2014
Total Cost
of Care Report
Comparison of Medical Group
Costs across Minnesota
To download the report and find more information visit: MNCM.org
Searchable results are available at our consumer-friendly website: MNHealthScores.org
MN Community Measurement 2014 Total Cost of Care Report
May 2015
MN Community Measurement is a catalyst for change; we
Every member of our community can benefit from this
drive improvement in our community’s health and health
information. Providers, purchasers and consumers need
care through public reporting of cost, quality and patient
reliable, consistent information on health care cost. Medical
experience information. We marked a significant milestone
groups can utilize it to compare themselves to other groups,
in that effort when we released the nation’s first statewide
and then reach out and learn from high-performing medical
Total Cost of Care (TCOC) results late last year.
groups. They can also use the detailed information about their
Reducing the cost
of health care is
a complex and
group’s particular cost breakdown to hone in on areas where
their costs are above the market average, allowing them to
target improvement initiatives.
urgent societal
The TCOC release also allows us to provide consumers
challenge that we
with actionable information in an unprecedented way
all must contribute
— by displaying all three aspects of the Triple Aim. Cost
toward — providers,
information is most valuable when paired with quality
patients, health
and patient experience results, providing consumers with
plans, employers,
a full-spectrum view of the care provided by medical groups.
policymakers and
others. The release
of the TCOC measure
is a critical first step
because it identifies
where variation
exists in cost and care, which allows medical groups to target
improvements and allows consumers to be more informed
about the cost of their care.
We know public reporting of quality and patient experience
results has helped patients and providers improve their care.
We expect we can have the same impact on health care cost
with the release of this information. However, we cannot
do this alone; our success relies on a multi-stakeholder,
collaborative model to identify the right measures and steps
for improvement. Our health care community should be
commended for working together to increase transparency
While we are the first to publicly report this information,
we are not the only community on this journey. Minnesota
is one of five communities participating in a project with
the Network for Regional Healthcare Improvement to
develop standardized methods that will allow total cost
of care information to be shared in communities across
the nation. We are excited to help move this conversation
forward nationally as well.
As we look toward the second year of Total Cost of Care
reporting later this year, we know our community must
continue to push ourselves — and, ultimately, the nation —
to achieve our shared goal of delivering the highest quality
care with the best patient experience for the most efficient
cost. To that end, we hope to evaluate year-over-year trends,
as well as how costs differ by community size, as part of the
second release.
of the cost of care and for using that information to improve
We look forward to deepening our partnership with many
the value of care. These conversations are not always easy,
of you as we continue along this critical path.
but the results are essential.
Sincerely,
Jim Chase
President, MN Community Measurement
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
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MN Community Measurement 2014 Total Cost of Care Report
2014 Total Cost
of Care Report
Report Preparation Direction
Tina Frontera, MHA
Chief Operating Officer
Technical Lead
Gunnar Nelson
Health Economist
Key Contributors
Tony Weldon
Project Manager & Data Analyst
Erin Ghere, MPP
Manager of Communications & Engagement
Direct questions or comments to:
Tina Frontera
612-454-4826
frontera@mncm.org
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© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Contents
Letter from the President
3
Introduction
6
Executive Summary
9
Analysis of Results
Statewide
10
By Region
20
By Type of Care
24
Pairing Cost and Quality
28
How to Use this Report
29
Future Plans
31
Acknowledgements
33
Medical Group Results
35
Appendices
Appendix 1: Data Sources and Collection
38
Appendix 2: Methodology
39
Appendix 3: Medical Group Report Sample
41
Appendix 4: Overview of Cost Information on MNHealthScores.org
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MN Community Measurement 2014 Total Cost of Care Report
Introduction
In 1960, just 6 percent of the nation’s gross domestic product was spent on health care; in 2013,
that number was 17 percent.i Worker contributions to employer-sponsored insurance premiums
increased an average of 81 percent between 2004 and 2014.ii Nearly 40 percent of Minnesota’s health
care spending in 2012 was through private health insurance, which is paid for largely by employers.iii
And current projections indicate that, without significant changes, Minnesota’s health care spending
will nearly double in the next decade and will account for about one of every five dollars of Minnesota’s
economic activity.iv
The amount spent on health care in Minnesota and nationally
have had the tools necessary to make adjustments within their
is growing; but that information is not new. Health care
practices to positively impact the overall cost of care.
experts, economists, policymakers and providers are
currently and have in the past attempted a variety of
methods to cut costs. Some, including many in Minnesota,
have been effective in curbing costs for particular types of
care or in particular markets. However, we have been unable
to truly assess whether those efforts add up to the societal
Similarly, health plans and employers that seek to incentivize
clinics and medical groups providing low-cost, high-quality
care only have data from their own members or employees
on which to base decisions. Without a larger view, they
struggle to impact health care cost in more systemic ways.
impact we need them to because we have not been able to
Finally, patients are beginning to demand cost information.
truly measure the cost of health care in Minnesota or the
In 2014, 80 percent of workers in employer-sponsored
United States.
health insurance plans had deductibles — up from 63
Without reliable, comparable and validated information,
providers, health plans, employers, patients and policymakers
cannot make informed decisions about how to reduce the
cost of health care.
percent just five years earlier.v As the burden of cost has
shifted more onto consumers, their appetite for health
care cost information has also increased. A recent study
concluded that more than half of Americans have sought
cost information prior to getting care, and one in five have
Clinics are not aware of what one another charges for services
compared prices across multiple providers before making
or are being paid by health plans. Thus, they don’t really
their care decision.vi
know where their practice stands on cost compared to others.
Additionally, when providers refer their patients to specialists
or other medical professionals, the costs incurred by their
patients at referral clinics are often unclear. Few providers
i
National Health Expenditure Accounts. Centers for Medicare and
Medicaid Services. http://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/NationalHealthExpendData/
NationalHealthAccountsHistorical.html. Viewed on March 18, 2015.
ii Gary Claxton, Matthew Rae, Nirmita Panchal, Anthony Damico, Nathan
Bostick, Kevin Kenwald and Heidi Whitmore. “Employer Health Benefit 2014
Annual Survey.” Henry J. Kaiser Family Foundation and Health Research and
Educational Trust. 2014.
6
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In 2011, MN Community Measurement (MNCM), alongside
stakeholders including providers, payers and consumers,
began development on a cost measure to fill the gap in
iii “Minnesota Health Care Spending and Projections, 2012.” Minnesota
Department of Health. June 2014. Page 6.
iv “Minnesota Health Care Spending and Projections, 2012.” Page 14.
v Claxton, et.al. “Employer Health Benefit 2014 Annual Survey.”
vi Claxton, et.al. “Employer Health Benefit 2014 Annual Survey.”
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
health care cost information. The group’s goal was noble, but
Our health care community has long been committed
extremely complex: to benchmark the per capita cost of care
to collectively improving the health of Minnesotans by
in order to control, or even reduce, it — thus making health
partnering to go further than any single entity could alone.
care more affordable for everyone.
In 1993, the Institute for Clinical Systems Improvement (ICSI)
To date, no one had been able to figure out how to
accomplish that goal. Determining the true cost of care had
been elusive for myriad reasons, including:
•
•
•
•
As these initiatives began to gain a foothold, the community
recognized it needed a consistent way to measure the
improvement. Thus, the idea of MNCM sprang forth in 2001
so the only central source is health insurance claims.
with the vision of reporting comparable data on the quality
There is no perfect way to attribute a patient’s costs
of health care in Minnesota. What began with a single
to one health care provider because patients often
measure and report on diabetes care in 49 ambulatory
move around.
care medical groups has expanded to the collection and
The actual amount paid for any given test, procedure or
Each patient is different and a few patients with
public reporting of more than 70 measures evaluating more
than 1,400 clinics, 535 medical groups and 140 hospitals in
Minnesota and neighboring communities.
high-cost medical conditions can swamp the entire
By 2011, MNCM had pioneered the collection and public
result. Thus, risk adjustment and outlier rules must be
reporting of quality and patient experience measures; a cost
employed — but what rules are fair for everyone?
measure would round out a Triple Aim-view of health care.
Medical services are reported by providers in different
ways: the price of a single procedure; the grouped price
for an “episode” of care; and the total cost of care for a
patient over a set amount of time.
•
committed to partnering to improve care across the state.
Patient medical records do not include cost information,
service varies by payer, network and moment in time.
•
was founded by multiple medical organizations that were
Additionally, MNCM had begun reporting the cost of about
60 common procedures, such as colonoscopies and certain
lab tests, two years earlier. Thus, our community had some
experience aggregating cost data for public reporting.
Does the amount paid by the health care system truly
Around the same time, Minnesota-based HealthPartners,
represent the cost of health care on our society? How
an integrated care organization, developed the Total Cost
can we quantify indirect aspects of care?
Index (TCI). TCI is a measure of a primary care doctor’s
Despite these challenges, Minnesota has gained significant
ground — largely due to the traditions of collaboration and
innovation that have long existed within our health care
community.
risk-adjusted, cost-effectiveness at managing the patients
that he or she cares for. TCI was endorsed by the National
Quality Forum (NQF) — the gold standard in health care
measurement — in January 2012.
As these building blocks began to fall into place, MNCM
saw the opportunity to convene varied stakeholders and
Putting Cost Measurement into Practice
begin conversations to put the pieces together into a stable,
consistent cost of care measure. The cornerstone to doing
Minnesota had the perfect combination of original thinking
that was an agreed-upon common methodology.
and expertise to produce the nation’s first community-wide
measure of the total cost of care and report on the variation
in cost between medical groups.
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
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MN Community Measurement 2014 Total Cost of Care Report
TCI is preferable to other methods of measuring health care
cost because it is:
•
•
•
•
•
Standardized;
A Level Playing Field
TCOC evaluates all costs for commercially-insured patients
over a 12 month period adjusted for diagnostic risk and
Complete - it measures all costs;
assigned to a single medical group. It includes all medical
Repeatable - it can be delivered across payer sources
costs involved with treating patients, including provider and
and across time;
facility fees, inpatient and outpatient care, pharmacy, lab,
Affordable - most payer databases can calculate it with
radiology, behavioral health services and other ancillary costs.
little additional resource; and,
Everyone in Minnesota can benefit from reliable health
Stable – it reduces the impact of a small number of
care cost information that’s delivered in a comparable,
high-cost patients.
consistent manner. We can all now use the same data to
set improvement goals and measure whether we’re hitting
A standardized and stable measure is particularly crucial
them. Medical groups can see where they stand on cost
for medical groups to utilize the information. Historically,
and collaborate with other groups to see what’s working
providers have received contradictory results on their costs,
to improve the value of care. Policymakers now have a
depending on who was conducting the measurement and
true measure of the cost of care in Minnesota so they can
how it was being done. A single, consistent methodology —
focus efforts and resources to lower it. Patients can see the
along with a process to validate the data — means it can be
variation in cost relative to quality and patient experience
a trusted barometer of cost upon which medical groups can
information. All of these efforts improve health and drive
base improvements.
change in health care.
Through MNCM’s consensus-based, multi-stakeholder
With Minnesota leading these efforts locally and nationally,
process, we were able to get broad agreement on a Total
it’s our hope that providers will soon have standardized
Cost of Care (TCOC) measure. More than 40 stakeholders
tools and information to compare their cost and utilization
from medical groups, health plans, state agencies, large
patterns to others, and identify opportunities to get better
employers, consumer groups and health economics
value for their patients. That is when controlling, or even
worked for three years to develop, test and validate the
reducing, costs will truly begin to occur.
measurement process and its results. Technical assistance
and validation were also obtained from independent
statisticians and local and national experts, including NQF,
the Network for Regional Healthcare Improvement and
Johns Hopkins University.
