Study 1: “8 Company”-- MA (HMO) Plan Data and FFS 5% File in Same Local Areas

2. Study 1: “8 Company”-- MA (HMO) Plan Data and FFS 5% File in Same Local Areas

3. Study 2: Preliminary MA vs. FFS Based on AHRQ (HCUP) Admissions, 2006

4. Study 3: Added Two Large Multi-State For Profit MA HMO Plans (Total Plan/Areas = 18) Source: Working Paper: Comparisons of Utilization in Two Large Multi-State Medicare Advantage HMOs and Medicare Fee-for-Service in the Same Service Areas (December 11, 2009) http://www.ahipresearch.org/pdfs/MAvsFFS-CO9and10.pdf

5. Study 4: Percentage Difference in Risk-Adjusted Utilization Rates, Persons with Admissions, Medicare Advantage vs. FFS

6. Study 4: Preliminary Assessment of Issues and Concerns with State Hospital Discharge Datasets for MA vs. FFS Comparisons

7. Study 4: Example of Data Checking: Tests for Validity of (encrypted) Person IDs

9. Study 4: Sub-state Geographic Composition, Local Comparisons

10. Study 4: Sub-state Geographic Composition, PA 2007

11. PFFS Enrollees Per County, All Counties within a 100-Mile Radius of Philadelphia

12. Study 5: Percentage Difference in 30-Day Readmission Rates (Various Denominators), Medicare Advantage vs. FFS

13. Study 6. Readmission Rates in Medicare --FFS vs. MA

14. Study 6. FFS vs. MA (All Enrollees), with Risk Adjustment (DRG Based)

16. Cost Conference, March 2011

17. Conference conclusions 1) the need to focus on improved care for patients with chronic illnesses, whose health care needs drive most health spending 2) the potential for sophisticated contracts between health plans and health care systems to improve care for patients with chronic diseases while also slowing the growth of costs 3) the importance of systematically addressing costs throughout the health care system and across the country, not simply focusing on individual payers, providers, or government programs

18. BCBSMN/Fairview Historical Shared incentives for value creation Pay for Performance Reduce Cost of Care Earned Incentive Reduce Cost of Care Earned Incentive Reduce Cost of Care Earned Incentive Improve Quality Earned Incentive Improve Quality Earned Incentive Fee for Service Increase Guaranteed Improve Quality Earned Incentive Fee for Service Increase Guaranteed Fee for Service Increase Guaranteed Fee for Service Increase Guaranteed Year 1 Year 1 Year 2 Year 3 Incentive payment based on measurable improvements in cost, quality, outcomes

19. BCBSMN/Fairview Quality Measures Safety • Reduction of elective deliveries • Hospital associated DVT/PE Utilization • Preventable events: Complications, admissions, re-admissions • Lower back pain • Advanced care directives Chronic Illness • Diabetic care • Vascular care • Hypertension control Prevention and Wellness • Breast cancer screening • Colorectal cancer screening • Body Mass Index • Tobacco cessation Patient Integration • Depression

20. BCBSMN Historical Shared incentives for value creation Pay for Performance Reduce Cost of Care Earned Incentive Reduce Cost of Care Earned Incentive Reduce Cost of Care Earned Incentive Improve Quality Earned Incentive Improve Quality Earned Incentive Fee for Service Increase Guaranteed Improve Quality Earned Incentive Fee for Service Increase Guaranteed Fee for Service Increase Guaranteed Fee for Service Increase Guaranteed Year 1 Year 1 Year 2 Year 3 Incentive payment based on measurable improvements in cost, quality, outcomes

21. Fairview Health Services -- Demonstrating Outcomes: Bending the Cost Curve 21

22. Specific, Clinical Targets? • Preventable and unnecessary hospital readmissions. • Adverse safety events and healthcare acquired conditions. • Overuse of high-radiation CT scans where ultrasound or MRI would suffice. • Unmanaged poly-pharmacy in patients with chronic illnesses. • Overuse of cardiac stents absent heart attack (?) • Overuse of interventions related to prostate cancer (?)

