Enhancing Value: Using WHIO Data for Evaluating Patient-Centered Medical Homes. November 2012 Data Mart Version 7

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1 Enhancing Value: Using WHIO Data for Evaluating Patient-Centered Medical Homes November 2012 Data Mart Version 7

2 2 Executive Summary Patient-centered medical home () refers to a model of care that generally includes the following characteristics: a personal physician in a physician-directed, team-based medical practice; whole-person orientation; coordinated and/or integrated care; quality and safety; and enhanced access and payment. By 2011, the National Committee for Quality Assurance (NCQA) recognized 791 Wisconsin medical practices as s. Health insurance claims between October 1, 2009, and September 30, 2011, in the current Wisconsin Health Information Organization (WHIO) Data Mart Version 7 (DMV7) overlap with the time period when most Wisconsin s first were recognized by NCQA. The purpose of this Enhancing Value Report is to study baseline demographic characteristics of WHIO beneficiaries and physicians in NCQA-recognized practices and non- practices within Wisconsin s five public health regions (Northeastern, Northern, Southeastern, Southern and ). In addition, we present two preventive care measures, as well as emergency department (ED), hospitalization and readmission utilization measures for attributed DMV7 beneficiaries with primarily commercial insurance or Medicaid. We will examine comparative data for the and non- groups one year from now using DMV9. Key Findings Beneficiary Demographics Of the 3,90,136 DMV7 beneficiaries, 1,661,095 (2%) were attributed to a group or non- group based on having at least two evaluation and management (E/M) visits to a medical practice or non- medical practice between October 1, 2009, and September 30, The highest concentration of beneficiaries was in the Northeastern (35.) and Northern (32.6%) public health regions. Physician Demographics 5,57 primary care physicians (PCPs) were attributed to a group or non- group. The highest concentration of physicians was in the Northeastern (23.1%) and the lowest percentage of physicians (3.3%) was in the Southern. Preventive Care Measures The group in the Northern had the highest percentage of breast cancer screening for 2- to 69-yearold women (8.8%) and significantly different results in comparison to the non- group in the Northern (71.1%). The range for breast cancer screening for the other groups was between 73.9% and 79.8%. In general, there was little difference in chlamydia screening rates for 16- to 2-year-old beneficiaries between the group and non- group within each public health region. The Southeastern had the highest screening rates for both the group (55.2%) and non- group (52.%). Utilization Measures Younger than 18 Among beneficiaries younger than 18, the Southern had lower utilization of ED visits and hospitalizations compared to the other public health regions. The group in the Southern had the lowest utilization of ED visits, hospitalizations and 30-day readmissions compared to either group in the four other public health regions. Utilization Measures Adults For beneficiaries 18 years and older, the Southern (both and non- groups) had the lowest utilization of ED visits and hospitalizations. The group in the had the lowest utilization of 30-day readmissions. Conclusion Most physicians like the idea of having access to information on health care costs and resource use to inform care, but few of them have been exposed to it. 1 This report provides baseline information about demographics and quality and resource utilization measures for Wisconsinites attributed to a group or non- group between October 1, 2009, and September 30, The baseline results are very often similar for both the and non- groups within a public health region. It should be noted that medical practices not designated as a may be providing many aspects of patient-centeredness without a formal designation. In order to achieve the threepart aim better patient care, improved population health and lower costs physicians will need more exposure to population-level reports as well as condition-specific and patient-reported data to determine optimum care at the lowest cost. About the Wisconsin Health Information Organization The Wisconsin Health Information Organization (WHIO) is a not-for-profit collaboration of health care providers, insurance companies, employers and public entities created in 2005 to develop a statewide database of health insurance claims. WHIO s goal is to use health care data to improve the quality, affordability, safety and efficiency of health care in the state. This report uses the seventh release of the WHIO data Data Mart Version 7 (DMV7) claims with dates of service from October 1, 2009, through September 30, DMV7 includes data from almost all major health care payers in Wisconsin except fee-for-service (FFS) Medicare. Sixteen data contributors provide health insurance claims for the database. The database is continuously populated with 2 months of health insurance claims data, and an updated version is released approximately every 6 months. More information about WHIO is available online at WHIO Data Mart Version 7 Key Statistics Population 3,90,136 distinct beneficiaries in entire DMV7 (October 1, 2009 September 30, 2011) 3,55,03 distinct beneficiaries in Time Period 2 (October 1, 2010, to September 30, 2011) Population by Age Bands (Wisconsin Residents, Time Period 2) Younger than 18: 29% 18 to 6: 59% 65 and older: 12% Population by Insurance Type (Wisconsin Residents, Time Period 2) 55% Commercially insured 37% Medicaid 9% Medicaid fee-for-service (FFS) 22% Medicaid HMO 6% Medicare/Medicaid Dual FFS 0.2% Medicare/Medicaid Dual HMO 8% Medicare 5% Medicare Advantage 3% Medicare Supplemental 0.1% Federal Employee Program Disclaimer The Wisconsin Medical Society (Society) has created this report to provide health care cost and utilization information for local, regional and statewide areas. The data source for this report is the WHIO Data Mart Version 7 (DMV7) database, which the Society relied upon without audit in the creation of this report. The collection and aggregation of all underlying data was undertaken by WHIO. The Society is not responsible for the accuracy or content of the underlying data contained in this report or for the concepts or methodologies contained in the software used in the analysis. Be advised of the possibility of errors in data collection or aggregation or in software concepts or methodology, which may affect the report results. Use of the data or conclusions contained 3 in this report for anything other than informational purposes is at recipient s own risk. Using WHIO Data for Evaluating Patient-Centered Medical Homes