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© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Executive Summary
The 2014 Total Cost of Care Report is the first milestone in an
regions is evident. The lowest cost region varies by age
initiative to publicly report reliable, comparable and validated
group, but the highest cost region is Southeast Minnesota
information on health care cost. Without it, providers, health
both overall and by age group.
plans, employers, patients and policymakers cannot make
informed decisions about how to reduce it. This report
provides an initial benchmark. It is our first view of how costs
differ by medical group, by region and by type of care. And it
is our first opportunity to use that information to isolate and
address the major cost drivers in health care.
This report reflects the actual costs of 1.5 million patients
insured by Minnesota’s four largest health plans. Their costs
totaled nearly $8 billion in 2013. The average total cost of
care in Minnesota is $435 per patient per month (pppm);
it is $514 pppm for adult patients and $144 pppm for
pediatric patients.
The average cost of the 115 medical groups that are reported
individually range from $269 to $826 pppm, on a risk
adjusted basis. Many of the medical groups above and below
that average range have unique roles in our community and
would be expected to have unusual costs, such as teaching
facilities on the high end and student health services on the
low end. However, 80 percent of the groups are in the range
considered average ($369 to $509 pppm). Most of the groups
within this standard range are full-range primary care or
multispecialty clinics, and yet still have a $1,500 difference
per patient per year.
When looking at all patients, Eastern North Dakota has
the lowest cost. The Metro region is the lowest cost for
adult patients and Southwest Minnesota is the lowest for
pediatric patients.
Pediatric patients spend about 11 percent more of their
health care dollars on primary care services than adult
patients. Children generally have few chronic conditions and
other risk factors; thus, a larger amount of their care would
be expected to occur in primary care. Pediatric patients
spend less money on health care overall and across every
type of care, with the greatest cost difference between adult
and pediatric patients being in the amount spent on specialty
care and ancillary services.
This report reflects Minnesota’s initial TCOC benchmarks and
begins to point us in the direction so we as a community can
reduce the cost of health care. It’s also noteworthy what’s
not reflected in this report. While foundational, TCOC is only
one piece of the puzzle that needs to be put together to slow
the growth in health care costs. MNCM has already convened
a multi-stakeholder group that is working to develop a
companion to the TCOC measure that will evaluate each
medical group’s relative resource use. It will reveal elements,
such as overutilization of certain services, which TCOC alone
The numbers are staggering: if we reduce the average cost by
cannot. With both pieces of information, our community will
just $12 per patient per month, more than $750 million would
be able to see both the overall cost and how efficient medical
be saved each year in Minnesota alone.
groups are being with their resources.
Minnesota has a very centralized health care market; large
To bend the cost curve in health care, we must understand
medical groups dominate. That characteristic was reflected in
what’s driving it. Measuring the total cost of care has
these results, as just seven medical groups care for 50 percent
historically been complex and difficult. The information in
of the 1.5 million patients accounted for in this measure.
this report should begin to inform medical groups, employers,
Similarly, the Metro region represents 61 percent of all
available primary care clinic locations and 66 percent of
health plans, policymakers and others about where efforts to
reduce the cost of health care can be most impactful.
all patients in this measure. Nevertheless, variation across
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
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MN Community Measurement 2014 Total Cost of Care Report
Analysis of Results
Statewide
The 2014 Total Cost of Care Report is the first to provide detailed analysis of the nation’s first
community-wide reporting of total cost of care by medical group for Minnesota and neighboring
communities.
The process of how to collect and report Total Cost of Care was agreed upon through a multistakeholder consensus process, which allowed us to create a consistent definition. The calculations
were endorsed by the National Quality Forum and the execution of those calculations was externally
validated by independent statisticians.
Overview
The results in this report are based on 2013 claims data
primary care medical group. All patient costs throughout
from the four Minnesota-based health plans with the largest
the year were assigned to that primary care group. The
commercially-insured patient populations: Blue Cross and Blue
methodology includes risk adjustment and outlier truncation
Shield of Minnesota, HealthPartners, Medica and PreferredOne.
to ensure that medical groups with the sickest, most
They are based on the actual costs of 1.5 million patients
complex patients do not skew the results. Full details on the
insured by those health plans, and the costs accounted for in
Methodology are available on page 39.
the claims evaluated total nearly $8 billion.
Once the Total Cost of Care calculations were completed
Patients were attributed (assigned) to medical groups
and validated, medical groups were given the opportunity to
based on the number of office-based primary care visits
review their own results. As is the standard process, MNCM
during the year. The medical group that the patient visited
allows a review period and appeal process for any groups
most frequently for Family Practice, Pediatric, Ob/Gyn and/
with concerns about the validity of their results.
or Internal Medicine services was considered the patient’s
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© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Statewide Results
With 1.5 million patients that accrued nearly $8 billion
As a result, only 115 medical groups were publicly reported
in claims during 2013, a significant number of medical groups
this year. Costs range from $269 to $826 per patient
in Minnesota and neighboring communities had patients
per month on a risk adjusted basis for those groups. The
attributed to them. In fact, 266 medical groups had at least
complete results by medical group are listed beginning on
one patient attributed. However, to be publicly reported
page 35.
and statistically valid at the medical group level, each group
needed at least 600 commercial patients attributed to it.
The patient distributions and average costs are illustrated in
Table 1.
Table 1: Total Cost of Care — 2013 Dates of Service
Patient Age Group
Adult
Patients attributed to medical groups
Patients attributed to medical groups eligible for reporting
Total cost (paid to provider by plan or patient)
Average cost per patient per month
Average risk (average = 1.0)
1,105,410
Pediatric
All Patients
396,078
1,501,488
1,089,402
392,241
1,481,643
$6,459 Million
$979 Million
$7,438 Million
$513
$216
$435
1.17
0.51
1.0
$649 Million
$102 Million
$752 Million
9.1%
9.4%
9.2%
All costs are limited to $100,000 per patient per year
Dollars removed from measure due to $100,000 limit
Percentage of costs over $100,000
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
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MN Community Measurement 2014 Total Cost of Care Report
Range of Costs
As we’ve noted, 115 medical groups, with costs ranging
Figures A and B show the range of results. Figure A shows
from $269 to $826 per patient per month on a risk adjusted
the range of risk adjusted dollars per patient per month;
basis, had at least 600 commercial patients. If the results
Figure B shows the Total Cost Index (TCI) ratio for each
from these groups were not truncated for outliers and risk
medical group. The TCI ratio is a medical group’s risk-
adjusted for patient mix, the range would be $144 to $1,878
adjusted total cost of care divided by the statewide average.
per patient per month.
In Figure B, the average for TCI ratio is defined as 1.00.
Figure A: Total Cost of Care by Dollars
Risk Adjusted Total Cost of Care
per Patient per Month
$900
$800
$700
$600
$500
Statewide average $435
$400
$300
$200
Medical Groups
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© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Range of Costs (cont.)
Figure B: Total Cost of Care by TCI Ratio
2.00
1.80
TCI: Risk Adjusted
Total Cost of Care Ratio
1.60
1.40
1.20
1.00
Average TCI ratio 1.0
0.80
0.60
Medical Groups
The standard range of costs, defined as one standard
No restrictions were put on the type of provider/patient
deviation from the mean, ranges from $369 to $509 per
interaction or treatment sought; as a result, a wide variety of
patient per month. In other words, the range within the
types of medical groups are included in the measure results.
average cost of medical groups is still $1,596 per patient
Many of the medical groups outside the standard range are
per year.
groups that would be expected to have unusual costs (i.e.
teaching facilities on the high end and student health services
on the low end). Most of the groups within the standard range
are full-range primary care or multispecialty clinics.
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
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MN Community Measurement 2014 Total Cost of Care Report
Patient Distribution
Figure C illustrates that the distribution of the average cost
While the results are a normal distribution, the actual
of care is normal (bell shaped curve), with most medical
distribution of patients is not evenly spread out. The patient
groups having costs between $375 and $525 per patient per
panels are not equal between medical groups, and the cost
month. The distribution has a longer tail on the right because
per patient is what would be expected for most insurance
there is no absolute limit on how high costs can be, whereas
products: 80 percent of the costs are consumed by
there are absolute business limitations on how low costs can
20 percent of the patients.
be on the left (low) side of the graph.
bo
ve
$5
75
an
d
A
–$
57
4
$5
50
$5
49
$5
25
–
$5
24
0–
$5
0
$4
99
$4
75
–
47
4
–$
$4
50
$4
49
$4
25
–
42
4
$4
00
–$
$3
99
$3
75
–
–$
37
4
$3
50
Le
ss
th
an
$3
50
Number of Medical Groups
Figure C: Total Cost of Care Cost Distribution by Medical Group
Risk Adjusted Cost per Patient per Month
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© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Size of Medical Group
The average number of patients attributed to each medical
patients across the full 266 medical groups as well as the
group is 5,645 patients. Table 2 outlines the distribution of
115 medical groups eligible for public reporting.
Table 2: Total Cost of Care — Patient Volume
Patient Age Group
Adult
Medical groups with primary care patients
Pediatric
All Patients
263
213
266
4,203
1,860
5,645
105
69
115
Average number of patients per group with reportable results
10,375
5,685
12,884
Percentage of primary care groups reported
39.9%
32.4%
43.2%
Percentage of attributed patients in reportable groups
98.6%
99.0%
98.7%
Average number of patients, all medical groups
Number of medical groups with reportable results (600 patients)
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MN Community Measurement 2014 Total Cost of Care Report
Size of Medical Group (cont.)
Figure D shows that just seven medical groups care for
The additional 259 medical groups care for the other half of
50 percent of all the patients accounted for in this measure.
the patients.
Figure D: Distribution of Attributed Patients By Medical Group
23 groups have 75% of patients
7 groups
have 50% of patients
25%
266 groups have attributed patients
75%
50%
115 groups eligible for reporting
72 groups have 99% of patients
Cumulative Distribution of Patients
100%
0%
7
23
72
115
266
Medical Groups
The seven medical groups with 50 percent of the patients in this report are:
• Allina Health System
• HealthPartners Clinics
• Park Nicollet Health Services
• Essentia Health – East Region
• Mayo Clinic Health System
• Sanford Health – Fargo Region
• Fairview Medical Group
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MN Community Measurement 2014 Total Cost of Care Report
Risk and Cost Distribution
No two patients are the same, of course, and not all medical
Less than half of 1 percent of the 1.5 million patients
groups care for the same mix of patient types. To limit the
evaluated by this report had costs above $100,000; however,
impact of a small number of complex, high-cost patients on
the patients who did have those high costs accounted for
the overall measure, patient costs are limited to $100,000
almost 18 percent of all claims accumulated. As Table 3
per patient per year. (For more details, see Methodology on
outlines, those patients averaged more than $192,000 per
page 39.)
person in health care claims during the year.
