High Cost Users for LHINs & Health Links Health Analytics Branch, HSIMI September 2013
Distribution of Costs, 2010/11 Proportion of Ontario Patients Proportion of Costs 2
Defining the high cost user In the following analyses, high cost users are the 10% of patients with the highest combined cost in 2010/11 for the following health care services: Acute Care Day Surgery Emergency Rooms Inpatient Rehabilitation Inpatient Mental Health Complex Continuing Care Home Care Long-Term Care Physician Claims These sectors account for approximately 74% of the Ministry/LHIN operating expenses The analysis is based on cost alone. This group of patients may include those with a single very expensive event (e.g. transplants) or multiple events with high combined cost (e.g., care for chronic conditions). 3
Purpose of Current Analyses Upon the establishment of the Early Adopter Health Links, the ministry received requests for high cost user analyses for these areas. The following describes analyses of the high cost users at the LHIN and Health Link levels (22 Health Links approved as of February 2013); the analysis focuses on the 10% of patients who reside within each Health Link area who had the highest combined cost in 2010/11. Due to the small size of some Health Link areas the analysis has been done only for the Top 10% patients. The analysis was done separately for each geographic area. Note that LHIN/Health Link High Cost Users may not be within the Ontario high cost users. 4
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Key Findings Regardless of whether we focus on the high cost users at the Health Link, LHIN or provincial level, the following key findings are applicable: 1. A patient who is a high cost user in one fiscal year may not continue to be a high cost user in future years. 2. Rare conditions, such as transplants, low birth weight babies, and burns have the highest average acute care cost, while chronic conditions, hip fracture, hip replacement and palliative care have the highest total cost. Health Links have the potential to impact certain groups of high cost users. 3. High cost users are a diverse group, but typically have two key characteristics: They receive treatment from multiple health care sectors and/or have long lengths of stay in inpatient settings. 7
Key Findings (continued) 4. For most sectors, the average number of episodes and cost per episode is similar for high cost users and all users. However, high cost users access a larger number of health care sectors. 5. The characteristics of patients and patterns of health care utilization among high cost users are similar across geographic areas. Seniors represent the largest percentage of patients/expenses and have the highest average cost per patient. Acute care, physician visits, and long-term care represent the largest percentage of expenses. 6. The profile of high cost users is consistent with the population structure of the area. Areas with more seniors will have more seniors among the high cost user patients. Areas with more young families will have more children and young adults among the high cost user patients. 8
Understanding the High Cost User, 2010/11 9
High Cost User Patients Example Profiles High cost users access multiple types of care and have long lengths of stay Female, age 25-39 yrs (cost: $1 million) Acute inpatient care : 5 discharges 190 acute days + 60 ALC days Male, age 50-64 yrs (cost: $570,000) Male, age 80+ yrs (cost: $240,000) Acute inpatient care: 2 discharges 70 acute days + 90 ALC days Acute inpatient care: 3 discharges 75 acute days Emergency: 5 visits Day surgery: 1 visit CCC: 1 episode, 340 days Homecare: 62 services Nursing, physiotherapy, OT and personal support Physician visits\claims: 105 Problems\Conditions: Heart transplant, congestive heart failure, digestive symptoms, cellulitis, cardiovascular screening, transplant rejection CCC: 1 admission, 80 days Inpatient Rehab: 1 discharge, 130 days Physician visits\claims: 170 Problems\Conditions: Respiratory failure, traumatic brain injury, craniofacial bone intervention Emergency Dept: 3 visits Day Surgery: 2 visits Homecare: 12 services Nursing, Physiotherapy Physician visits\claims: 105 Problems\Conditions: AMI\angina, AMI\shock arrest\with cardiac cath., respiratory intervention, gastrointestinal intervention, screening exam, cardiac study, endoscopic inspection digestive tract 10
