measuring the impact of the healthy outcomes plan

Ana Lòpez–De Fede, PhDResearch Professor and DirectorDivision of Medicaid Policy ResearchInstitute for Families in SocietyUniversity of South Carolina

September 24, 2015

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Measuring the Impact of the Healthy Outcomes Plan: Preliminary Evaluation

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“All things are created twice; first mentally; then physically. The key to creativity is to begin with the end in mind, with a vision and a blueprint of the desired result.”— Stephen Covey

Preventable Inpatient Visits

Preventable ED Visits

Reduction of Avoidable ED and Readmission

Care Plan Executed

Identification of Behavioral Health Needs

Patient Engagement

Reduction on Total Charges –Inpatient and ED Visits

Hospital and Clinic Proviso Evaluation Framework

Technical Assistance Proviso Context: Healthcare Reform

Sustaining Activities

CollaborationsInterventions Targeted At:Interventions Targeted At: Intermediate

Outcomes• Improved care

coordination within and across providers

• Heightened patient activation and compliance

• Improved patient outcomes

• Diffusion of best practices• Patient satisfaction • Community engagement

Long-termOutcomes

• Community improvement in quality measures

• Improvement in health status

• Reduction in costs trends

• Reduction in disparities • Ongoing collaboration

to improve healthcare

Feedback on implementation and results

Public Reporting

Consumer and

Community Engagement

Quality Improvement

Payment Reform

Proviso Stakeholders

Alliance development, setting vision and strategies

Disparity Reduction

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TIMELINE

Programmatic alignment

Evaluation Questions and Data Elements –Part 1 Presentation – September 24, 2015

– How does participation in HOP improve the quality of participants health? Hospital Discharge Data

– How does participation in HOP impact total charges for inpatient and ED stays? Hospital Discharge Data

– How does participation in HOP increase consumer engagement? Patient Activation Measure

– How does participation in HOP result in greater program alignment to meet the needs of uninsured? GAINS (Behavioral Health)

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INTERVENTIONS

Evaluation Questions and Data Elements –Part 2 Presentation TBD

– Does HOP increase collaboration across service delivery entities serving the uninsured? Collaboration Index with Case Study Interviews; Hospital and Community Partnerships; Development of Common Reporting

– Does HOP participation result in enhanced public reporting? Hospital Reports; Participation/Enrollment; Adoption of Common Reporting Tools and Measurements

– Does HOP facilitate the reduction of health disparities by addressing social and cultural determinants as a component of the care plan? SDOH Standardized Tool

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COLLABORATION

Evaluation Time Period

EvaluationReport

BASELINEJune 2012 –June 2013

FEASIBILITY/RECRUITMENT

July 2013 –June 2014

IMPLEMENTATIONJuly 2014 –June 2015

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PHASE 1 PHASE 2

HOP Population Demographics 8,342 Participants Enrolled for at Least Six Months

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Ages 18-24 10.09% 8.64% 6.68%

Ages 25-44 43.49% 41.82% 41.91%

Ages 45-54 34.65% 34.46% 34.92%

Ages 55-64 11.57% 14.91% 16.15%

Baseline Year Feasibility Implementation

Male Gender 40.79% 43.27% 42.05%

Female Gender 59.19% 56.73% 57.95%African American Race 50.62% 49.40% 49.96%White Race 47.25% 48.10% 47.91%Other Race/Ethnicity 2.13% 2.50% 2.13%

Total Patients With Claims(% of Total Participants)

5,403 (64%) 6,640 (79%) 5,498 (66%)

HOP Inpatient and ED Utilization8,342 Participants Enrolled for at Least Six Months

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Time PeriodTotal

Patients Total InpatientsInpatients With 2+ Discharges

Total Emergency Department

Patients

Emergency Department

Patients With 2+ Discharges

Baseline Year 5,403 1,337 481 5,196 3,819

Feasibility Year 1 6,640 2,171 794 6,293 4,864

Implementation Year 1 –To Date

5,498 1,640 627 5,192 3,810

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EVALUATION QUESTION 1“How does participation in HOP improve the quality of participants’ health?”

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PHASE I: COMPARISON OF BASELINE (FY 13) TO FEASIBILITY YEAR 1 (FY 14)

• Preventable inpatient stays continued to drop during the first full year of implementation (FY 15).

• The monthly overall and chronic visits also decreased, as well as the average acute prevention composite visits.

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25.5

4.37

21.1324.79

3.91

20.8822.54

3.61

18.92

05

1015202530

Overall CompositeDischarge Rate

Acute PreventionComposite Discharge Rate

Chronic PreventionComposite Discharge Rate

Baseline Feasibility Implementation

Key Findings:Preventable Inpatient Stays

• Preventable inpatient readmission rates decreased during implementation.

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5.75

9.27

15.2

5.89

10.56

17.58

5.66

10.64

17.25

0

5

10

15

20

7 Day InpatientReadmissions Rate



Baseline Feasibility Implementation

Key Findings:Preventable Inpatient Stays

Key Findings:Preventable Inpatient Stays• Lower overall (-0.71%, rel. change -2.78%), acute (-0.46%, rel. change -

10.53%), and chronic preventable inpatient stay rates (-0.25%, rel. change -1.18%).