3 Using WHIO Data for Evaluating Patient-Centered Medical Homes This report uses the WHIO data to assess baseline performance (around the time of accreditation) for patients in patient-centered medical homes (s) compared to patients in non- practices. Although there is no single standard definition of a medical home, there is an agreedupon set of principles behind the concept, and most medical homes share common elements. 2 In 2007, the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP) and American Osteopathic Association (AOA) released the Joint Principles of the Patient-Centered Medical Home. 3 The Joint Principles are intended to describe the characteristics of a, including a personal physician in a physician-directed, teambased medical practice; whole-person orientation; coordinated and/or integrated care; quality and safety; enhanced access and payment. In 2011, the AAFP, AAP, ACP and AOA released the Guidelines for Patient-Centered Medical Home Recognition and Accreditation Programs to assist with the development and use of recognition and accreditation programs to assess whether a given practice is delivering care based on the model. A comparison tool was developed by the Medical Group Management Association (MGMA) to assess how each of the four national programs (the Accreditation Association for Ambulatory Health Care, Joint Commission, National Committee for Quality Assurance [NCQA], and URAC [formerly known as the Utilization Review Accreditation Commission]) meets these guidelines. 5 In Wisconsin, NCQA recognition is the most prevalent and has increased dramatically over the past few years. Most Wisconsin practices became accredited in 2010 and 2011, which overlaps with health insurance claims in WHIO DMV7 for dates of service between October 1, 2009, and September 30, 2011 (Figure 1). The current health care system incents high volumes of high-cost care and largely ignores considerations of value. 6 The Patient-Centered Primary Care Collaborative (PCPCC) Payment Reform Task Force examined representative payment reform models and derived a set of basic payment principles and guidelines as essential to the establishment and sustained operation of the, especially practice transformation and desired outcomes in patient experience, cost, clinical quality, efficiency, patient safety and professional satisfaction. 6 In a systematic review of the commissioned by the Agency for Healthcare Research and Quality (AHRQ), the strength of evidence was judged to be low or insufficient for most outcomes. 7 The authors concluded that health care value would be increased if ongoing and future studies indicate that improved care processes translate to improved clinical outcomes or economic benefit. Cost data 639 and emerging evidence from pilot evaluations suggest that -like interventions have the potential to decrease total health care costs by reducing emergency department (ED) use and hospitalizations for ambulatory care-sensitive conditions Figure 1. NCQA-Accredited Patient-Centered Medical Homes in Wisconsin, by Year Accredited ( ) This report provides baseline information about several utilization measures (ED visits, hospitalizations and readmissions) for beneficiaries in WHIO DMV7 attributed to and non- delivery models in Wisconsin About the Wisconsin Medical Society With more than 12,000 members dedicated to the best interests of their patients, the Wisconsin Medical Society (Society) is the largest association of medical doctors in the state and a trusted source for health policy leadership since 181. The Society together with the Wisconsin Medical Society Foundation (a nonprofit organization founded in 1955) and Wisconsin Medical Society Insurance & Financial Services, Inc. works to improve the health of all Wisconsin residents. To learn more, visit www. wisconsinmedicalsociety.org. The Society and physicians across the state have made a commitment to transparency by using credible, robust data to improve quality and efficiency and make health care more accessible for Wisconsin citizens. One way the Society is accomplishing this is by analyzing health insurance claims data from the Wisconsin Health Information Organization (WHIO) database to assess differences in health care quality and utilization. The Society is one of the 13 founding members of WHIO, and Linda Syth, CEO Wisconsin Medical Society Holdings Corporation, is treasurer of WHIO s Board of Directors. As a founding member of WHIO, the Society is interested in how claims data may be helpful in studying utilization patterns in relation to appropriate-use criteria and cost-sensitive best practices. The goal of these efforts is to enhance value and to ensure that as many people as possible have access to highquality, affordable health care. Using WHIO Data for Evaluating Patient-Centered Medical Homes 5

