Wisconsin Health Information
Organization
June 2011
Presentation
I.
II.
III.
IV.
V.
VI.
What is WHIO & How was it Formed?
Mission & Goals
Business Model
Description of the WHIO Data Mart
Other State Data Aggregation Efforts
Description of the Functionality of the Health
Analytics Exchange
VII. Sample Provider Standard Report
VIII.Description of Standard Cost, Attribution Logic &
Risk Adjustment
IX. The Business Case for Using WHIO
WHIO
• 2004-2005
• WCHQ had only clinical data
• Physician performance
measurement on the horizon
• Physicians wanted credible data,
input into measurement development,
standardized measures, that
produced actionable information
• POVD Legislation & WI Chapter 153
Goals of WHIO
• To aggregate health care data from sources across
Wisconsin to create a single reliable data source to
be used by multiple stakeholders to examine
variations in efficiency, quality, safety and cost
• To improve the quality, cost, safety and efficiency
health care in Wisconsin by sharing the results with
providers, purchasers and consumers
• To support provider quality improvement initiatives
• To encourage value-based health care choices by
consumers
WHIO Members
• Greater Milwaukee
Business Foundation on
Health
• Humana
• The Alliance
• United Healthcare of WI
• Anthem BC/BS of WI
• WEA Trust
• WPS Health Insurance
• Wisconsin Medical
Society
• Gundersen Lutheran
Health Plan
• Mercy Health Plan
• Physicians Plus Insurance
• The Wisconsin
Collaborative for
Healthcare Quality
• Wisconsin Department of
Health Services
• Wisconsin Department of
Employee Trust Funds
• Wisconsin Hospital
Association
• Group Health Cooperative
South Central Wisconsin
• Health Tradition Health
Plan
• Unity Health Plan
• Dean Health Plan
• Security Health Plan
• Network Health Plan
WHIO Subscribers
Aurora Health
Aspirus
Bellin Health
Prevea
ThedaCare
NEWHVN
Others—stay tuned
Business Model
•Voluntary
•Private-Public
•Non-Profit 501 (c) 3
•Funded by Members & Subscriptions
WHIO
Data Mart V3 Vs. Data Mart V2
10
DMV4 General Facts
DMV3
Members Included^
DMV4
2,822,985
3,436,661
47.1%
58.0%
136.8M
207.1M
% Commercial Claims
52%
40%
% Medicaid FFS Claims
42%
29%
% Medicaid HMO Claims
0%
20%
% Medicare Claims
6%
11%
$20.7B / $35.7B
$28.9B / $51.6B
11.1M
18.8M
1.2M
2.3M
133,845
88,171
26,910
19,301
% WI Population*
Claims Included
Claim $ Included (Std. Cost/Billed)
Episodes of Care
Episodes of Care in PNA
Providers Included
WI Providers in Peer Definition
^All individuals included in data mart for Impact Intelligence. There were 2,651,947 and
3,259,919 WI individuals in DMV3 and DMV4, respectively.
*Estimated 1-1-2010 at 5,621,847
DMV 5 General Facts
Members Included^
DMV4
3,436,661
DMV5
3,730,210
% WI Population*
58.0%
62.8%
Claims Included
207.1M
233.5M
% Commercial Claims
40%
42%
% Medicaid FFS Claims
29%
26%
% Medicaid HMO Claims 20%
19%
% Medicare Claims
11%
13%
Claim $ Included
(Std. Cost/Billed)
$28.9B / $51.6B $32.2B / $59.3B
Episodes of Care
WI Providers in
Peer Definition
18.8M
21.5M
19,301
19,272
WHIO Cost vs WCHQ Clinical Quality
WHIO Cost vs WCHQ Clinical Quality
WHIO Current Business
Value Model
Data
Contributors
send claims
and eligibility
data
To
Commercial
Insurers
Aggregate
data and
match
patients &
providers
across
health
plans
Member
Information
is DeIdentified to
satisfy
HIPAA and
then loaded
to the Data
Mart
Claims are
grouped into
episodes for
each patient
and then
attributed to
providers
Application
accessed by
Members &
Subscribers
to produce
physician
performance
reports &/or
extract data
Efficiency
Measures
compare a
providers
performance
to the mean
performance
of his/her peer
group based
on relative
resource
utilization
Ingenix
Health Plans
TPAs/
Self- Funded
Employers
Medicaid Medicare
?
