The Relationship between Chronic
Illness Care Quality and Current and
F t
Future
Resource
R
Use:
U
A
An application
li ti
of NCQA’s HEDIS Relative Resource
Use (RRU) and Quality Measures
Academy Health Annual Research Meeting
June, 2010
Overall Project: Comparing Medicare Advantage Health Plan
Efficiency with Medicare FFS using NCQA’s
NCQA s HEDIS Relative
Resource Use (RRU) Measures
• Funding: RWJ Program on Changes in Health Care
Financing and Organization (HCFO)
• Grantee: University of Minnesota - Division of Health
Policy and Management // Collaborator: NCQA
• Project
j
Team: David Knutson,, MS ((PI);
); Beth Virnig,
g,
PhD (Co-PI); Schelomo Marmor, PhD candidate;
Jessica Zeglin, MS // NCQA: Sarah Scholle, PhD;
R b tS
Robert
Saunders,
d
PhD
PhD; S
Sally
ll T
Turbyville,
b ill MS
(Currently with the National Quality Forum)
Today’s Presentation: Results from Phase One
• Phase One Objective: Examine MA health plan
performance characteristics and the relationship between
quality and resource using health plan reported HEDIS
quality and RRU measures for performance years 2007
and 2008
• Phase Two Objective:
j
Compare
p
resource use and q
quality
y
of MA plans with Medicare FFS using health plan reported
HEDIS quality and RRUs measures and quality and RRUs
measures computed on a Medicare FFS claims using a
national Chronic Care Warehouse (CCW) sample from
2007-2008
Presenter: Schelomo Marmor
Research Objectives
• Use of Healthcare Effectiveness Data
and Information Set (HEDIS) quality
measures and Relative Resource Use
measure (RRUs) to determine the
relationship
l ti
hi between
b t
quality
lit and
d costt for
f
Medicare patients with diabetes
• To determine whether prior quality
performance predicts future resource
use
Methods: Data and Analysis
• Data/Population
• Measures
• Analysis
Population
• Data submitted by
y Medicare managed
g care p
plans
for reporting years 2007 and 2008 (based on
2006 and 2007 experience)
• Three NCQA Comprehensive Diabetes Care
HEDIS quality indicators- percentage of
individuals with diabetes who had evidence of:
(1) annual glycosyated hemoglobin (A1c)
screening
(2) low-density lipoprotein (LDL) screening
(3) retinal eye exams performed
Relative Resource Use (RRU) Measures
• RRU measures,
measures calculated by NCQA
NCQA, for
reporting plans for year 2007 and 2008
• RRU costs reported separately for:
Evaluation and Management (EM) services
Inpatient
p
Facility
y ((IP)services
)
Surgery
Pharmacy services
Analysis
y
• In total 141 plans reported HEDIS quality
measures and RRUs for both 2007 and
2008 which had no more than one missing
quality or RRU variable were included
• Pearson and Spearman rank correlations
were calculated for quality and RRU
measures to determine the stability of the
relationships across the measures in a
given yyear
g
Analysis
• A linear regression model was used to
predict the relationship between quality
in 2007 and resource use in 2008
• All models controlled for plan type,
comorbidities and region
• A sensitivity analysis confirmed that
results were stable across a variety of
minimum plan sizes
Does HEDIS Qualityy Change
g from Year to Year?
Basic HEDIS Characteristics: 2007-2008
Median HEDIS Quality Measures: 141 Plans
HbA1c Screening
2008
LDL-C screening
2007
Eye exams
0%
10%
20%
30%
40%
Median eligible plan size: 2,272
50%
60%
70%
80%
90%
100%
Does Resource Use Change from Year to Year?
Basic RRU Characteristics 2007-2008
Median RRU Measures: 141 Plans
EM
2008
IP
2007
Surgery
Pharmacy
$0
$50
$100
$150
$200
$250
$300
$350
Do HEDIS Quality
y Measures Correlate?
Results: Correlation Table 2007
2007 HEDIS Quality Measure (%)
HbA1c Test
2007 HEDIS
Q lit
Quality
Measure (%)
HbA1c Test
LDL-C Screen
Eye Exam
* p-value <0.0001
† p-value <0.05
LDL-C
Screen
Eye
Exam
1
0.6964
1
0.7751*
0.7751
0.5673*
0.5673
1
Do RRU Measures Correlate?
Results: Correlation Table 2008
Relative Resource Use Standard Cost 2008 (% PMPM)
E&M
Relative
Resource Use
Standard Cost
2008
($ PMPM)
E&M
Surgery
Pharmacy
1
IP
0.4279*
1
Surgery
0.3029†
0.2649†
1
0.0797
0.1429
-0.159
Pharmacy
* p-value <0.0001
† p-value <0.05
IP
1
Does 2007 Quality Predict 2008 Resource Use?
Results: Correlation Table 2007-2008
2007 2008
HEDIS Quality Measures
2007 (%)
HbA1c LDL-C Eye
Test
Screen Exam
HEDIS
Quality
Measures
2007 (%)
Relative
Resource
Use
Standard
Cost 2008
($ PMPM)
Relative Resource Use Standard Cost 2008
(% PMPM)
E&M
IP
Surgery
Pharmacy
HbA1c
Test
LDL-C
Screen
Eye Exam
1
E&M
- 0.278† - 0.139
- 0.16
1
IP
- 0.225† - 0.31†
- 0.035
0.4279* 1
Surgery
- 0.0366 - 0.021
0.167
0.30†
0.265† 1
Pharmacy
- 0.0919 - 0.118
0.001
0.0797
0.1429 - 0.16
0.6964
1
0.7751*
0.5673* 1
* p-value <0.0001 † p-value <0.05
1
What Does a 1% increase in Quality Save PMPY for a
Median Size Plan?
Relationship between Previous Performance and Current Cost
($ PMPY per Percentage increase in test rate)
2007 Q
Quality
lit P
Performance
f
T ti %)
Testing
2008 C
Costs
t
HbA1C
LDL-C
Eye
EM
$-8.16†
$-9.84†
$-1.92
IP
$
$-22.32
$
$-61.92†
$
$-13.20
Surgery
$1.68
$-7.68
$-5.16
Pharmacy
$5.52
$-12.96
$-6.36
($ PMPY)
* p-value <0.0001
† p-value <0.05
Conclusions
• Higher quality in components of NCQA’s
comprehensive diabetes care seems to
predict lower subsequent resource use
• Increases in rates of HbA1C and LDL-C
testing appear to be most significantly
associated with decreased resource use
• Broader relationship between quality of care
and resource use remains complex
Policy Implications
• The first explicit test of correlation
between quality and cost points to highb t imperfect-correlation
but
i
f t
l ti b
between
t
RRU
and HEDIS Quality measures
• Deeper understanding of the resource
use inputs required for higher levels of
quality and the potential impact on
future resource use
Next Steps
• Geographical variation
• Could there be a way to compare
Medicare Advantage plans to
– Fee
F ffor S
Service
i
– Medicaid
– Commercial Plans
For More Information
Please contact:
Dave Knutson
Knutson, MS
Email: dknutson@umn.edu
@
Schelomo Marmor, M.P.H.
E il marm0014@umn.edu
Email:
0014@
d