• Average overall and chronic prevention composite visits and monthly overall and acute prevention composite visits also decreased.

• Significant differences in favor of the HOP participants existed for the overall (p<.001) and acute (p = 0.011) prevention composite rates.

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25.50%

4.37%

21.13%24.79%

3.91%

20.88%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Overall Prevention CompositeDischarges Rate

Acute Prevention CompositeDischarges Rate

Chronic Prevention CompositeDischarges Rate

Statewide HOPBaselineStatewide HOPFeasibility Year 1

Initial Areas for Improvement:Preventable Inpatient Stays

• Average inpatient visits, patients with 2+ discharges inpatient Average visits, Average acute prevention composite visits, monthly chronic prevention composite visits rate, and 7-, 14-, and 30-day readmission rates

• The increases in all three readmission rates were statistically significant compared to the matched comparison group (p <.001).

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5.75%

9.27%

15.20%

5.89%

10.56%

17.58%

0.00%2.00%4.00%6.00%8.00%

10.00%12.00%14.00%16.00%18.00%20.00%

Rate 7 Day InpatientReadmissions



Statewide HOP BaselineStatewide HOP Feasibility Year 1

• HOP participants had lower monthly emergent primary care treatable (-2.51%, rel. change -3.87%) and non-emergent ED visits (-1.41%, rel. change -3.02%)

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64.96%

46.82%

62.44%

45.41%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

Monthly EmergentPrimary Care Treatable

ED Visits Rate

Monthly Non-EmergentED Visits Rate

Statewide HOPBaselineStatewide HOPFeasibility Year 1

Key Findings:ED Stays

Initial Areas for Improvement: ED Stays

• With the exception of the two monthly measured presented on the previous slide, all the ED measures increased between Baseline Year and Feasibility Year 1 for the HOP participants. [Again, this was not surprising given that HOP recruited patients with high ED utilization.]

• For HOP participants, the increases in Average overall ED visits(p = 0.001) and Average alcohol ED visits (0.006) were statistically significant compared to the matched comparison group. For the Average injury ER visits, Statewide HOP did not show a significant change, but the comparison group actually had a significant decrease (p = 0.012).

• Our preliminary cost analysis revealed that reducing these three measures would equal at least a cost savings of .04 standard deviations of the total cost for services rendered.

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PHASE II: COMPARISON OF FEASIBILITY YEAR (FY14) TO IMPLEMENTATION YEAR 1 TO DATE(FY15) [PRELIMINARY RESULTS]

Key Findings: Decrease in ED Visits 4.68

1.78 1.8

1.2

4.32

1.67 1.8

1.32

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Average EDVisits

AverageInjury ED

Visits

AverageAlcohol ED

Visits

AverageSubstanceAbuse ED

Visits

FeasibilityImplementation

• Overall decrease in 12 of 17 measures associated with ED visits during implementation Year.

• It is estimated that a decrease in average overall, injury, and alcohol ED visits would result in measurable cost savings —$40 for every $1,000 charged.

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Total Charges Comparison of Feasibility and Implementation Periods

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Overall,18% decrease in total charges for inpatient staysand ED visits between feasibility and implementation periods

Measure Feasibility Year 1Implementation

Year 1 Difference Relative Change

Total Charges $66,793,561 $54,817,923 -$11,975,638 -17.93%19

Overall Inpatient and ED Findings

• The number of measures with a relative decrease increased from 9 to 20 with the greatest impact seen for preventable inpatient stays.

• Our initial cost savings analysis predicted that a reduction in average total, alcohol, and injury ED visits would result in measurable cost savings. Two of these measures (total and injury visits) did decrease.

• Further cost analyses once FY 15 claims data close with a matched comparison group will be necessaryto confirm.

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“Does Care Plan Make a Difference on Inpatient and ED Measures? Total Charges?”

Key Findings:Preventable Inpatient Stays (Care Plan)

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• Having a care plan made the biggest difference for inpatient stays that could have been prevented by coordinating care for patients with diabetes, COPD, asthma, hypertension, congestive heart failure, and angina without procedure (chronic prevention composite rate). For patients with a care plan, this measure had the largest relative decrease (-16.12%) of any measure, but for patients without a care plan there was a 1.10% relative increase.

26.44%22.91%

3.17%4.75%

23.27%

18.16%

23.53%21.60%

4.00% 3.25%

19.52% 18.36%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

OverallPrevention

Composite CarePlan

OverallPrevention

Composite NoCare Plan

Acute PreventionComposite Care

Plan

Acute PreventionComposite No

Care Plan

ChronicPrevention

Composite CarePlan

ChronicPrevention

Composite NoCare Plan

Feasibility Year 1

Implementation Year 1 to date

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• All three inpatient readmission rates decreased for patients with a care plan.