Table 3: Total Cost of Care — Outlier Patients
Cost per patient
Patients
Costs
Per Patient
Under $100,000 per year
1,494,030
$6,692 Million
$4,479
Over $100,000 per year
7,458
$1,435 Million
$192,411
Outlier patients as percent of total
0.5%
17.7%
3439.2%
Even after accounting for high-cost patients, substantial
group is then assigned a risk score based on how many
differences in patient risk remain. The TCOC measure adjusts
patients attributed to them fall into each ACG actuarial cell.
for patient risk by using the Johns Hopkins Adjusted Clinical
The average risk score is 1.00. The result is a risk adjustment
Groups (ACG) System. Every claim that occurred during the
process that uses the actual costs of the patients included
measurement year for each patient is reviewed; through that
instead of a national weight scale. This local weight process
process, the patient is assigned to one of 90 ACG actuarial
was recommended by the Cost Technical Advisory Group
cells, or categories. The costs for all attributed patients are
during the measure development process.
then used to create a risk weight for each cell. Each medical
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MN Community Measurement 2014 Total Cost of Care Report
Risk and Cost Distribution (cont.)
Figure E demonstrates the range of risk scores for medical
The distribution of patient risk between medical groups is
groups publicly reported in this report. They range from 0.35
more dispersed than the final TCOC results. In other words,
(or 65 percent less risky than average) to 1.64 (or 64 percent
the distribution is less bell-shaped and there are fewer medical
more risky than average).
groups huddled in the middle. The dispersal of patient risk
reinforces the need for risk adjustment in this measure.
Figure E: Total Cost of Care – Risk Score Distribution
1.60
1.40
Risk Score Distrubution
1.20
Average Patient Risk 1.0
1.00
0.80
0.60
0.40
0.20
Medical Groups
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© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Risk and Cost Distribution (cont.)
There is a strong relationship between the unadjusted costs
medical groups with risk scores higher than their unadjusted
and the final risk score. Figure F illustrates the strength of
cost ratios have efficient costs, given the mix of patients they
that relationship. The mathematical relationship was tested
are treating.
with an R Square test with a result of 0.81. This indicates
1
Figure F: Total Cost of Care - Unadjusted Cost and Patient Risk Correlation
Unadjusted Cost Ratio
1.9
1.5
Less
Efficient
1.1
More
Efficient
0.7
0.3
0.3
0.5
0.7
0.9
1.1
1.3
1.5
Risk Score
u
1
Medical Group
R Square can vary from -1.00 to +1.00. Result of 0 would indicate no relationship between cost and risk. Result of 1.00 would indicate an absolute relationship between
cost and risk.
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
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MN Community Measurement 2014 Total Cost of Care Report
Analysis of Results
By Region
Just as variation between medical groups can be seen in the Total Cost of Care results, variation
between regions of Minnesota and neighboring states is also evident.
Overview
The regional analysis is calculated by using the proportion of
The regions assigned to each medical group are noted in the
clinic addresses per medical group per region, and weighting
Medical Group Results that begin on page 35.
by the proportional patient population. The regions are
determined by the zip code of the clinics, not by patients’
home locations.
All 1.5 million patients and 266 medical groups that had at least
one patient attributed to them are included in this analysis.
It should be noted that a handful of clinics with patients
The results are broken into nine regions: six areas within
included in this measure are in Northern Iowa; however, it
Minnesota (Central, Metro, Northeast, Northwest, Southeast
was too few to include in this regional analysis.
and Southwest), North Dakota, South Dakota and Wisconsin.
Northwest
North
Dakota
Northeast
Central
Wisconsin
South
Dakota
Southwest
Metro
Southeast
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© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Overall Results
The Metro region of Minnesota represents 61 percent of all
The results of this analysis match closely with regional
available primary care clinic locations and 66 percent of
health care rates seen elsewhere, such as in MNsure and
all patients in this measure. This size difference between
Minnesota’s individual/small group health insurance markets.
the Metro region and the other eight regions means the
Metro region will, by default, have a larger impact on the
overall state average. It’s also notable that some regions are
dominated by a small number of medical groups (e.g. Sanford
Health in Eastern North Dakota). This analysis is valuable, in
part, because travel is not always an option for patients.
As indicated in Figure G, the Eastern North Dakota region
has the lowest cost at $415 per patient per month (pppm), on
a risk adjusted basis; the Southeast region of Minnesota has
the highest cost at $535 pppm.
The Northeast and Southeast regions of Minnesota are both
significantly higher than average; no region is significantly
lower than average (at a 99 percent confidence level).
Figure G: Total Cost of Care - by Region
Overall
average
$435 per
patient
per
month
$535
$497
$471
$459
$427
Central
MN
$440
$422
$416
Metro
MN
Northeast
MN
Northwest
MN
$415
Southeast
MN
Southwest
MN
North
Dakota
South
Dakota
Wisconsin
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
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MN Community Measurement 2014 Total Cost of Care Report
Adult Patients
The Metro region has the lowest cost per adult patient at
significantly higher than average, no region is significantly
$490 pppm on a risk adjusted basis. The Southeast region
lower than average (at a 99 percent confidence level). This is
has the highest cost at $642 pppm. Additionally, while
illustrated in Figure H.
the Northeast and Southeast regions of Minnesota are
Figure H: Total Cost of Care – Adult Patients by Region
Overall
average
$513 per
patient
per
month
$642
$591
$507
Central
MN
22
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$564
$557
$505
$490
Metro
MN
Northeast
MN
Northwest
MN
$495
Southeast
MN
Southwest
MN
North
Dakota
$525
South
Dakota
Wisconsin
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Pediatric Patients
The Southwest region of Minnesota has the lowest cost per
while the Northwest and Southwest regions are both
pediatric patient at $189 pppm on a risk adjusted basis;
significantly lower than average (at a 99 percent confidence
whereas the Southeast region has the highest at $247 pppm.
level). This is illustrated in Figure I.
The Southeast region is significantly higher than average,
Figure I: Total Cost of Care – Pediatric Patients by Region
Overall
average
$216 per
patient
per
month
$247
$207
$213
$235
Central
MN
Metro
MN
Northeast
MN
$194
Northwest
MN
Southeast
MN
$189
$194
$207
Southwest
MN
North
Dakota
South
Dakota
$226
Wisconsin
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
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MN Community Measurement 2014 Total Cost of Care Report
Analysis of Results
By Type of Care
A critical goal of the Total Cost of Care measure is to provide detailed enough information that health
care providers can utilize it to begin to reduce their costs and provide more efficient care. One way to
do that is to evaluate the categories of care that drive the majority of their costs.
Overview
All 115 publicly reported medical groups received their own
The custom reports provided to each medical group included
detailed reports that outlined the actual-to-expected ratios
information on how the costs were distributed for their
for their costs compared to other groups. Costs were divided
patients compared to the expected amount based on the
into five categories of care: Inpatient Facility; Outpatient
market averages for their specific mix of patients.1
Facility; Primary Care; Pharmacy; and Specialty Care and
Ancillary. Table 4 outlines the descriptions of each category,
as well as the percentage of costs evaluated for the measure
that fall into each area.
Table 4: Total Cost of Care – Type of Care Categories
Type of Care
Percentage of Total
Category Description
The facility (hospital) payment for an inpatient stay. Does not
Inpatient Facility
16%
include physician fees. UB04 claims with a room and board
revenue code.
The facility (hospital) payment for services provided in a hospital
Outpatient Facility
23%
outpatient setting. Does not include the physician fees. UB04
claims without a room and board revenue code.
All primary care provider claims. Not limited to the primary care
Primary Care
16%
clinic to which the patient was attributed. All services and all
locations (clinic, hospital, surgery center).
Pharmacy
16%
Specialty Care and Ancillary
29%
Pharmacy costs processed through the plan’s pharmacy benefit.
All other medical costs billed on a HCFA (physician) claim form,
primarily for specialty care and ancillary services (e.g. radiology,
durable medical equipment).
1
Calculated by creating a statewide average cost per patient per month by ACG cell by type of claim and applying the medical groups’ patient months by ACG cell to
estimate an expected (average).
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© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Overview (cont.)
A sample of the custom medical group report is included in
the Appendix on page 41, as well as excerpted below.
Distribution of Cost by Type of Care
The distribution of costs differs across adult versus pediatric
patients, so the analysis is segmented by age. Additionally,
the $100,000 outlier limit was applied but risk adjustment
Example Medical Group Report
Analysis by type of claim
Actual
was not. All 266 medical groups that had at least one patient
Expected
Ratio*
attributed were included. Finally, pharmacy data that was not
Inpatient Facility
$3,335,262
$3,205,693
1.04
available to the health plan was estimated. For more details
Outpatient Facility
$7,605,495
$4,696,707
1.62
on the estimation process, see Methodology on page 39.
Primary Care
$2,837,504
$2,971,198
0.96
As depicted in Table 5 and Figures J and K (on page 26),
$2,311,725
$2,140,779
1.08
there is little difference between the percentage of costs
$4,618,309
$5,783,465
0.80
$20,708,294
$18,797,842
1.10
Pharmacy
Specialty Care and Ancillary
Total
*Ratio is the actual amount divided by the expected amount.
spent by pediatric and adult patients in most categories.
The category where this differs is Primary Care; pediatric
patients spend about 11 percent more of their health care
dollars on primary care than adult patients. This would be
expected considering the average risk score for a pediatric
patient is less than half of the risk score for an adult patient;
In this example, the medical group’s higher-than-average
they have fewer complex needs and, therefore, more of the
costs are primarily in the Outpatient Facility category.
care would be from a primary care provider.
However, it also indicates the group has 20 percent lowerthan-expected costs in the Specialty Care and Ancillary
This does not mean, however, that more actual dollars
category. This suggests the group may be providing services
are spent on pediatric primary care. The next section
in an outpatient hospital setting that most groups are
will illustrate this more clearly. The distribution indicates
providing at a stand alone specialty center. The location of
only that a larger percentage of the health care spend for
a service can be a significant factor in its cost. For example,
pediatric patients is in primary care.
if x-rays are performed at a hospital, those costs would be
included in Outpatient Facility; if they are performed at a
standalone radiology center, they would be in Specialty Care
and Ancillary. It is not unusual for the price of a x-ray to
be more expensive at a hospital. The medical group in this
example might evaluate its referral patterns for services like
x-rays as a strategy to lower costs.
These detailed reports were distributed only to medical
groups for the purpose of better understanding their own
cost drivers. However, the overall trends can be summarized.
We expect to release additional detail on the breakdown of
costs across various types of services in future reports.
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
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MN Community Measurement 2014 Total Cost of Care Report
Distribution of Cost by Type of Care (cont.)
Table 5: Total Cost of Care - Distribution of Cost by Type of Care
Type of Care
Adult Patients
Difference between
Age Groups
Pediatric Patients
Inpatient Facility
17%
13%
-4%
Outpatient Facility
23%
23%
0%
Primary Care
14%
25%
11%
Pharmacy
17%
13%
-4%
29%
27%
-2%
100%
100%
NA
Specialty Care and Ancillary
Total
Figure J: Total Cost of Care —
Adult Patient Spending by Type of Care
Specialty Care
and Ancillary
29%
Pharmacy
17%
Figure K: Total Cost of Care —
Pediatric Patient Spending by Type of Care
Pharmacy
13%
Specialty Care
and Ancillary
27%
Inpatient
Facility
17%
Primary
Care
14%
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Outpatient
Facility
23%
Primary
Care
25%
Inpatient
Facility
13%
Outpatient
Facility
23%
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Monthly Cost by Type of Care
When focusing on what types of care are driving costs, it’s
gaps can illuminate unwarranted variation in care that could
useful to understand the difference in cost between similar
drive costs up.
services for adult and pediatric patients. It’s not surprising
that costs are lower for pediatric patients for a variety of
While in the previous analysis the largest differential was in
the Primary Care category, Table 6 and Figure L illustrate
reasons (e.g. fewer chronic conditions, lower medication
that the greatest difference in cost is in the Specialty Care
dosages); however, identifying the areas with the largest
and Ancillary category.