Once a high cost user not necessarily always a high cost user 11
Conditions in Acute Care Highest Average Cost Case Mix Group Separations/ Discharges Top 10% Patient Segment Total Expense ($) Average Expense ($) 160 Heart or Lung Transplant 65 $ 11,360,000 $ 169,600 710 Extensive Burn with Skin Graft 35 $ 5,320,000 $ 161,100 571 Newborn/Neonate 1500+ gm with Major 145 $ 20,830,000 $ 145,700 Cardiovascular Intervention 110 Lung Transplant 60 $ 7,520,000 $ 121,300 578 Newborn/Neonate <750 grams 200 $ 21,420,000 $ 108,200 131 Failure/Rejection Lung Transplant 10 $ 890,000 $ 98,400 570 Newborn/Neonate 1500+ gm with Major 170 $ 16,420,000 $ 95,500 Gastrointestinal/Diaphragm Intervention 579 Newborn/Neonate 750-999 grams, Gestational 305 $ 27,720,000 $ 90,900 Age <29 Weeks 270 Liver/Pancreas/Duodenum Transplant 195 $ 15,910,000 $ 81,200 581 Newborn/Neonate 1000-1499 grams, Gestational Age <29 Weeks 375 $ 25,420,000 $ 68,100 List includes relatively rare events with very high acute care cost. 12
Conditions in Acute Care Highest Total Cost Case Mix Group Separations/ Discharges Top 10% Patient Segment Total Expense ($) Average Expense ($) 139 Chronic Obstructive Pulmonary Disease 23,520 $ 187,110,000 $ 8,000 545 Vaginal Delivery, No Other Intervention 64,505 $ 179,670,000 $ 2,800 196 Heart Failure without Cardiac Catheter (CHF) 19,100 $ 170,380,000 $ 8,900 321 Unilateral Knee Replacement 19,335 $ 163,560,000 $ 8,500 138 Viral/Unspecified Pneumonia 19,220 $ 142,940,000 $ 7,400 810 Palliative Care 12,660 $ 134,050,000 $ 10,600 221 Colostomy/Enterostomy 4,315 $ 127,420,000 $ 29,500 162 Cardiac Valve Replacement 3,150 $ 119,620,000 $ 38,000 175 Percutaneous Coronary Intervention with MI/Shock/Arrest/Heart Failure (Angioplasty) 9,410 $ 118,920,000 $ 12,600 727 Fixation/Repair Hip/Femur (Hip Fracture) 7,285 $ 115,300,000 $ 15,800 List includes chronic conditions with moderate to high acute care costs. Patients with vaginal delivery are among the high cost users because they have numerous physician visits, and other types of care in addition to the cost of the birth. 13
Number of Sectors Used Top 10% patients for Ontario Top 10% patients by Health Link Health Link Area of Residence Average # of Sectors Used 3% used a single sector. 89% used 2-4 sectors. 7% used 5 or more sectors. The average number of sectors used was 3.0. The average number of sectors used by LHIN of patient residence ranged from 2.8 to 3.4. Perth County 3.3 Huron 3.4 Guelph 3.0 Hamilton Central 3.3 N. Etobicoke-Malton-W. Woodbridge 2.9 Dufferin 3.1 South East Mississauga 2.9 Mid Toronto West 2.8 Don Valley/Greenwood 2.8 North Toronto East 2.8 S. Simcoe and Northern York 2.9 North York Region 2.9 Peterborough 3.3 Rural Hastings 3.3 Quinte 3.3 Rural Kingston 3.0 Kingston 3.1 Thousand Islands 3.3 Barrie Community 3.0 South Georgian Bay 3.2 Temiskaming 3.4 Timmins 3.4 The average number of sectors used ranged from 2.8 to 3.4. 14
Proportion of patients by sector type If we compare all Ontario users to the top 10% : Nearly 100% of patients had a physician visit. 26% of all users and 63% of high cost users had an emergency visit 7% of all users and 61% of high cost users had an acute care discharge 9% of all users and 33% of high cost users had a day surgery visit 4% of all users and 27% of high cost users received a homecare service 1% of all users and 9% of high cost users spent time in long-term care While the magnitude varied, the patterns of utilization for both groups were similar at the Health Link and LHIN of residence level. 15