5.84% 5.88%

10.40% 10.63%

17.28% 17.65%

5.27%6.03%

10.18%11.07%

17.13% 17.36%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

20.00%

7-Day Care Plan 7-Day No CarePlan



Feasibility Year 1


Key Findings:Inpatient Readmissions (Care Plan)

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• 9 of the 12 average ED measures decreased for patients with a care plan: total, emergent, emergent not preventable avoidable, emergent preventable avoidable, emergent primary care treatable, patients with 2+ discharges.

• The only average measures that did not decrease were the unclassified, substance abuse, and alcohol visits. The monthly emergent ED visits rate and monthly emergent primary care treatable ED visits rate also increased.

4.70

2.451.60 1.84 2.07

5.77

4.20

2.311.46 1.81 1.94

5.42

0.001.002.003.004.005.006.007.00

Average EDVisits

AverageEmergent ED

Visits

AverageEmergent Not

Prevent.Avoidable ED

Visits

AverageEmergentPrevent.

Avoidable EDVisits

AverageEmergent

Primary CareTreatable ED

Visits

Average EDVisits Among

Patients with 2+ED Discharges

Feasibility Year 1


Key Findings:ED Stays (Care Plan)

Overall Key Findings: Care Plan

• For 16 measures tracked by the Initiative, HOP patients enrolled for at least six months with a care plan saw a greater relative decrease than HOP patients without a care plan.

• As expected, the care plan made the biggest difference for inpatient stays related to chronic conditions. This may be why there was also a greater decrease of 7- and 14-day inpatient readmissions rates and average primary care treatable ED visits.

• There was also an 11.01% relative decrease in overall preventable inpatient stays for patients with a care plan.

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HOP Care Plan Impacts onTotal Cost Charges

Care Plan Status Feasibility Implementation Difference

Relative Change

Total Charges

Plan $35,489,471 $28,419,689 ($7,069,782) -19.92%

No Plan $31,304,090 $26,398,234 ($4,905,856) -15.67%

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EVALUATION QUESTIONS “How does participation in HOP result in greater program alignment to meet the needs of uninsured? [GAIN-SS]”

“How does participation in HOP increase consumer engagement? [PAM]”

PAM and GAIN-SS Samples

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• As of March, 2014, during Feasibility Year 1, 3,201 patients had been screened with PAM and 3,317 had been screened with GAIN-SS, which represented 38% and 39% of active members, respectively.

• Due to increased enrollment in HOP and improved HOP implementation during Implementation Year 1, by the end of February, 2015, screening had more than doubled with 8,377 PAM patients and 9,005 GAIN-SS patients.

• 90% of active HOP members had been administered the PAM, and 97% had been administered the GAIN-SS.

Statewide HOP PAM Results: Percentage by PAM Level

19.6521.24

33.46

25.65

17.9820.86

34.42

26.72

0

5

10

15

20

25

30

35

40

Level 1 NotEngaged

Level 2 BecomingAware

Level 3 TakingAction

Level 4 Engaged

2014 2015

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Statewide HOP GAIN-SS Results

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20.8 18.51

60.57

23.97

17.25

58.75

0

10

20

30

40

50

60

70

Low Percent Moderate Percent High Percent

2014 2015

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Subscreenand Risk Level

Feb. 2014 Feb. 2015 Difference Relative Change

Low Risk 84.38% 84.92% 0.54% 0.64%

Moderate Risk 14.14% 13.74% -0.40% -2.83%

High Risk 1.39% 1.30% -0.09% -6.47%

Statewide HOP GAIN-SS Subscreen Results

Substance Disorder SubscreenLow Risk 72.41% 73.88% 1.47% 2.03%

Moderate Risk 18.63% 18.13% -0.50% -2.68%

High Risk 8.86% 8.46% -0.40% -4.51%

Internalizing Disorder SubscreenLow Risk 25.23% 28.22% 2.99% 11.85%

Moderate Risk 24.27% 22.24% -2.03% -8.36%

High Risk 50.38% 49.51% -0.87% -1.73%

Externalizing Disorder SubscreenLow Risk 54.18% 55.41% 1.23% 2.27%

Moderate Risk 26.98% 25.43% -1.55% -5.74%

High Risk 18.75% 19.13% 0.38% 2.03%

Statewide HOP PAM and GAIN-SSImplications and Next Steps

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• Stability of population

• HOP patients are diverse in their readiness for patient engagement.

• Future reporting of PAM and GAIN-SS consistent and timely

• High need for further assessment and referral for behavioral health – mental health and substance abuse

Acknowledgments

• The HOP members who provided the data to frame this evaluation

• The external members of the Data Committee –SCHA and RFA

• Members of the HOP Vision Council for guidance

• The IFS, Division of Medicaid Policy Research and our colleagues at SCDHHS

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“You can have data without information, but you cannot have information without data.” -- Daniel Keys Moran

Next Presentation Data Elements

• Collaborative Index

• Social and Cultural Determinants of Health

• Web Portal for Data Entry

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Questions?

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Ana Lòpez – De [email protected](803)777-5789ifs.sc.edu/MPR

measuring the impact of the healthy outcomes plan

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