Table 6: Total Cost of Care — Cost Per Patient per Month by Type of Care
Adult Patients —
cost per patient per month
Type of Care
Pediatric Patients —
cost per patient per month
Difference between
Age Groups
Inpatient Facility
$86
$27
-$59
Outpatient Facility
$120
$49
-$72
Primary Care
$73
$55
-$19
Pharmacy
$85
$28
-$57
Specialty Care and Ancillary
$149
$57
-$91
Total
$513
$216
-$298
Figure L: Total Cost of Care — Unadjusted Costs By Age
n
n
Adult Patients (18–64)
$149
Pediatric Patients (1–17)
$120
$86
$85
$73
$49
$55
$57
$28
$27
Inpatient Facility
Outpatient Facility
Primary Care
Specialty Care and Ancillary
Pharmacy
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
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MN Community Measurement 2014 Total Cost of Care Report
Pairing Cost and Quality
Cost of care is a critical piece of data for consumers as they determine the medical group that will
provide the highest value care to them; however, it is just one piece of information. Without appropriate
context, particularly related to clinical quality, cost of care data can mislead consumers.
During the development of the Total Cost of Care measure,
Despite these differences, a key factor that affects both the
MN Community Measurement received input from many
quality and cost of care (as well as patient experience) is
stakeholders and reviewed published literature focused on
efficiency. In other words, how well is care coordinated and
the importance of displaying cost and quality information
communicated between providers and patients? Examples
together.
and results of inefficiency or poor communication include
The Cost Technical Advisory Group and other stakeholders
prioritized the need to balance the two types of data as we
moved forward with public reporting on MNCM’s consumerfocused, public reporting website, MNHealthScores.org.
Research illustrates that Americans believe more expensive
goods are also higher quality – and that they think this
same logic extends to health care. However, the results we
display on MNHealthScores do not support this myth. There
is great variability in both cost and quality, with instances
of high-quality, low-cost medical groups, and vice versa.
A similar dichotomy can be found with patient experience
(satisfaction) survey results when they’re paired with cost
and/or quality results. In other words, more expensive health
care does not necessarily result in better care.
Total Cost of Care is a measure of overall cost; however,
unfortunately, a measure of overall quality does not yet exist.
Variation in the quality of a provider’s care may exist based
on the type of care or condition being treated. For example,
some perform better when providing diabetes care, others
for asthma care, and others on follow-up care for patients
with depression.
repeat tests; missed or delayed appointments; avoidable
complications; avoidable hospital readmissions; drug
interactions; condition relapse; and more. All of these can
result in increased cost, decreased quality of care and poor
patient experience.
Users of this information should look at both sides of
the cost/quality equation when making evaluations.
MNHealthScores.org allows side-by-side viewing of
quality metrics and Total Cost of Care data. This can serve
as a basis for further discussion between providers and
patients, as well as aid patients in decision making. For more
information on the Total Cost of Care data displayed on
MNHealthScores.org, see page 48.
In the future, the Total Cost of Care measure may also hold
value as a building block in a total value equation, which
would combine these elements (cost, quality and patient
experience) to provide an overall assessment of a provider’s
performance. As the Centers for Medicare and Medicaid
Services and other purchasers emphasize value-based
payments, these types of metrics are becoming increasingly
important in contract negotiations and reimbursement
methodologies. A uniform method of measuring Total Cost of
Care in Minnesota can now be further considered in the total
value equation.
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© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
How to Use this Report
Through myriad ways over the past two decades, health care experts, economists, policymakers and
providers have attempted to reduce the cost of health care. However, they often came up against the
same stumbling block: how do we know we’re reducing cost when we don’t have a reliable, comparable
and validated way to measure it?
Driven by MNCM’s consensus-based, multi-stakeholder process, our community has been able to
overcome that hurdle and develop broad agreement on a standard, stable Total Cost of Care measure.
Everyone in Minnesota can benefit from reliable health care cost information that’s delivered in a
comparable, consistent manner. Standardization and stability are particularly crucial to make
TCOC data actionable for our community. A single, consistent methodology — along with a process to
validate the data — means it can be a trusted barometer of cost upon which to base reforms, public
policy and improvements.
Medical groups can use the information to identify where
and what’s working in their clinics. These knowledge-sharing
they have the highest costs and understand why. MNCM
conversations are one of the most valuable outcomes of
provided groups with group-specific detail on their costs.
publicly reporting health care performance information.
This information allows the group to understand what types
of care (e.g. outpatient, inpatient, pharmacy, etc.) are driving
the majority of their costs. With that knowledge, groups
can look at their own organization to understand why. Is
there variation in care between clinic sites? Are more costly
medications being prescribed or tests being ordered when
a lower-cost option is available that’s the same quality? Is
the group unknowingly referring patients to more expensive
specialists? Medical groups can now evaluate those questions
and subsequently identify improvements that lower costs
while maintaining high-quality care and superior experience
for patients.
However, clinics and medical groups are not the only utilizers
of TCOC information. By using MNHealthScores.org,
consumers can pair this data with provider quality and
patient experience information to make educated decisions
about where to get care. Total cost of care gives consumers
a sense of which medical groups are higher or lower cost,
which they can use to make provider choices or ask their
clinic about the cost of their care. No patient is average,
so the exact dollar amount is less important for patients
than the overall cost rating and comparing that to quality
information. Patients ultimately need to decide what
represents a good value for them and their families. By
We also know from more than a decade of reporting on
factoring the total cost of care into their decisions, we hope
health care quality that it’s important for medical groups to
consumers will focus on higher-quality, lower-cost medical
learn from one another. By making this information public,
groups more often which will help propel the market in that
providers can share with one another what they’ve learned
direction.
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
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MN Community Measurement 2014 Total Cost of Care Report
Employers have not previously had access to such a
Health plans can utilize TCOC data to inform contracts
large data set to help inform their health care purchasing
with medical groups, particularly as they move to more
decisions, including negotiations and discussions with
value-based contracts that reward the quality and cost-
health plan administrators. Traditionally, employers receive
effectiveness of care instead of simply the volume of
information from their health plan about the cost of their
procedures done. This will help shape the supply and demand
own employee population; however, there has not been
in our health care market, which will support movement to a
something for employers to compare that to. As employers
more efficient market.
continue to look for ways to manage increasing health costs,
they are expressing more interest in Accountable Care
Organizations and narrow network plan options. Additionally,
large employers are more frequently building relationships
directly with medical groups. TCOC data will inform these
conversations and enhance employers’ decision-making
abilities.
Finally, this report provides policymakers with a reliable
measure of the cost of health care in Minnesota, which
will support efforts to reduce it over time. In particular,
information on differences between regions of the state can
be utilized to drive public policy that addresses challenges
faced by certain communities.
Medical Groups
Consumers
Employers
Health Plans
policymakers
can use this data
can pair this data
can use this data
can utilize this data
can use this data
to help identify
with provider
to inform their
to help support
to help inform
where they have
quality and
health care
value-based
efforts to reduce
the highest costs
patient experience
purchasing
contracts with
cost over time and
and understand why.
information to make
decisions.
medical groups.
drive public policy to
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educated decisions
address challenges
about where
faced by poorer
to get care.
communities.
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Future Plans
While the release of the inaugural Total Cost of Care (TCOC) data in late 2014 was a significant
milestone, we cannot rest on our laurels. Public reporting of the information by itself will not bend the
health care cost curve in Minnesota or nationally. We must share the information; partner on medical
group improvement strategies; continue reporting data to identify trends; and develop additional data
sets that can be paired with TCOC to provide even more well-rounded information to drive decisions.
Year-Over-Year Comparisons and Trends
Refresh Procedure Cost Data
As we have done for more than a decade with quality
Though not comprehensive in the same way as TCOC, the
measures, we expect to update Total Cost of Care data
procedure cost information provided on MNHealthScores.
annually. These regular reports will help us identify trends in
org shows price in a way consumers can easily understand
the community, as well as allow medical groups to evaluate
and identify variation. For example, knowing a difference of
the impacts of their efficiency efforts. MNCM hopes to
more than $500 for the same colonoscopy can exist between
publicly report the second year of Total Cost of Care data
providers is actionable for consumers as they make care
on medical groups before the end of 2015 and make another
choices and begin conversations with their providers. MNCM
comprehensive report, like this one, available soon after.
will continue to publish and update this information on the
most common procedures.
Continued Refinement of the Total Cost of Care
Measure
Develop Relative Resource Use Measurement
We know after many years of developing new measures
Another important piece of information to have alongside
that refinement occurs over time. We have already and
TCOC is utilization. There are two major inputs to TCOC:
will continue to receive feedback on this first year of TCOC
1) unit price, or what medical groups are being paid for
results. Additionally, our community will develop more
the services; and 2) utilization, or how much they’re using
comfort with the information and some practices may
the services. For example, a medical group could have a
change in the community. As these evolutions occur, we will
high total cost of care with a low unit price because they
continue to analyze the results, collaborate with our partners
overutilize certain services or have inefficiencies in their
and explore refinements of the measure and data that is
processes that drive up the overall cost. The opposite can
reported, such as adjustments to the outlier threshold and
also be true: a group could have a low total cost with a high
possible expansion to include Medicare or Minnesota Health
unit price because they’re using services very efficiently.
Care Program patients.
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MN Community Measurement 2014 Total Cost of Care Report
For medical groups, both pieces of information are important
to understand where improvements can be made. A Relative
Resource Use measure would make prices neutral for all
medical groups, thus measuring and providing an evaluation
of utilization alone. This would allow the medical group’s
overall efficiency to be more transparent. MNCM will be
working with our partners to provide this type of information
in the near future.
Exploration of Further Analysis
There is a significant number of cost metrics that we could
pursue in Minnesota. The Cost Technical Advisory Group
chose to report TCOC as the first comprehensive cost
measure because it is the most complete measure available
and all inclusive of all costs. However, providers, consumers
and purchasers each have different levels of understanding
of the complexities of health care cost. To maintain
alignment and avoid unintended consequences, cost must be
analyzed from many angles. Over time, we will further evolve
and explore which cost measurements can and should be
conducted to benefit our community.
Share the
information
Partner on
improvement
strategies
Year-over-year
comparisons
and trends
Explore
further
analysis
Health
care cost
measurement
Continue
reporting data
Continue
refinement
of TCOC
measure
Refresh
Procedure
Cost data
Consider
additional data
sets to pair
with TCOC
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Develop
Relative
Resource Use
measure
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Acknowledgements
The 2014 Total Cost of Care Report was a collaborative effort lead by MN Community Measurement
on behalf of the Minnesota health care community and the broader public. We want to acknowledge
the contributions of all who made this report possible, including the organizations that shared their
resources and the individuals that shared their time and expertise.
