical Procedures • Hysterectomy Between 1998 – 2001 Procedure rate for all hysterectomies increased from 42.7 to 55.8 per 10,000 female members Complications rates for both abdominal and vaginal hysterectomies decreased

27. Report Highlights Surgical Procedures • Hysterectomy 2001 Abdominal procedure* more likely than vaginal procedure for HMO Members than for those in fee-for service plans (*higher length of stay and complication rate)

28. Report Highlights • The study statistically shows a correlation between well-controlled blood pressure levels and lower hospitalization rates. • Overall hospitalization rates for diabetes decreased which may also suggest that HMO prevention measures are having a positive effect.

29. Disease Management Value to the benefits purchaser: • Helps control costs associated with chronic diseases • Increases employee productivity • Fewer days of lost work time

31. Conclusions • Wide variations in rates and preventive care measures suggest an uneven approach to disease management. • PHC4’s data shows that better preventive and primary care helps patients avoid unnecessary trips to the hospital. • The cost implications could have a major impact on the health care delivery system.

33. “We want to use indicators that are fairly well accepted.” Among those sources are statistics gathered by Pennsylvania Health Care Cost Containment Council, a state agency that collects and analyzes information related to the performance of hospitals in the state. Sept. 13, 2002

35. HMO Report Distribution 1998 HMO Report:  3,000 1999 HMO Report:  8,000 2000 HMO Report:  7,500 2001 HMO Report:  23,800

36. HMO Report Web Downloads HMO 2001 Data = 14,605 - Released March 2003 HMO 2000 Data = 130,569

37. The Web - WWW.PHC4.Org New Interactive Databases Easy Access to PHC4’s Free Public Reports DownloadablePDF Files New Purchaser Section

38. Create Your Own Reports on the Web

39. For more information on PHC4: 225 Market Street, Suite 400 Harrisburg, PA 17101 (717) 232-6787 www.phc4.org