23. Medicare FFS 2008 100% Inpatient Dataset

24. Same-Hospital Readmission Rates in Medicare Fee-for-Service, 2008, Hospitals with the Highest Numbers of Medicare FFS Admissions

25. Same-Hospital Readmission Rates in Medicare Fee-for-Service, 2008, Hospitals with the Highest Numbers of Medicare FFS Admissions

26. Same-Hospital Readmission Rates in Medicare Fee-for-Service, 2008, Hospitals with 4,000+ Admissions Ranked by CMI-Adjusted Readmission Rate

27. Same-Hospital Readmission Rates in Medicare Fee-for-Service, 2008, Hospitals with 8,000+ Admissions Ranked by CMI-Adjusted Readmission Rate

28. IP_100_2008 -- FFS Only; SGMT_NUM = 1; No Transfers; No Jencks; Select Hospitals -- Same Qtr, Any DRG, Same HRR Readmits

29. IP_100_2008 -- FFS Only; SGMT_NUM = 1; No Transfers; No Jencks; Select Hospitals -- Same Qtr, Any DRG, Same HRR Readmits

30. IP_100_2008 -- FFS Only; SGMT_NUM = 1; No Transfers; No Jencks; Select Hospitals -- Same Qtr, Any DRG, Same HSA Readmits

31. IP_100_2008 -- FFS Only; SGMT_NUM = 1; No Transfers; No Jencks; Select Hospitals -- Same Qtr, Any DRG, Same HSA Readmits

32. Readmission Rates by Hospital Service Area (Medicare FFS 5% Sample Files)

33. Healthcare Acquired Conditions, Never Events 1.       Foreign Object Retained After Surgery 2.       Air Embolism 3.       Blood Incompatibility 4.       Stage III and IV Pressure Ulcers 5.       Falls and Trauma • Fractures, Dislocations, Intracranial Injuries, Crushing Injuries, Burns, Electric Shock 6.       Manifestations of Poor Glycemic Control • Diabetic Ketoacidosis, NonketoticHyperosmolar Coma, Hypoglycemic Coma, Secondary Diabetes with Ketoacidosis, Secondary Diabetes with Hyperosmolarity 7.       Catheter-Associated Urinary Tract Infection (UTI) 8.       Vascular Catheter-Associated Infection 9.       Surgical Site Infection Following: • Coronary Artery Bypass Graft (CABG):  Mediastinitis • Bariatric Surgery:  Laparoscopic Gastric Bypass,  Gastroenterostomy, Laparoscopic Gastric Restrictive Surgery • Orthopedic Procedures: Spine, Neck, Shoulder, Elbow 10.   Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) • Total Knee Replacement, Hip Replacement §  Clostridium difficile Infections (CDI) §  Ventilator-associated Pneumonia (VAP) §  Methicillin-resistant Staphylococcus Aureus infection (MRSA).  V09.0  Infection with microorganisms resistant to penicillins.  MRSA is always a secondary diagnosis.  The diagnosis co-exists at the time of admission or develops during the stay.

34. Identifying HACs from Discharge Datasets, NY and CA 2008

35. Identifying HACs from Discharge Datasets, NY 2008

36. Supplemental Q&A Slides

37. Study 1 -- 8 MA Plans vs. FFS (5%), Compared Individually in the Same Counties • HMO enrollees only (MA) • 7 Non-profit, one Blue • 2005 and 2006 data (pooled) • 12 month enrollees, age 65-89 • Same counties • “CMS-Style” Risk Scores from age, sex, 70 HCCs, serious diagnoses, primary and secondary diagnoses, inpatient, outpatient, office • No Medicaid in FFS • FFS 5% sample file coding logics given to plans • 13 “potentially avoidable” admissions logic from AHRQ • Readmissions per enrollee, by DRG in same quarter

38. Study 1: Eight Company/FFS Sample Basics

39. Study 1: Eight Company/FFS Sample Basics (Continued)

40. Study 1: Eight Company/FFS Severe Diagnosis Rates and Risk Scores

41. Study 1: Eight-Company/FFS Severe Diagnosis Rates and Risk Scores (continued)

42. Age/Sex Risk Incremental Values

43. Disease Group Values (15 of 70 HCCs)

44. Criteria for Identifying Potentially Avoidable Admission for Bacterial Pneumonia

45. Study 2: California and Nevada (2006) HCUP Sample Basics

46. Study 4: Alternative Risk Adjustments

47. Study 6. Jencks (FFS) vs. MA

48. Study 6. Jencks (FFS) vs. MA

49. Study 5. Percentage Difference in Risk-Adjusted Readmission Rates (Various Definitions),Medicare Advantage vs. FFS

50. Studies 4,5,6: DRG-Based Risk Adjustment