We offer our sincerest thanks to:
The health plans that contributed data and expertise:
The MNCM Measurement and Reporting Committee
Blue Cross and Blue Shield of Minnesota, HealthPartners,
which provided expertise in reporting policy and measure
Medica and PreferredOne.
selection, and the MNCM Board of Directors, which set
the vision of creating a TCOC measure and granted
The medical groups that participated in the initial piloting
organizational oversight and leadership.
and testing phases: Affiliated Community Medical Centers,
Allina Health, Buffalo Clinic, Entira Family Clinics, Essentia
The organizations that provided collaborative learnings
Health – East, Fairview Health Services, HealthEast Clinics,
and national perspective, through a coalition put together
HealthPartners Clinics, Mayo Clinic, Park Nicollet Health
by the Network for Regional Healthcare Improvement
Services, Sartell Pediatrics and St. Cloud Medical Group.
(NRHI): Center for Improving Value in Health Care
(Colorado), Maine Health Management Coalition, Midwest
The Cost Technical Advisory Group, which developed
Health Initiative (Missouri) and Oregon Health Care Quality
the methodology and oversaw implementation of the
Corporation.
measure: Allina Health, American Cancer Society, Blue
Cross and Blue Shield of Minnesota, Entira Family Clinics,
The organizations that provided funding for measure
Essentia Health, Fairview Health Services, HealthEast Clinics,
development and implementation: MNCM’s founding
HealthPartners, Integrity Health Network, Life Touch, Medica,
members (Blue Cross and Blue Shield of Minnesota,
Minnesota Council of Health Plans, Minnesota Department
HealthPartners, Itasca Medical Care, Medica, Metropolitan
of Health, Minnesota Health Action Group, Minnesota
Health Plan, Minnesota Medical Association, Minnesota
Hospital Association, Minnesota Medical Association, State
Hospital Association, PreferredOne, PrimeWest Health
of Minnesota (employer), PreferredOne, Target Corporation
System, South Country Health Alliance and UCare
and individual consumers.
Minnesota), as well as the Robert Wood Johnson Foundation.
The Total Cost of Care Data Mechanics Subcommittee
which created a unified data collection and submission
process across health plans: Ginelle Uhlenkamp and
Amanda Wobbema at Blue Cross and Blue Shield of
Minnesota; Chad Heim and Gary Kitching at HealthPartners;
Peter Thibodeau and Sarah Taylor at Medica; and Terry
Bernhardt and Margareth Ranheim at PreferredOne.
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
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MN Community Measurement 2014 Total Cost of Care Report
Multispecialty and Primary Care Medical Groups Publicly Reported:
7 Day Clinic
AALFA Family Clinic
Adefris & Toppin Women’s Specialists
Affiliated Community Medical Centers
All About Children Pediatrics
Allina Health Clinics
Altru Health System
Apple Valley Medical Clinic
Avera Medical Group
Baldwin Area Medical Center
Buffalo Clinic, PA
Burnett Medical Center
Burnsville Family Physicians
Catalyst Medical Clinic
CentraCare Health
Central Pediatrics
Children’s Hospitals and Clinics of Minnesota
Children’s Physician Network
Chippewa County Montevideo
Hospital & Medical Clinic
Clinic Sofia Ob/Gyn
Community University Health Care Center
Comprehensive Healthcare for Women
Cuyuna Regional Medical Center
Dawson Clinic
Deer River Healthcare Center
Dulcimer Medical Center
Eagan Valley Pediatrics
Edina Sports Health & Wellness
Entira Family Clinics
Essentia Health - Central Region
Essentia Health - East Region
Essentia Health - West Region
Essentia Health St. Mary’s
Fairview Health Services
Fairview Mesaba Clinics
Family Practice Medical Center of Willmar
FamilyHealth Medical Clinics
First Care Medical Services
FirstLight Health System
Foley Medical Center
France Avenue Family Physicians
Fridley Children’s & Teenagers’
Medical Center
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Gateway Family Health Clinic
Glencoe Regional Health Services
Glenwood Medical Center
Grand Itasca Clinic
Gundersen Health System
HealthEast Clinics
HealthPartners Clinics
Hennepin County Medical Center Clinics
Hudson Physicians
Hutchinson Health
John A. Haugen Associates, PA
Lake Region Healthcare
Lake View Clinic – Two Harbors
Lakeview Clinic
Lakewood Health System
Mankato Clinic, Ltd.
Mayo Clinic
Mayo Clinic Health System
Mendakota Pediatrics, Ltd.
Metropolitan Medical Associates
Metropolitan Obstetrics & Gynecology
Mille Lacs Health System
Minnesota Gyn & Surgery
Multicare Associates
Murray County Clinic
North Clinic
North Memorial
NorthPoint Health & Wellness Center
Northwest Family Physicians
Obstetrics and Gynecology Associates
Olmsted Medical Center
Ortonville Area Health Services Northside Medical Clinic
Park Nicollet Health Services
Parkview Medical Clinic
Parkway Family Physicians
Paul Larson Ob/Gyn Clinic
Pediatric & Young Adult Medicine
Pediatric Services - Children’s
Physician Network
Planned Parenthood of Minnesota,
North Dakota, South Dakota
Prairie Ridge Hospital & Health Services
Renville County Hospital and Clinics
Richfield Medical Group
Ridgeview Clinics
Ridgeview Sibley Medical Center
River Falls Medical Clinic
RiverView Health
Riverwood Healthcare Center
Saint Cloud State University
Student Health Services
Sanford Health – Fargo Region
Sanford Health – Sioux Falls Region
Sartell Pediatrics
Sawtooth Mountain Clinic
Scandia Clinic
Scenic Rivers Health Services
Sleepy Eye Medical Center
South Lake Pediatrics
Southdale Pediatric Associates, Ltd.
St. Cloud Hospital Clinics
St. Cloud Medical Group NW, So.,
Cold Spring, Clear Water – Integrity
St. Croix Regional Medical Center
St. Luke’s Clinics
Stevens Community Medical Center
Stillwater Medical Group
Tri-County Hospital
United Family Medicine
United Hospital District Clinic
Unity Family Healthcare,
Family Medical Center
University of Minnesota Physicians
University of St. Thomas
Student Health Service
Wayzata Children’s Clinic
West Side Community Health Services
Winona Health
Women’s Health Consultants
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Medical Group Results
2014 Report Year
Overall
Medical Group
Adult Patients, Ages 18–64
Per Patient
per Month
Ratio
Rating
Per Patient
per Month
Ratio
Rating
Pediatric Patients, Ages 1–17
Per Patient
per Month
Ratio
Rating
Region
7 Day Clinic
$269
0.618
Lower
$313
0.610
Lower
NW
Saint Cloud State University
Student Health Services
$306
0.704
Lower
$361
0.704
Lower
Central
Hudson Physicians
$344
0.790
Lower
$418
0.815
Lower
WI
Catalyst Medical Clinic
$346
0.795
Lower
$401
0.780
Lower
Metro
Northwest Family Physicians
$360
0.827
Lower
$418
0.814
Lower
$435
0.846
Lower
North Clinic
$368
0.845
Lower
Pediatric & Young Adult Medicine
$368
0.846
Lower
$369
0.848
Lower
$436
0.849
Average
$379
0.872
Average
$451
0.879
Average
Burnett Medical Center
$381
0.876
Average
Stillwater Medical Group
$381
0.876
Average
$448
0.873
Average
St. Cloud Medical Group NW, So.,
Cold Spring, Clear Water - Integrity
Community University
Health Care Center
$214
0.992
Average
Metro
$170
0.789
Lower
Metro
$183
0.848
Average
Metro & WI
$180
0.835
Average
Central
& Metro
Metro
WI
$196
0.909
Average
Metro
Burnsville Family Physicians
$382
0.877
Average
$449
0.876
Average
Wayzata Children's Clinic
$382
0.877
Average
$542
1.056
Average
$183
0.849
Average
Metro
Metro
AALFA Family Clinic
$384
0.881
Average
$457
0.891
Average
$175
0.811
Average
Metro
University of St. Thomas
Student Health Service
$386
0.888
Average
$456
0.888
Average
Foley Medical Center
Metro
$390
0.896
Average
$472
0.919
Average
Parkview Medical Clinic
$391
0.898
Average
$471
0.917
Average
$167
0.774
Lower
Central
Metro
HealthPartners Clinics
$392
0.902
Average
$460
0.896
Average
$204
0.944
Average
Metro
Essentia Health - Central Region
$392
0.901
Average
$462
0.899
Average
$199
0.922
Average
NW
Buffalo Clinic, PA
$392
0.901
Average
$466
0.907
Average
$188
0.870
Average
Central
Central Pediatrics
$396
0.910
Average
$608
1.185
Higher
$191
0.884
Average
Metro
Entira Family Clinics
$398
0.913
Average
$468
0.912
Average
$203
0.940
Average
Metro
North Memorial
$398
0.914
Average
$469
0.914
Average
$191
0.886
Average
Metro
France Avenue Family Physicians
$399
0.917
Average
$470
0.915
Average
Essentia Health St. Mary's
$400
0.918
Average
$482
0.939
Average
$154
0.715
Lower
NW
$401
0.921
Average
$622
1.211
Higher
$191
0.885
Average
Metro
South Lake Pediatrics
Metro
Essentia Health - West Region
$402
0.924
Average
$480
0.934
Average
$184
0.850
Average
NW & Central
Apple Valley Medical Clinic
$403
0.926
Average
$474
0.924
Average
$204
0.943
Average
Metro
Multicare Associates
$405
0.930
Average
$470
0.916
Average
$230
1.066
Average
Metro
$405
0.931
Average
$515
1.003
Average
$199
0.920
Average
Metro
$405
0.931
Average
$478
0.932
Average
Metro
Metro
Southdale Pediatric
Associates, Ltd.