Event Frequency by Sector Among the Ontario top 10% patients: 96% had 6 or more physician visits in 2010/11. For all other sectors, among the patients with activity, the largest proportion had a single event. 26% of patients had 1 emergency visit, while 21% had 3 or more visits. Less than 10% of patients received treatment in mental health, rehabilitation, CCC, or LTC. 27% of patients received homecare with an average of 77 visits/hours per patient. 16
Total Length of Stay (LOS) Patients in the top 10% in Ontario: Account for 95-100% of the total LOS for all Ontario users within each sector. Have 6.3 million total days in acute care, including 1 million ALC and 720,000 special care unit days. Have 718,000 days in inpatient rehabilitation. Have 1.4 million days in inpatient mental health. Have 1.7 million days in complex continuing care. Have 27.4 million days in long-term care. 17
Comparison of Analyses - 2009/10 vs. 2010/11 All Users Top 10% 2009/10 2010/11 Total Patients 3,901,620 11,160,290 Total Expense (Billions) $14.2 $25.2 Average Cost per Patient $3,500 $2,300 Patients 390,160 1,116,030 Total Expense (Billions) $10.6 $19.4 Average Cost per Patient $27,000 $17,400 % of Total Expense 75% 77% With the addition of LTC and Physician visits, the number of patients and the expense increased among all users and high cost users; however the average cost per patient declined. However, regardless of the method, 10% of patients account for just over 75% of the included health care expenditures. 18
Expense Summary Early Adopter Health Links The top 10% patients account for 74-81% of the total expenses for Health Link residents and 74-78% of expenses for LHIN residents, indicating that the proportion of total expenses for high cost users is consistent across Health Links and LHINs. All Users Health Link Area of Residence Total Patients Expense (Millions) Perth County 61,045 143 Huron 51,860 141 Guelph 119,740 246 Hamilton Central 123,820 417 N. Etobicoke-Malton-W. Woodbridge 189,490 384 Dufferin 57,220 118 South East Mississauga 159,915 317 Mid Toronto West 123,210 350 Don Valley/Greenwood 68,075 173 North Toronto East 100,605 225 S. Simcoe and Northern York 224,990 444 North York Region 554,125 1,258 Peterborough 118,415 333 Rural Hastings 33,875 92 Quinte 106,615 283 Rural Kingston 27,380 61 Kingston 113,440 332 Thousand Islands 63,065 185 Barrie Community 168,435 343 South Georgian Bay 49,795 124 Temiskaming 28,185 95 Timmins 36,855 99 Patients Total Expense (Millions) Top 10% % of Total Expense for All Users Average Expense $ 6,105 $ 112 78 $ 18,300 $ 5,185 $ 108 76 $ 20,800 $ 11,975 $ 190 77 $ 15,900 $ 12,385 $ 336 81 $ 27,100 $ 18,950 $ 287 75 $ 15,200 $ 5,720 $ 90 76 $ 15,600 $ 15,990 $ 237 75 $ 14,800 $ 12,320 $ 280 80 $ 22,700 $ 6,810 $ 137 79 $ 20,100 $ 10,060 $ 173 77 $ 17,200 $ 22,500 $ 330 74 $ 14,700 $ 55,415 $ 958 76 $ 17,300 $ 11,840 $ 254 76 $ 21,400 $ 3,390 $ 70 77 $ 20,800 $ 10,660 $ 216 76 $ 20,200 $ 2,740 $ 47 77 $ 17,200 $ 11,345 $ 264 80 $ 23,300 $ 6,305 $ 146 79 $ 23,100 $ 16,845 $ 262 77 $ 15,600 $ 4,980 $ 95 76 $ 19,000 $ 2,820 $ 74 78 $ 26,300 $ 3,685 $ 73 74 $ 19,800 19
