Variation
V
i ti in
i Medicaid
M di id Managed
M
d Care
C
Emergency
g
y Department
p
Discharge
g
among Members with Asthma
Sally Turbyville, MA, MS
Robert Saunders, PhD
June 2010
Academy Health ARM, Boston
28 June 2010
1
Today’s Objectives
• Research Question
• Study Design
– Measure Descriptions
– Design
• Principal
p Findings
g
• Limitations
• Implications Going Forward
Academy Health ARM, Boston
28 June 2010
2
Research Question
• Is there a relationship between
– quality
lit off care and
d resource use…
– for treatment of patients with asthma…
– in Medicaid HMOs
• Quality: Percent of patients with
“persistent asthma” that receive a
“
“preferred
f
d asthma
th
therapy
th
medication”
di ti ”
• Resource use: Risk adjusted
j
rate of
ambulatory ED use per 1000 member
years (i.e.,
(i e discharged to community)
Academy Health ARM, Boston
28 June 2010
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Why This Study?
• ED use is an important driver of cost of
care and often an inappropriate setting,
setting
especially for children (IOM, 2006a,b).
• Asthma is a condition that can be
managed effectively without ED use
• Asthma is a prevalent and costly
condition
diti
for
f Medicaid
M di id and
d society
i t
– $1.8b/yr
y direct treatment ((Gergen,
g
2001))
– 7.2m days of lost productivity, $1.2b/yr
(http://www.ncqacalculator.com/)
Academy Health ARM, Boston
28 June 2010
4
NCQA’s Experience: Quality
• An established quality measure
–A
Ages 5-56
5 56 (5-9,
(5 9 10
10-17,
17 18
18-56)
56)
– In 2008, the average commercial plan
provided appropriate asthma treatment 92%
of the time (NCQA, 2009)
– We expect higher quality implies less ED use
(patient’s asthma is managed
(p
g
and does not
progress to emergent level)
Academy Health ARM, Boston
28 June 2010
5
NCQA’s Experience: RRU
• NCQA’s Relative Resource Use (RRU)
measures compare a plan’s observed
utilization rate to their expected utilization
for select chronic diseases (indexed O/E)
– Indirect standardization
– Risk adjusted by age, gender, presence of
select comorbid conditions
– For ED, we collect ED visits because of
inconsistent billing practices (other services
we convert to dollars using standard prices)
Academy Health ARM, Boston
28 June 2010
6
Health Plans Can Impact Costs
Health Plan Functions
Disease Management
Wellness Programs
Benefit Design
Network Design
Reimbursement Policy
Provider Contracting
Results
Utilization
Unit Price/Discount
RRU Focus
Premium
Admin. costs, Strategic considerations, etc
Academy Health ARM, Boston
28 June 2010
7
Population Studied
• 74 Medicaid HMO plans (out of 163)
– Submitted
S b itt d both
b th quality
lit and
d RRU HEDIS
• Excludes plans with < 30 asthma cases (n=28)
• Excludes plans that elect not to report RRU
– Members with asthma continuously enrolled
in same plan for at least 22 months across
2008 and 2007
• A very select group of members but…
• Can’t blame discontinuity
y for p
performance
– 60% of cases under age 18
Academy Health ARM, Boston
28 June 2010
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Box Plot, Asthma Quality & ED RRU (n=74)
ED Index O/E
Quality Index
0
.5
1
1.5
2
HEDIS 2009, Medicaid HMO data
Academy Health ARM, Boston
28 June 2010
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.05
Density
y
.1
.15
.2
Histogram, Asthma Quality (n=74)
0
 = 89.1
80
85
90
95
Asthma Quality (%)
HEDIS 2009, Medicaid HMO data
Academy Health ARM, Boston
28 June 2010
10
.5
nsity
Den
1
1
1.5
Histogram, ED RRU (n=74)
0
 = 1.00
0.00
0.50
1.00
1.50
2.00
ED RRU Index O/E
HEDIS 2009, Medicaid HMO data
Academy Health ARM, Boston
28 June 2010
11
Principal Findings
• Despite similar, high levels of quality,
there is substantial variation in ED utilization
among plans
• Plans with higher quality were associated with
lower ED use among these members
(-0.3322, p<0.004).
– similar pattern for commercial plans
Academy Health ARM, Boston
28 June 2010
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Asthma Quality & ED RRU (n=74)
1.30
High Quality, Low Use
High Quality, High Use
1.20
Quality
1.10
1.00
 = -0.3322
0.90
p < 0.004
0.80
Low Quality, Low Use
Low Quality, High Use
0.70
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
Relative Resource Use
HEDIS 2009, Medicaid HMO data
Academy Health ARM, Boston
28 June 2010
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Limitations
• Cross-sectional data, so causality is weak
• Voluntary reporting of RRU
• Measures are restricted to members
continuously enrolled in Medicaid for 2yr
• Measures
M
are restricted
t i t d to
t ambulatory
b l t
ED
visits (i.e., not admitted to inpatient)
– Complex sorting/selection process
Academy Health ARM, Boston
28 June 2010
14
Going Forward
• 4th year of collecting plan-level data in
commercial Medicare and Medicaid
commercial,
• This y
year NCQA will p
publicly
y report
p
its RRU
measures for commercial plans
– Expect to report Medicaid and Medicare in
future years
– With public reporting
reporting, we expect plans will
address their own excess utilization
– Working
ki
tto improve
i
our RA methodology
th d l
(address more comorbid conditions)
Academy Health ARM, Boston
28 June 2010
15
Going Forward
• Plans can “slice-and-dice” their own data
– Plans have received and will continue to
receive from NCQA O/E ratios for reporting
cohorts (i.e.,
(i e risk adjustors)
• Are there members who require case management
due to complex comorbidities?
• Are there other interventions for the sub-population?
– They still have the underlying data,
data too
• There may be limits to plan actions
– Are these ED visits “money makers” for
p
Hospital
p
market p
power issues?
hospitals?
Academy Health ARM, Boston
28 June 2010
16
References
• Gergen PJ. (2001). Understanding the economic burden
of asthma. J Allergy
gy Clin Immunol,, 107:S445-8.
• IOM. (2006a). Emergency care for children: Growing
pains. Washington, DC: National Academy of Sciences.
• IOM. (2006b). Hospital-based emergency care: At the
breaking point. Washington, DC: National Academy of
Sciences.
• NCQA. (2009). State of health care quality 2008.
W hi t
Washington,
DC:
DC N
National
ti
lC
Committee
itt
for
f Quality
Q lit
Assurance.
Academy Health ARM, Boston
28 June 2010
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Contact
• Robert Saunders, PhD
Research Scientist,
Scientist NCQA
saunders@ncqa.org
202-955-3500
Academy Health ARM, Boston
28 June 2010
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