Comprehensive Healthcare
for Women
United Family Medicine
$406
0.933
Average
$477
0.929
Average
Hennepin County
Medical Center Clinics
$408
0.938
Average
$485
0.946
Average
$178
0.825
Average
Sanford Health - Fargo Region
$408
0.938
Average
$485
0.945
Average
$191
0.883
Average
Fairview Health Services
$409
0.939
Average
$480
0.936
Average
$208
0.964
Average
Metro
NW, Central
& ND
NE, Central
& Metro
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
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35
MN Community Measurement 2014 Total Cost of Care Report
Overall
Adult Patients, Ages 18–64
Pediatric Patients, Ages 1–17
Per Patient
per Month
Ratio
Rating
Per Patient
per Month
Ratio
Rating
NorthPoint Health
& Wellness Center
$409
0.940
Average
$491
0.956
Average
Lakeview Clinic
$409
0.940
Average
$485
0.945
Average
$198
0.917
Average
Metro
$486
0.947
Average
$198
0.916
Average
NW
Medical Group
Lake Region Healthcare
$411
0.943
Average
Dawson Clinic
$411
0.944
Average
Pediatric Services Children's Physician Network
$412
0.945
Average
Dulcimer Medical Center
$412
0.947
Average
Per Patient
per Month
Ratio
Rating
Region
Metro
SW
$203
$487
0.949
0.940
Average
Metro
Average
SE
Ridgeview Clinics
$413
0.948
Average
$487
0.949
Average
$202
0.936
Average
Central
& Metro
Children's Hospitals and Clinics
of Minnesota
$413
0.949
Average
$471
0.917
Average
$206
0.953
Average
Metro
Parkway Family Physicians
$415
0.953
Average
$497
0.968
Average
John A. Haugen Associates, PA
$415
0.953
Average
$490
0.955
Average
HealthEast Clinics
$416
0.955
Average
$486
0.947
Average
Paul Larson Ob/Gyn Clinic
$416
0.955
Average
$490
0.955
Average
Sartell Pediatrics
$418
0.959
Average
Richfield Medical Group
$418
0.960
Average
$493
0.961
Average
Metro
First Care Medical Services
$419
0.962
Average
$503
0.981
Average
NW
Unity Family Healthcare,
Family Medical Center
$419
0.962
Average
$507
0.987
Average
Planned Parenthood
of MN, ND, and SD
$421
0.968
Average
$494
0.963
Average
Metro
Metro
$216
1.000
Average
Metro & WI
$205
0.951
Average
Central
Metro
$167
0.776
Lower
Central
NE, Central,
Metro & SE
Mille Lacs Health System
$424
0.974
Average
$485
0.944
Average
Park Nicollet Health Services
$424
0.974
Average
$497
0.968
Average
Metropolitan Obstetrics
& Gynecology
$428
0.983
Average
$504
0.982
Average
FamilyHealth Medical Clinics
$429
0.985
Average
$513
0.999
Average
Edina Sports Health & Wellness
$430
0.987
Average
$506
0.987
Average
Family Practice Medical Center
of Willmar
$431
0.989
Average
$510
0.993
Average
$209
0.970
Average
Allina Health Clinics
$434
0.996
Average
$511
0.995
Average
$214
0.991
Average Metro, SE & WI
Fridley Children's &
Teenagers' Medical Center
$436
1.002
Average
$219
1.015
Average
Metro
Glencoe Regional Health Services
$438
1.006
Average
$526
1.025
Average
$189
0.876
Average
Central
Obstetrics and Gynecology
Associates
$438
1.007
Average
$517
1.008
Average
Grand Itasca Clinic
$439
1.008
Average
$520
1.013
Average
$208
0.966
Average
NE
FirstLight Health System
$439
1.008
Average
$514
1.001
Average
$231
1.069
Average
NE
Mankato Clinic, Ltd.
$439
1.008
Average
$517
1.007
Average
$220
1.019
Average
SE
Sanford Health - Sioux Falls Region
$440
1.011
Average
$524
1.020
Average
$203
0.942
Average
SW & SD
$440
1.011
Average
$532
1.036
Average
$185
0.859
Average
Central & SW
$441
1.014
Average
$521
1.015
Average
Metro
Affiliated Community
Medical Centers
Adefris & Toppin
Women's Specialists
Central
$221
1.022
Average
Metro
Metro
$195
0.903
Average
Metro & SE
Metro
Central
Metro
Women's Health Consultants
$443
1.018
Average
$523
1.018
Average
Metro
Clinic Sofia Ob/Gyn
$448
1.030
Average
$529
1.031
Average
Metro
Cuyuna Regional Medical Center
$449
1.032
Average
$535
1.042
Average
$202
0.937
Average
NW & Central
Scandia Clinic
$452
1.037
Average
$552
1.075
Average
$164
0.761
Lower
Metro
Mendakota Pediatrics, Ltd.
$452
1.039
Average
$217
1.006
Average
Metro
CentraCare Health
$454
1.043
Average
$226
1.047
Average Central & Metro
36
|
$535
1.042
Average
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Overall
Medical Group
Per Patient
per Month
Ratio
Adult Patients, Ages 18–64
Rating
Per Patient
per Month
Ratio
Rating
Pediatric Patients, Ages 1–17
Per Patient
per Month
Ratio
Rating
Region
Glenwood Medical Center
$456
1.047
Average
$542
1.056
Average
St. Croix Regional Medical Center
$457
1.051
Average
$548
1.068
Average
$201
0.931
Average
Metro & WI
Avera Medical Group
$459
1.056
Average
$563
1.096
Average
$171
0.793
Lower
SE & SW
Deer River Healthcare Center
$460
1.057
Average
$548
1.068
Average
Lake View Clinic - Two Harbors
$460
1.057
Average
$547
1.066
Average
NE
Ridgeview Sibley Medical Center
$460
1.058
Average
$553
1.078
Average
Central
$461
1.059
Average
$553
1.078
Average
$205
0.949
Average
Central
$194
0.900
Average
NE & WI
Hutchinson Health
Central MN
NE
St. Luke's Clinics
$462
1.061
Average
$552
1.075
Average
Metropolitan Medical Associates
$465
1.069
Average
$549
1.069
Average
Metro
Prairie Ridge Hospital
& Health Services
$466
1.071
Average
$561
1.094
Average
NW &, Central
Altru Health System
$466
1.071
Average
$561
1.093
Average
Renville County
Hospital and Clinics
$469
1.078
Average
$555
1.080
Average
River Falls Medical Clinic
$473
1.087
Average
$552
1.076
Average
$250
RiverView Health
$475
1.092
Average
$569
1.108
Average
Tri-County Hospital
$476
1.094
Average
$575
1.121
Average
Baldwin Area Medical Center
$476
1.094
Average
$557
1.086
Average
Gateway Family Health Clinic
$477
1.096
Average
$568
1.106
Average
Ortonville Area Health Services Northside Medical Clinic
$479
1.101
Average
$577
1.124
Average
Eagan Valley Pediatrics
$486
1.116
Average
Scenic Rivers Health Services
$491
1.128
Average
$577
1.125
Average
$197
0.913
Average
NW & ND
Central
1.159
Average
WI
$220
1.019
Average
NW
$187
0.864
Average
NW & Central
$214
0.991
Average
NE
WI
NW
$240
1.110
Average
Metro
NE
Fairview Mesaba Clinics
$494
1.134
Average
$589
1.147
Average
$223
1.035
Average
NE
Stevens Community
Medical Center
$496
1.140
Average
$599
1.167
Higher
$210
0.971
Average
Central
Sawtooth Mountain Clinic
$498
1.144
Average
$603
1.174
Higher
Sleepy Eye Medical Center
$501
1.150
Average
$590
1.150
Average
SE
Minnesota Gyn & Surgery
$502
1.153
Higher
$594
1.157
Higher
Metro
All About Children Pediatrics
$502
1.153
Higher
United Hospital District Clinic
$502
1.154
Higher
$584
1.137
Average
SE
Chippewa County Montevideo
Hospital & Medical Clinic
$508
1.167
Higher
$610
1.188
Higher
SW
NE
$247
1.147
Average
Metro
Lakewood Health System
$513
1.178
Higher
$622
1.213
Higher
$197
0.912
Average
NW & Central
Winona Health
$513
1.179
Higher
$611
1.190
Higher
$232
1.075
Average
SE
Mayo Clinic Health System
$524
1.204
Higher
$625
1.218
Higher
$236
1.093
Average
Metro, SE,
SW & WI
West Side Community
Health Services
$535
1.230
Higher
$646
1.258
Higher
Essentia Health - East Region
$543
1.248
Higher
$646
1.258
Higher
Riverwood Healthcare Center
$552
1.268
Higher
$660
1.285
Higher
Metro
$253
1.171
Average
NE & WI
NE & Central
Olmsted Medical Center
$557
1.281
Higher
$677
1.318
Higher
Murray County Clinic
$566
1.301
Higher
$688
1.339
Higher
$223
1.034
Average
SE
University of Minnesota
Physicians
$567
1.304
Higher
$639
1.245
Higher
$426
1.974
Higher
St. Cloud Hospital Clinics
$568
1.304
Higher
Gundersen Health System
$569
1.308
Higher
$686
1.337
Higher
$232
1.073
Average
SE
Children's Physician Network
$599
1.376
Higher
$296
1.370
Higher
Metro
Mayo Clinic
$826
1.899
Higher
$972
1.894
Higher
$426
1.976
Higher
SE
SW
Metro
Central
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
|
37
MN Community Measurement 2014 Total Cost of Care Report
Appendix 1: Data Sources and Collection
The collection of this data is unique nationally as it uses a
The data set from each plan was compared to the aggregate
distributed model, and an all payer claims database was not
of the other data providers to ensure none differed
utilized. This speaks to the deep tradition of collaboration
dramatically, which would have indicated data specifications
that exists in Minnesota’s health care community, where
had not been followed uniformly. The following data aspects
competitors came together to jointly develop and execute
were evaluated:
this method of cost measurement.
•
•
The primary data source for the Total Cost of Care (TCOC)
measure is administrative claims from local health plans. All
data elements and processing rules were specified by MN
Community Measurement (MNCM) in the Total Cost of Care
Data Guide and Specifications. This guide provided detailed
steps and instructions to ensure health plans processed and
submitted data in a standard and consistent format.
The definition of a medical group is defined by the medical
groups themselves as they register in the MNCM Data Portal
each year. It is based on group Tax Identification Numbers
(TIN), which are used by the health plans involved in the
measure to process health care claims.
The data specifications were developed and tested by
•
Total per member per month costs
Distributions
•
•
•
•
•
•
Risk categories (ACG)
Medical groups
Attributed vs. unattributed patients
Age
Attribution types
Outliers
Tests of stability across data sources
Finally, measure calculations were confirmed by an outside
statistician. The firm independently tested the input files for
compliance to data specifications and built the model using the
raw input files and methodology specifications. Their results
matched those produced by MNCM’s original calculations.
MNCM’s Cost Technical Advisory Group and monitored by
the National Quality Forum measure steward for TCOC.
Participating health plans submitted administrative data
Total Cost of Care Decentralized Data Model
Community
Health
Wide
Plans
Stakeholders
clustered by medical group and patient risk level to MNCM.
MNCM aggregated the data and facilitated a review by the
medical groups before being publicly reported.
Establish
Methodology
All data providers agreed to a singular set of data
Compile
Patient Cost
l
specifications, creating uniformity across data creation. All
Patient
Assignment
l
Risk Cell
Assignment
l
DST Health Solutions, to agree upon specifications and
software settings. MNCM also met with each data provider
(health plans), including software programmers from each
plan, to review methodology and process to further ensure
uniformity. Finally, each health plan provided attestation that
data specifications were followed.
Process Flow
data providers met with the risk adjustment software vendor,
l
l
MN
Community
Measurement
Medical
Groups
l
l
Audit, Validation
of Input Files
l
Merge Files,
Establish Risk
Weights
l
Report Creation
l
Analysis of
Results
l
l
Report Review
Public Reporting
l
l
l
Risk weights based on combined data from contributing health plans. Patient
rosters distributed, on request, directly from health plans to medical groups.
38
|
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement 2014 Total Cost of Care Report
Appendix 2: Methodology
TCOC is a measure of a provider’s cost effectiveness at
managing a specific population of patients. This is an
attributed population and includes all costs associated with
treating patients including professional, facility inpatient
and outpatient, pharmacy, lab, radiology, ancillary and
behavioral health services.
Numerator Requirements
The metric measured is allowed payment available in
administrative claims and includes all allowed payments
associated with attributed patients, including professional,
facility inpatient and outpatient, pharmacy, lab, radiology,
ancillary and behavioral health services. It includes out-
This methodology is consistent with the National Quality
of-network claims but excludes claims where payer is not
Forum’s (NQF) TCOC measurement methodology standard.
primary payer and dental claims (except where adjudicated
The measure contains specifications that were part of
via the medical benefit). All denied claims are also excluded.
the endorsed measure as well as specifications that
were submitted as guidelines and which could be locally
customized. Attribution was the one component of the
measurement that was deemed guideline by NQF and is
therefore able to be modified by users. Our process took
advantage of this to land on a single method acceptable
across multiple stakeholders.
