Total Cost of Care in Action

Transcription

1 Total Cost of Care in Action Meredith Roberts Tomasi, Sr. Program Director, Q Corp Doug Rupp, Sr. Health Analyst, Q Corp The information in this presentation may be subject to copyright and may not be reproduced without permission of the presenters.

2 Objectives for Today 1. Describe what Total Cost of Care is and why it is important 2. Distinguish between the measures that go into Total Cost of Care 3. Explore how to use Total Cost of Care Reports with primary care practices to make actionable improvements 2

3 Background 3

4 What is Total Cost of Care? 4

5 Health Partners Total Cost of Care Overview 5

6 Q Corp s Phases of Cost of Care Reporting 6

7 Clinic Comparison Reports 7

8 Clinic Comparison Report Package Quality, Cost and Utilization at the clinic level Clinic reports mailed and ed to 79 medical groups in Oregon. A total of 143 adult and 44 pediatric clinic-level reports were sent in Cover letter Definitions and Glossary Sheet Report Demographics & Cost Overview Professional Outpatient Imaging and ER Inpatient Chronic Conditions Pharmacy Year over Year Frequently Asked Questions (FAQ) Includes Section on How to Use These Reports 8

9 Expanding to Medicare Population Providers eager to see more than Commercial population Q Corp is able to access data through CMS Qualified Entity program Key issues: Attribution Dual Eligibles Pharmacy Compatibility with QRUR reports 9

10 Feedback from Clinics There is value to using the report template/ format for both the commercial and Medicare FFS populations when reporting TCOC. Medicare patients are more likely to be attributed to specialists and therefore might be missing from the report. We need further understanding of this attribution issue. Clinics understood why exclusions were made for dual eligible and ESRD patients. There were mixed reactions about the validity of the risk adjustment and this is an area that should be delved into further. Not having pharmacy data was a gap but delayed pharmacy data would have limited value. There is limited experience and familiarity with the QRUR reports. However, CPC clinics are much more familiar with the Medicare FFS data they receive, although these data lacks indices. 10

11 Technical Assistance Priorities 11

12 Questions? Meredith Roberts Tomasi Doug Rupp Douglas. 12

13 Appendix 13

14 Claims Data Summary 14

15 About the Total Cost of Care Measures Population-based measure of average cost for the health care of an attributed population. Total per capita costs (or resources used) for a panel of patients attributed to a primary care clinic. Includes all care delivered to all attributed patients Professional, Outpatient, Inpatient and Pharmacy Includes all allowed amounts All payments made by the patient and the insurer Commercially insured patients only Clinic-level reporting measured against a benchmark Based on the patented algorithm of HealthPartners, Inc. In use for over 10 years and adopted nationally. Over 160 licensees in 35 states. 15

16 Risk-Adjusted Costs Costs per member per month (PMPM) are adjusted to account for patient characteristics. Patients are grouped based on diagnoses, age and gender using Johns Hopkins Adjusted Clinical Groups (ACG) risk adjusters One ACG per person per time period 92 different ACGs active at a given time. Each ACG includes individuals with a similar pattern of morbidity Unit of analysis is patient and not visit or service Person-focused: captures longitudinal, multi-episode dimension of care Exclusions: Costs over $100k per patient for one year measurement period Patients under the age of 1 or over the age of 65 This material was prepared by HealthInsight, the Medicare Quality Innovation Network-Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-CORP OR 16