Average Cost Per Event Sector Average Cost/Event All Users Top 10% Average Cost/ Inpatient Day Average Cost/Event Average Cost/ Inpatient Day Acute Separation $ 7,678 $ 1,875 $ 8,150 $ 2,026 Rehabilitation Discharge $ 17,944 $ 898 $ 17,913 $ 888 CCC Episode $ 35,775 $ 584 $ 37,133 $ 589 Mental Health Episode $ 18,111 $ 554 $ 21,662 $ 575 LTC Episode $ 20,750 $ 99 $ 24,044 $ 99 Day Surgery Visit $ 981 $ 1,407 Emergency Visit $ 249 $ 391 Physician Visit $ 69 $ 135 Home Care Service (Hour/Visit) $ 54 $ 75 Among all users and Ontario patients in the top 10%: Acute and rehabilitation have the highest average cost per day. Homecare, physician and ED visits have relatively low costs per event. The difference in the average cost for the top 10% vs. all users is relatively small, suggesting that the higher cost is due to a greater number of events rather than more expensive events. 20
Patients and Cost by Age Group If we compare the Ontario population to patients in the top 10%: Seniors account for 41% of high cost user patients, but only 14% of the population. Although infants represent 1% of the population they account for 2.5% of high cost users. Children and young adults (age 18-44 years) combined account for 58% of the population and 33% of high cost user patients. Seniors and infants have the highest average health care costs, while young adults have the lowest. 21
High Cost User Profile is Consistent with Population Age Structure A comparison of Health Links with larger proportions of seniors (Peterborough, South Georgian Bay) to those with smaller proportions of seniors but larger proportions of children/young adults (Guelph, Dufferin) reveals that: Peterborough and South Georgian Bay have greater proportions of seniors amongst their high cost users (areas above the red lines top 10% bars). In contrast, Guelph and Dufferin have smaller proportions of seniors (areas above the red lines top 10% bars), but larger proportions of children/young adults (areas below the green lines) amongst their high cost users. The profile of high cost users is consistent with the age structure of the population. 22
Average Costs are Similar for LHINs and Health Links Among the top 10% patients for LHIN and Health Link residents: North West and North East LHINs had the highest average cost, while Mississauga Halton and Central LHINs residents had the lowest. Hamilton Central and Temiskaming Health Links had the highest average cost, while residents of South Simcoe and Northern York and South East Mississauga Health Links had the lowest. The average cost for the top 10% within a Health Link is similar to the average cost for the top 10% for the LHIN of residence. 23
Health Links vs. LHINs Per Cent of Total Expense Health Link/LHIN of Residence Perth County Huron South West LHIN Mid Toronto West Per Cent of Total Expense Don Valley/ Greenwood North Toronto East Toronto Central LHIN Temiskaming Timmins Sector Acute 40.3 43.0 42.8 33.0 36.9 37.4 36.8 53.5 42.9 48.9 Long-Term Care 21.6 20.3 16.4 14.7 14.6 10.5 12.7 17.8 14.7 15.1 Physician Visits 14.2 13.2 15.4 17.3 19.2 21.2 19.3 10.9 14.1 12.5 CCC 5.1 3.7 3.7 5.4 9.4 10.6 8.2 1.6 7.9 3.2 Inp. Mental Health 3.5 3.7 6.5 14.4 6.6 4.3 7.3 6.0 6.7 7.4 Homecare 5.5 7.4 6.2 7.1 5.0 6.4 6.9 3.8 6.1 5.5 Emergency 3.7 4.1 3.4 3.4 3.2 3.3 3.4 2.9 4.0 3.6 Day Surgery 3.4 2.9 3.2 2.0 2.4 3.0 2.4 2.0 2.7 2.2 Inp. Rehabilitation 2.7 1.6 2.4 2.8 2.7 3.3 3.1 1.4 0.9 1.6 North East LHIN Among patients in the top 10% for select Health Links/LHINs: Although there is variation in the magnitude, the per cent of total expense by sector for the Health Links is consistent with the overall values for the LHIN. Acute care accounted for the largest per cent of the expense for all LHINs/Health Links. Long-term care was the 2 nd highest proportion for the South West and North East LHINs and Health Links, while physician visits accounted for the 2 nd highest proportion of expenses for the Toronto Central LHIN and Health Links. 24