Population
The measurement period is 12 consecutive months and
includes services rendered on 1/1/2013 through 12/31/2013.
All claims where dates of service occurred within the
measurement period are included. If a portion of the
attributed population does not include pharmacy costs due
to self-insured employers carving out the pharmacy benefit
to a separate vendor, the pharmacy per patient per month
(pppm) costs will be based on the total pharmacy costs
divided by the number of patient months for those attributed
The population is commercial patients only, including all
patients with pharmacy claims adjudicated by the submitted
fully- and self-insured commercial plan patients where the
payer. The pharmacy pppm value will be added to the overall
payer has access to final adjudicated claims; and group and
medical pppm value to calculate the total pppm costs (NQF
individual plan patients (where available), excluding rental
endorsed standard). The administrative claims used for
PPO network population where adjudication is completed by
measurement must have at least a three month run out
a different payer. There are no geographic requirements on
period between the end of the measurement period and the
patients; however, claims were used exclusively from health
first day the data are made available for study.
plans domiciled in Minnesota. Data from national carriers
was not included.
Denominator Requirements
Patients must be enrolled in the health plan for at least nine
consecutive months within the measurement period. Patients
must be at least one year and no more than 64 years old at
the end of the measurement period. Additionally, patients
must have adjudicated administrative claims with dates
of service within measurement period. All secondary COB
claims are excluded; if all claims for a patient are secondary
Providers define attribution at the medical group level.
The medical group is defined as a grouping of the tax
identification number (TIN). The association follows the
TIN that is present on the administrative claim and not the
individual provider indicator. The TIN is then associated
with a single medical group. The mapping of provider TINs
to medical groups is based on the MNCM Medical Group
definition supplied by the medical groups during their
registration in the MNCM Data Portal for quality measure
data submission.
COB (i.e. payer is not primary payer), patient is excluded.
The calculations are based on total member months.
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
|
39
MN Community Measurement 2014 Total Cost of Care Report
Appendix 2: Methodology (cont.)
Patient Attribution
Risk Adjustment
Patients are attributed to primary care providers only.
Patient cost is adjusted for known risk factors that are
Primary care specialties are defined as Family Medicine,
reported in administrative claims. Version 10.1 of the Johns
Internal Medicine, Pediatrics, and OB/GYN. Acceptable
Hopkins Adjusted Clinical Groups (ACG) System is the
provider types are defined as doctor (MD, DO), nurse
agreed on risk grouper and is also part of the NQF-endorsed
practitioner and physician assistant. Specialty definition
methodology. Lab, Radiology, and Pharmacy claims are
is based on practicing specialty and board certification. If
excluded from risk adjustment via the specific grouper
specialty is undefined, provider will not have any patients
software standard rules.
attributed to him/her. Patients are attributed to the medical
group with the majority (>50 percent) of the patient’s
primary care office visits during the measurement period.
Patients can be attributed to only one medical group. An
office event is defined as any claim with a place of service
of 11 (office) or 22 (hospital outpatient). There is not a
requirement of evaluation and management CPT code.
Denied claims and claims where payer is not primary payer
are excluded from the attribution process.
Risk score calculations use the same truncation methodology
noted above. It is strongly preferred that the risk score be
based on the Minnesota weight file using actual current data
from participating providers and payers. If, however, the
administration of such a file proves unwieldy and too costly,
the standard national file is acceptable. The time period for
the data included in the risk score calculation is the same
as the measurement period. The number of diagnosis codes
available per claim must be the same for all payers that input
Attribution is a two-step process. First, calculate the
data to the process; therefore, in order to have a level impact
attribution using all claims within the measurement
of risk score, the number of codes must be equal to the
period. If the patient remains unattributed, second,
minimum available from all participating payers. As of May
calculate attribution using all claims in the 12-month
2014, the requirement is four diagnosis codes per claim. This
period immediately prior to the measurement period. This
will be re-addressed before each measurement period.
secondary attribution process is only used if there is at least
one office visit claim to the attributed medical group in the
final three months of the secondary period. Attribution is
retrospective; claim activity after measurement period does
not impact the attribution process.
Six hundred unique attributed patients are required within a
medical group for the medical group to be included in public
reporting. All attributed patients are included in the risk
score and population-wide outputs (e.g. statewide average).
A minimum of one provider is required within each medical
If a patient has more than $100,000 in total allowed
group. A percentage of patients exist without a pharmacy
payments in the measurement period, the patient is included;
benefit; therefore, pharmacy costs were estimated and must
however, the metric calculation truncates (caps) the expense
be included in the output to medical groups.
at $100,000 per patient per measurement period.
40
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© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
Sample Clinic
999
1/1/2013 ‐ 12/31/2013
41‐1234567
Page 1 of 5
5/14/2015
This report contains information from multiple providers and health plans. It is intended to used as a directional guide to enhance cost of care understanding. MNCM's will publicly report some or all of the information included on Page 2 of this report on MNHealthScores.org. TCOC is intended to serve medical groups, consumers and employers as a directional guide to enhance understanding of cost of care, confirm previous findings and illuminate new trends. Additionally, the separation of adult and pediatric costs provide even more specific data for medical groups and consumers. TCOC is a measure of all costs associated with treating commercially insured patients. It’s based on actual costs, and includes professional; facility inpatient and outpatient; pharmacy; lab; radiology; ancillary; and behavioral health services. Patients are attributed to medical groups based on the majority of their primary care claims. The primary measure is the Total Cost Index which is the medical clinic's risk adjusted average cost per patient divided by the market's average cost per patient. The cost is defined as the total allowed amount ‐ both insurance payment and patient responsibility ‐ from four major Minnesota health plans: Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica and PreferredOne.
Over the past two years, MNCM worked with an advisory group to create a standardized and risk‐adjusted measure of Total Cost of Care (TCOC) for the Minnesota market. This is the first stable overview Minnesota medical groups, employers and consumers have of total cost of care between medical groups, due to the standard methodology and data from more than 1.5 million commercially‐insured patients. MN Community Measurement is proud to present this inaugural Total Cost of Care report to your medical group.
Date Of Service Range
MNCM Medical Group ID
Tax ID(s) used for patient attribution
Commercial Patients
Total Cost Of Care Summary Report
MN Community Measurement
MN Community Measurement 2014 Total Cost of Care Report
Appendix 3: Medical Group Report Sample
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
|
41
42
|
Sample Clinic
999
Average
47
69
32
83
105
21
93
116
20
Average
Pediatric Patients
Group Total
$215
$480
$216
$435
0.99 1.10
Average
Adult Patients
$571
$513
1.11
1/1/2013 ‐ 12/31/2013
41‐1234567
Low TCI
100th percentile = lowest Total Cost Index.
Total number of medical groups with at least 600 patients each.
Rank from lowest Total Cost Index to highest Total Cost Index.
groups in measure. Comparison is based on one standard Average for all medical groups in measure.
Cost per patient per month, adjusted for patient risk.
Page 2 of 5
5/14/2015
This report contains information from multiple providers and health plans. It is intended to used as a directional guide to enhance cost of care understanding. High TCI
Overall Results
Risk Adjusted cost per patient
State Average cost per patient
Total Cost Index (TCI)
Comparison to mean
Rank
Medical groups eligible for reporting
Percentile
Date Of Service Range
MNCM Medical Group ID
Tax ID(s) used for patient attribution
Commercial Patients
Total Cost Of Care Summary Report
MN Community Measurement
MN Community Measurement 2014 Total Cost of Care Report
Appendix 3: Medical Group Report Sample (cont.)
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
$592
Cost Per Patient Per Month (PPPM)
Medical
Pharmacy
Cost Per Patient Per Month (PPPM)
5
7
9
17
16
15
14
13
12
11
10
8
6
0.3814
0.5055
$432
$165
$153.10
$11.51
$1,755,330
$81,685
$1,837,014
1.0102
1.0000
$480
$436
$485
$404.76
$80.14
$18,396,569
$2,311,725
$20,708,294
$21,595,997
45,450
28,847
1.1119 0.9905 1.1016
$514
$217
$436
$571
$215
$480
0.160 0.231 0.158
1.2223
1.1751
$484
$16,641,239
$2,230,041
$18,871,280
$1,837,014
11,465
7,097
`
Adjusted for differences between age groups (line 14 x line 15).
Average of all medical groups in measure, by age group.
Average of all medical groups in measure.
Risk adjusted cost divided by state average, all patients (line 12 / line 13).
Cost pppm divided by ACG risk score (line 9 / line 10).
Average ACG risk score for all medical groups in measure.
Johns Hopkins ACG, 1.00 = average risk , see ACG report for details.
Line 7 + line 8.
Line 6 / line 3.
Line 5 / line 2.
Cost after truncation, divided by patient months.
Limited to $100,000 per patient per year.
Total costs for patients attributed to medical group.
Total patient months, pharmacy claims.
Total patient months, medical claims.
Total number of months patient was enrolled in health plan during year.
Page 3 of 5
5/14/2015
This report contains information from multiple providers and health plans. It is intended to used as a directional guide to enhance cost of care understanding. Total Cost Index (TCI)
State Average PPPM by Age Group
Risk and Age Group Adjusted PPPM
TCI Standard Deviation
Adjusted Clinical Groupings Risk Score
State Average Risk Score
Risk Adjusted Costs PPPM
State Average PPPM
$489.66
$102.53
Costs after truncation applied
Medical
Pharmacy
$19,758,983
Total Costs
4
3
33,985
21,750
Adult Patients Pediatric Patients
Total Definitions
2,843 961 3,804 Total commercial patients attributed; 600 patients required to report.
Detail Results
Attributed Patients
Patient Months
Medical
Pharmacy
1/1/2013 ‐ 12/31/2013
2
1
999
41‐1234567
Date Of Service Range
MNCM Medical Group ID
Tax ID(s) used for patient attribution
Sample Clinic
Commercial Patients
Total Cost Of Care Summary Report
MN Community Measurement
MN Community Measurement 2014 Total Cost of Care Report
Appendix 3: Medical Group Report Sample (cont.)
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
|
43
44
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999
Patients
1,503
1,021
928
352
3,804
By Health Plan
Blue Cross Blue Shield of MN
HealthPartners
Medica Health Plans
PreferredOne Health Plans
Total
0.6%
14.4%
22.5%
50.7%
9.5%
2.4%
Percentage
Expected 1
$3,205,693
$4,696,707
$2,971,198
$5,783,465
$2,140,779
$18,797,842
0.8%
14.4%
22.9%
49.8%
10.0%
2.2%
State Average
Ratio
1.04
1.62
0.96
0.80
1.08
1.10
Expected by claim type: Calculated by creating a statewide average cost per patient per month by ACG cell by type of claim and applying the medical groups' patient months by ACG cell to estimate an expected (average) cost per type of claim.
1
The Johns Hopkins ACG Grouper analyzed the full year of patient claims and assigned the patient to one of 104 possible ACG cells. The 104 cells are then grouped into six Relative Resource Bands based on expected level of resource use. See the accompanying ACG Report for further details. The information on the left compares the medical group to the general distribution for all medical groups in the measure.
available to health plans.
All remaining health care claims, including specialty care.
Same primary care definition as attribution rules. See notes on Page 5.
UB claim form, non inpatient.
UB claim form with room and board codes.
Expected based all reported medical groups and adjusted for risk mix.