Actual cost
information
replaced w/
standard
costs
WHIO
Data
Mart
Web-based
application
Application
accessed to
produce
practice level
reports
Reports
Quality Process
Measures compare
providers to the
Evidence Based
Medicine National
Standards
Other Data Aggregation Measurement
Efforts
• Massachusetts Group Insurance
Commission (GIC)
– Covers 300,000 state employees
– Aggregates data for 6 health plans for those
employees
– Tiers physicians by quality and costeffectiveness
• CMS Better Quality Information (BQI)
Project
– Aggregated Medicare data with other data sets
– Created specific quality performance metrics
– 6 Regional participants including Wisconsin
Collaborative for Healthcare Quality and MN
Community Measurement
• CMS MedPar
19
– Hospital only data
Other Data Aggregation Measurement
Efforts
• California Integrated Healthcare Association (IHA)
P4P program
– Integrates specific measure data from 7 health plans
– Measures clinical quality, patient experience, health
information technology (HIT) adoption, coordinated
diabetes care and appropriate resource use at the group
practice level
– Health plans submit data elements required and are
audited
• RHIOs/HIEs-not significant traction
• All other cost effectiveness assessments of
physicians and groups appear to be at the health
plan level
– No large employers doing this
. 20
ETG 7.x – Episode Classification
 Clinical Condition
–
1.2 Concepts Guide: Pgs 4-2 to 4-9
the underlying condition described by the episode (base class)
 Complications
–
identification of condition complications that may require more
extensive treatment for a related condition*
 Comorbidities
–
identification of ongoing chronic conditions that affect treatment
requirements for other episodes*
 Treatment Indicator (new)
–
*
21
identification of treatment relative to the condition such as a
defining surgery, dialysis, chemotherapy, radiation, and
radiotherapy*
The presence of complications, comorbidities, and defining treatments will determine the ETG
assignment for the member’s episodes of care.
WI Health Improvement Zone –
Care Improvement Dialogues
(WHIZ-CIDs)
From WHIO Data
Tim Bartholow, MD, Sr. VP,
Wisconsin Medical Society
Tim.Bartholow@WisMed.org
22
DMV 2 $9.3B
Major Practice Category
Total Cost
Orthopedics and Rheumatology
$1,385,441,127
15%
14.9%
Cardiology
$1,059,460,415
11%
26.3%
Gastroenterology
$725,004,310
8%
34.1%
Neurology
$509,719,451
Endocrinology
$477,072,185
Gynecology
$416,557,300
Pulmonology
$411,812,819
Psychiatry
$339,460,224
4%
37.7%
Otolaryngology
$316,876,675
Dermatology
$278,801,477
Urology
$276,364,095
Preventative and Administrative
$244,974,208
Obstetrics
$217,017,851
Hematology
$201,882,166
Ophthalmology
$180,212,386
Nephrology
$155,013,507
Hepatology
$127,087,312
Neonatology
$101,243,402
Infectious Diseases
$74,333,244
Chemical Dependency
$51,025,242
1%
38.3%
Late Effects, Environmental Trauma and Poisonings
$34,809,976
Isolated Signs and Symptoms
$25,157,886
Not assigned an MPC
$
1,690,672,000
% of $9.3 B
23
IHD with Angioplasty: TOTAL
STANDARD COST
TYPE OF SERVICE
Second Year of DMV2: $63,144,592
16% , $10,404,778
5% , $3,153,732
2% , $1,360,688
17% , $10,694,920
60% , $37,530,473
Ancillary
Facility Inpatient
Facility Outpatient
Pharmacy
Professional Services
24
IHD with Angioplasty,
2 Groups 2 Hours From One Another,
Doctors with at Least 10 Episodes, DMV2
$40,000
3
$36,009
$33,911 $33,508
$30,865
2.5
$29,853
Std Cost per Episode
$30,000
$26,728
$25,221 $24,897 $24,890 $24,772
2
$25,000
$21,863
$20,000
1.5
$15,000
1
$10,000
Health Risk, Retrospective
$35,000
Std Cost per Episode
Health Risk
0.5
$5,000
$-
0
A
A
A
A
A
A
A
Doctor in Clinic A or B
B
A
B
B
25
IHD with Angioplasty,
2 Groups 2 Hours From One Another,
Doctors with At Least 10 Episodes, DMV 2
$3,000,000
3
$2,500,000
2.5