Health Links vs. LHINs Average number of events Health Link/LHIN of Residence Perth County Huron South West LHIN Mid Toronto West Average Number of Events Don Valley/ Greenwood North Toronto East Toronto Central LHIN Temiskaming Timmins Sector Homecare 50.1 70.8 62.4 108.9 83.5 86.5 94.9 61.8 96.7 84.2 Physician Visits 22.9 24.3 26.0 31.2 30.6 28.6 30.7 27.4 25.7 26.6 Emergency 2.8 3.9 3.0 2.8 2.5 2.2 2.7 4.2 3.5 3.6 Acute 1.4 1.6 1.4 1.3 1.4 1.3 1.4 1.7 1.6 1.6 Day Surgery 1.5 1.5 1.5 1.7 1.5 1.5 1.6 1.5 1.4 1.6 Inp. Mental Health 1.5 1.4 1.5 1.6 1.6 1.4 1.6 1.3 1.7 1.5 Long-Term Care 1.2 1.3 1.3 1.4 1.3 1.3 1.3 1.4 1.4 1.3 Inp. Rehabilitation 1.0 1.0 1.1 1.0 1.1 1.1 1.1 1.1 1.0 1.0 CCC 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.0 1.1 1.0 North East LHIN Among patients in the top 10% for select Health Links/LHINs: Although there is variation in the magnitude, the average number of events by sector for the Health Links is consistent with the overall values for the LHIN. Homecare and physician visits had the largest average number of events. Homecare services showed the greatest variation within and between LHIN areas. This may be due to the differences in the age structure of the population and/or different service delivery patterns. 25
Summary and Conclusions: High cost users are a small, but diverse group; however, their patterns of health care utilization are relatively consistent across geographic areas. The top 10% account for approximately 75% of all health care expenditures. They access an average of 3 different health care sectors. They account for 95-100% of the total LOS in each sector. Acute care represents the largest proportion of their expenses. Seniors are more likely to be high cost users than those in other age groups. Only 44% of patients who were high cost users in one fiscal (2009/10) year were still high cost users the following fiscal year (2010/11). The high cost user analyses will always be retrospective. The analysis demonstrates that there is a spectrum of high cost users (from transplant patients to patients with multiple chronic diseases). Health Links have the potential to impact certain groups of high cost users and improve patient care coordination. It is important to focus on the features (patient demographics, diagnoses, utilization trends) that are associated with being identified as a high cost user in order to target populations and assist with planning and service coordination for LHINs and Health Links. 26
Appendix 27
Changes to the High Cost User Methodology - 2009/10 vs. 2010/11 Addition of Long-Term Care and Physician Claims Increases the # of patients from 3.9 million in 2009/10 to 11.1 million in 2010/11 Increases the total expense from $14.2 billion in 2009/10 to $25.2 billion in 2010/11 Inclusion of activity and costs from private, federal, and specialty facilities that receive provincial funding Increases the total hospital expense by $103 million 28
Acute Care by Location of Service - LHIN Nearly half, of acute care expenses for Central (49%) and Central West (48%) LHIN residents were for care provided in hospitals outside the LHIN of residence. Only 3% of acute care expenses for Champlain residents were incurred in other LHINs. 29
Acute Care by Location of Service Health Link Among the Top 10% of patients by Health Link: 58% of the acute expense for North York residents was for care provided outside Central LHIN. 53% of the acute expenses for North Etobicoke-Malton-West Woodbridge and 48% of the expenses for Dufferin residents were incurred in hospitals outside the Central West LHIN. The large expense for residents of North York Region is due to the large population size of that Health Link. 30
Limitations: 31 The ministry is unable to provide the following information: 1. A summary of health care utilization for actual health card numbers. 2. A summary of information for small geographic areas (postal code, FSA). 3. A summary information for specific health care providers. 4. Information for Top 1% and 5% patient segments. 5. Information for all planned areas. 31