Page 4 of 5
5/14/2015
This report contains information from multiple providers and health plans. It is intended to used as a directional guide to enhance cost of care understanding. 21
549
855
1,927
360
92
3,804
Patients
Actual
$3,335,262
$7,605,495
$2,837,504
$4,618,309
$2,311,725
$20,708,294
1/1/2013 ‐ 12/31/2013
41‐1234567
0 ‐ Non user (previous year claims only)
1 ‐ Very Low Risk Patient
2 ‐ Low Risk Patient
3 ‐ Moderate Risk Patient
4 ‐ High Risk Patient
5 ‐ Very High Risk Patient
By ACG Relative Utilization Band
Patient Distribution
Detail Results
Analysis by type of claim
Inpatient Facility
Outpatient Facility
Primary Care
Other Medical
Pharmacy *
Total
Date Of Service Range
MNCM Medical Group ID
Tax ID(s) used for patient attribution
Sample Clinic
Commercial Patients
Total Cost Of Care Summary Report
MN Community Measurement
MN Community Measurement 2014 Total Cost of Care Report
Appendix 3: Medical Group Report Sample (cont.)
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
999
5.7%
Sample Clinic
37%
20
0.53%
$887,703
4.1%
218
2.2%
6.4%
9.2%
5.7%
0.56%
0.50%
All Eligible Medical Groups
Mean
standard deviation
26.44%
8.79%
1/1/2013 ‐ 12/31/2013
41‐1234567
Claims processed as of April 30, 2014.
Percentage of total dollars removed from measure due to the $100,000 per patient limit.
Patients assigned to medical group based on primary care activity in previous year. All costs are from measurement year only. Number of patients with total costs over $100,000 in measurement year.
Percent of patients where pharmacy data was unavailable from the health plan.
Page 5 of 5
5/14/2015
This report contains information from multiple providers and health plans. It is intended to used as a directional guide to enhance cost of care understanding. Please contact MN Community Measurement at tcoc@mncm.org if you have any questions or concerns.
Risk adjustment calculated using Johns Hopkins ACG system. Weights calculated using all costs in reported medical groups.
Primary care is defined as family medicine, internal medicine, pediatrics, geriatrics, and obstetrics and gynecology. Office defined as site of service 11 or 22.
Attribution completed at a medical group level. Patients assigned if a single medical group had the majority of a patient's primary care activity during the dates of service. Activity defined as number of in‐office services delivered within dates of service.
Pharmacy claims administered by a different payer are estimated as shown above. See lines 5 through 9 on Page 3 for details.
Patient eligibility parameters included: 1) Commercially‐insured patients only, with a minimum of 600 patients required for calculation. 2) Patients must be between ages 1 and 64 at the end of the measurement year. Pediatric age group defined as ages 1 through 17; adult age group defined as ages 18 through 64. 3) Patients must be in a single health plan for at least nine of the 12 month measurement period.
Commercial patients include individual and group plan members, fully and self insured. It excludes self pay and any group where the health plan does not have access to fully adjudicated medical claims. The data source is commercially‐insured patient claims from four health plans, excluding denied, dental and Coordination of Benefit claims. Costs are defined as total allowed payment from health plan claims, including patient responsibility. All patient costs are included, regardless of where they originate.
The Total Cost of Care measure is intended to create a standard methodology for measuring cost and displaying the variation in costs between medical groups. The methodology has been endorsed by the National Quality Forum (NQF).
Methodology and Process Notes
Costs removed from model due to the
$100,000 limit per patient
Patients attributed in previous year
Pharmacy data estimated
Patients with total dollars over $100,000
Summary Statistics
Date Of Service Range
MNCM Medical Group ID
Tax ID(s) used for patient attribution
Sample Clinic
Commercial Patients
Total Cost Of Care Summary Report
MN Community Measurement
MN Community Measurement 2014 Total Cost of Care Report
Appendix 3: Medical Group Report Sample (cont.)
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
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45
46
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1722
1800
1900
2000
2100
2200
2300
2400
1400
1600
1710
1711
1712
1720
1721
ACG
100
200
300
400
500
600
700
800
900
1000
1100
1200
Acute Minor and Eye/Dental
Acute Minor and Chronic Medical: Stable
Acute Minor and Likely to Recur, Age > 5, with Allergy
Acute Minor and Likely to Recur, Age > 5, w/o Allergy
Acute Minor and Likely to Recur, Age 2 to 5
Acute Minor and Likely to Recur, Age 1
Acute Minor and Acute Major
Pregnancy: 2‐3 ADGs, no Major ADGs, not delivered
Pregnancy: 2‐3 ADGs, no Major ADGs, delivered
Pregnancy: 2‐3 ADGs, no Major ADGs
Pregnancy: 0‐1 ADGs, not delivered
Pregnancy: 0‐1 ADGs, delivered
Pregnancy: 0‐1 ADGs
Preventive/Administrative
Psychosocial, with Psych Unstable, w/o Psych Stable
Chronic Specialty, Unstable
Eye/Dental
Chronic Specialty, Stable
Chronic Medical, Stable
Chronic Medical, Unstable
Asthma
Likely to Recur, with Allergies
Likely to Recur, w/o Allergies
Acute Major
Acute Minor, Age > 5
Acute Minor, Age 2 to 5
Description
Acute Minor, Age 1
Sample Clinic
Total Cost Of Care Summary Report
MN Community Measurement
ACG Report 9 11
162 145
5 13
28 46
79 115
5 16
32 35
62 42
108 0.50
1,931 0.34
60 0.50
333 0.22
946 0.21
60 0.25
384 0.25
730 0.16
12 0.47
2,704 0.09
‐
‐
48 2.36
36 0.33
‐
‐
81 2.62
1 2
227 241
‐
‐
4 5
3 4
‐
‐
7 14
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
Risk Cost Per Patient Per Month1
Weight
Actual Market Average
0.36
$xxx
$xxx
0.13
$xxx
$xxx
0.11
$xxx
$xxx
0.24
$xxx
$xxx
0.17
$xxx
$xxx
0.18
$xxx
$xxx
0.17
$xxx
$xxx
1.14
$xxx
$xxx
0.20
$xxx
$xxx
0.14
$xxx
0.11
$xxx
$xxx
0.22
$xxx
Actual Patient
Months
60
343
1,951
1,181
1,148
69
93
84
695
12
1,091
12
Patients
Actual Average Group
5 7
29 35
164 181
99 84
97 97
6 10
8 6
7 6
58 59
1 2
92 61
1 2
The Johns Hopkins ACG Grouper analyses a full year of patient claims and assigned each patient to a single ACG cell. The risk weights are determined by calculating the market wide average cost per patient per cell compared to the overall average cost per patient. The market is defined as all medical groups with at least one patient in this measure. The Average Group column is to show the average distribution of patients for a medical group of this size.
MN Community Measurement 2014 Total Cost of Care Report
Appendix 3: Medical Group Report Sample (cont.)
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
Acute Minor and Psychosocial, with Psych Unstable and Description
$xxx
22 38 264 0.92
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
$xxx
Totals 3,804 3,804 45,180 45,643
$485
$440
Risk Score: sum(Risk Weight*Patient Months)/Total Patient Months
Expected Value
1.0102
for patient mix
Actual to expected 1.102
TCI 1.102
For more information on the Johns Hopkins ACG System
http://acg.jhsph.org/index.php/the‐acg‐system‐advantage/acgs
1
Required minimum of five patients to display cost per patient Infants: 0‐5 ADGs, 1+ Major ADGs
Infants: 0‐5 ADGs, no Major ADGs
407 0.13
249 ‐
‐
‐
‐
‐
34 32
21 29
‐
‐
‐
‐
Non‐Users (2 input files)
No Diagnosis or Only Unclassified Diagnosis (2 input files)
5110
5200
5310
5320
‐
$xxx
4 ‐
61 79 729 2.81
‐
383 343 4,574 1.57
5040 10+ Other ADG Combinations, Age > 17, 0‐1 Major ADGs
5010
10+ Other ADG Combinations, Age 1 to 17, no Major ADGs
4910 6‐9 Other ADG Combinations, Age > 34, 0‐1 Major ADGs
4730
6‐9 Other ADG Combinations, Males, Age 18 to 34, 2+ Major ADGs
4610 ADGs
$xxx
$xxx
$xxx
57 49 675 0.38
366 309 4,366 0.46
4000 2‐3 Other ADG Combinations, Females Age 18 to 34
4100 2‐3 Other ADG Combinations, Age > 34
4 7 48 3.38
$xxx
47 61 560 1.05
3700 Acute Minor/Acute Major/Likely Recur/Psychosocial
6‐9 Other ADG Combinations, Age 6 to 17, no Major $xxx
119 131 1,423 1.08
3300
3600 Acute Minor/Acute Major/Likely Recur/Eye & Dental
$xxx
26 29 310 0.47
$xxx
$xxx
Risk Cost Per Patient Per Month1
Weight
Actual Market Average
1 2 11 1.34
6 11 72 0.89
Patients
Actual Patient
Actual Average Group
Months
12 15 144 0.62
Acute Minor/Acute Major/Likely to Recur, Age > 11, with Allergy
3000 Acute Minor/Acute Major/Likely to Recur, Age 2 to 5
2700 Psych Stable
2900 Acute Minor/Acute Major/Likely to Recur, Age 1
ACG
MN Community Measurement 2014 Total Cost of Care Report
Appendix 3: Medical Group Report Sample (cont.)
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
|
47
MN Community Measurement 2014 Total Cost of Care Report
Appendix 4: Overview of Cost Information on MNHealthScores.org
A critical component of MN Community Measurement’s
Cost information is available in multiple areas on
(MNCM) mission is to publicly report health care information,
MNHealthScores.org:
with the goal of driving improvement. Our public reporting
•
website is MNHealthScores.org; it is focused on and
and compare Total Cost of Care (TCOC) and Procedure
designed for patients, their families and the public to help
Cost information across medical groups; find health
them make educated choices about where to obtain care and
plan cost tools; read tips on stretching their health care
understand what care they should expect.
dollars further; and get linked to consumer resources on
health care cost.
In 2014, we redesigned MNHealthScores.org to better
meet the needs of Minnesota health care consumers. To
actively participate in their care and help drive improvement,
•
Medical Group Search Results: When comparing
medical groups, cost and quality information appear
consumers must understand and be able to use the
side-by-side in the search results. Displaying this
information that MNCM reports. The site features consumer-
information together is vital to giving consumers a full
friendly data displays that represent best practices gleaned
picture through which to interpret TCOC results.
from more than a decade of academic research on consumer
interpretation of health care cost and quality data displays.
Managing Cost: In this section, consumers can search
•
Medical Group Profile Pages: On each medical
They highlight a HealthScore for each clinic, medical group
group’s profile page, the group’s specific TCOC results
or hospital for each measure. This HealthScore is an easy-
are displayed alongside its specific quality results.
to-understand icon and label that categorizes data into clear
Consumers can also view procedure costs at that
groupings. This provides consumers with important context
medical group on this page.
to understand the rates.
We hope you’ll visit MNHealthScores.org and recommend it
as a resource to your patients and other community members.
48
|
© MN Community Measurement 2015. All rights reserved. May be used by participating provider groups as defined in the Medical Group Data Sharing Agreement.
MN Community Measurement
Broadway Place East, Suite 455
3433 Broadway Street NE
Minneapolis, MN 55413
612-455-2911 | info@mncm.org
www.MNCM.org
www.MNHealthScores.org