$2,000,000
2
$1,500,000
1.5
$1,292,215
$1,280,143
$1,000,000
1
$795,803
$676,468
$721,476
$504,415
$385,606
$346,480
$280,645
$500,000
Health Risk, Retrospective
Total Std Cost
$2,604,664
Total Std Cost
Health Risk
0.5
$338,544
$-
0
A
A
A
A
A
A
A
Doctor in Clinic A or B
B
A
B
B
26
Medicaid Data Add-New Capabilities
• More Comparisons
– Expansion of episodes per provider expands the pool of
those with enough episodes to provide meaningful
comparisons
• Different Comparisons
– Standard pricing provides to opportunity to evaluate for
unit and mix of service differences in equivalent episodes
between Medicaid and Commercial
• Different Population Demographics
– Inclusion of the Medicaid FFS data provides a broader
cross section and demographic look at WI health care
27
If I Were a State Health Agency With
Access to WHIO DMV5, I Could . . .
• Get data on disease prevalence for a large portion
of the WI population at the state/regional/local
levels
• Assess Wisconsin wide/regional performance on
key health care quality measures to drive health
quality improvement programs
• Understand performance differences between WI
providers who see Medicaid patients and those
who don’t
• Assess regional/local differences in the use of
health care technology or procedures across a
wide swath of the WI population
28
If I Were a Health Plan/Insurer With Access
to WHIO DMV5, I Could . . .
• Compare disease prevalence and other population
health measures for my population with the
combined WHIO commercial population
• Assess the performance on evidence-based quality
metrics of my provider network compared to other
networks and WI as a whole
• Compare the cost efficiency of different providers
within my network and encourage programs to
improve cost efficiency
• Track and understand the variation around the
utilization of – e.g. spine surgeries-- by providers of
care for my health plan
29
If I Were a Large, Self-Funded Employer
With Access to WHIO DMV5, I Could . . .
• Compare disease prevalence and other population
health measures for my population with the
combined WHIO commercial population
• Assess the performance on evidence-based quality
metrics of my provider network compared to other
networks and WI as a whole
• Compare the cost efficiency of different providers
within my network and initiate discussions with
those less efficient
• Track and understand the variation around the
frequency of– e.g. readmission rates-- by hospitals
that care for my employees
30
If I were a Large Integrated Medical System
I could --
•Evaluate quality process measures of individual
physicians & groups of physicians, and compare them
to internal peer groups and to competitors
•Identify opportunities for Quality Improvement
•Monitor Quality Improvement Projects
•Identify and evaluate business development
opportunities
•Level playing-field dialogue when contracting with
payors
•Identify hospital admissions & readmissions, and
compare readmission rates with other hospitals by
service line, DRG or ETG
•AND MORE!
If I Was WHIO-Oh, Wait! I Already Can . . .
Do all of the above, plus use the depth and breath
of the claims and episode data to create units of
measurement to facilitate Improvement in the
Quality of Health Care and the Health of the
Population in Wisconsin based on a variety of
approaches-almost all of which require
comparable clinical units of care, identification of
the mix of services and associated costs.
. 32
WHIO 2011-2012
• Added claims data from Dean Health Plan,
Security Health Plan, GHC-SC, Mercy Health Plan,
& MA-HMO-- DM V4 Oct 2010
• Added claims data from Network Health Plan,
Physicians Plus Health Plan, & Health Traditions
Health Plan– DM V5 Apr 2011
• Add claims data from Unity Health Plan October
2011
• Add Medicare data
• Expand peer definition specialties
33