4 6 (n=157,77) % 53.8% Burnett Polk St Croix Pierce Southern (n=35,693) % 58.8% 1.9% Douglas Barron Dunn Pepin Washburn Buffalo Southern 12.7% Bayfield Sawyer Chippewa Rusk Eau Claire Trempealeau La Crosse Ashland Crawford Clark Jackson Monroe Vernon Grant Non- 80.8% Taylor Price Richland Iowa Adams Green Columbia Dane Green Lake Iron Northern Wood Juneau Lafayette Sauk 6.5% Non- 93.5% Non- 19.2% Lincoln Marathon Non- Vilas Oneida Portage Waushara Marquette Langlade Rock Forest Menominee Waupaca Shawano Dodge Florence Fond du Lac Jefferson Oconto Outagamie Walworth Marinette Brown Sheboygan Ozaukee Washington Waukesha Northeastern Racine Kenosha Milwaukee Kewaunee Manitowoc Calumet Winnebago Southeastern Door Northern (n=157,823) % 19.8% Northeastern (n=30,89) % 52.6% 17.7% Southeastern (n=568,983) % 53.1% 13.1% Non- 67.% Non- 65. Non- 89.% Non- 32.6% Non- 35. Non- 10.6% Figure 2. WHIO Beneficiary Demographics by Public Health This figure displays the percentage of beneficiaries attributed to a in each Wisconsin public health region (as identified by the Department of Health Services) 9 and the age distribution of the beneficiaries in each region. The range of beneficiaries in a varies considerably from 6.5% in the Southern to 35. in the Northeastern, while the percentage of beneficiaries in each age category varies less from region to region. The range of patients younger than age 18 was lowest in the Southern with 28.5% and highest in the Southeastern with 33.7%. For the 18- to 6-year-old group, the range was narrower between regions, with 51.2% in the Northern and 58.8% in the Southern. The percent of patients above age 6 was highest in the Northern (19.8%) and lowest in the Southern (12.7%). Using WHIO Data for Evaluating Patient-Centered Medical Homes 7

5 8 Using WHIO Beneficiary Demographics by Group and Public Health 55% 5 5% 8.1% 9.3% 8.8% 8.1% 50.2% 9.7% 7.1% 9.2% Non- 7.2% 8.9% Figure 3. Percent of Female Beneficiaries younger than 18 in WHIO DMV7 by Group and Public Health Non Figure. Average Age of Beneficiaries younger than 18 in WHIO DMV7 by Group and Public Health 6% 62% 6 58% 56% 5% 52% 5 8% % 58.7% % 58.2% % 60.5% Non- 56.8% 57.7% % 59.% Non- Figure 5. Percent of Female Beneficiaries 18 and older in WHIO DMV7 by Group and Public Health Figure 6. Average Age of Beneficiaries 18 and older in WHIO DMV7 by Group and Public Health 8.0 Younger than 18 There was little difference in the gender distribution between the and non- groups across public health regions with the percentage female ranging from 7.1% to 50.2% (Figure 3). The average age of patients in DMV7 ranged from 6.7 years in the group to 8. years in the Southern group. Three regions had beneficiaries in groups who were slightly younger on average than the non- groups in that region, and two regions had beneficiaries in the group who were older on average than the non- group in that region (Figure ). 18 and Older The percentage of females in the groups and non- groups varied between 53.% and 62.6%. Within public health regions, there was little difference between the percentage of females in the group and non- group except in the Northern (Figure 5). The average age of beneficiaries was higher for all groups in comparison to non- groups in each region. In the Northern, there was a significant difference in the average age of beneficiaries in the group (57.3 years) in comparison to the average age of beneficiaries in the non- group (9.6 years). In the Southern, the average age for the beneficiaries in the group was 53.1 years in contrast to beneficiaries in the non- group with an average age of 7.8 years (Figure 6). Preventive Care Measures The group in the Northern had the highest percentage of breast cancer screening in the last 2 months (8.8%) for 2- to 69-year-old women and significantly different results in comparison to the non- group in that region (71.1%). For the other eight and non- groups, the range for breast cancer screening was 73.9% to 79.8% (Figure 7). In general, there was little difference in the chlamydia screening rates for 16- to 2- year old females in the last 12 months of DMV7. Beneficiaries in the WHIO database were attributed to each public health region using the following plurality- of-care rules. At least two evaluation and management (E/M) visits* with primary care physicians (family physicians, internal medicine physicians and pediatricians) in a region s group or non- group. Group ( or non-) with highest total standard costs In case of a tie on the total standard costs, beneficiaries were attributed to the group ( or non-) with the highest number of E/M visits % Northeastern Beneficiary Attribution Methodology 8.8% 71.1% 3.3%.1% Northern 78.1% 73.9% 55.2% 52.% Southeastern Figure 7. Percent of Beneficiaries in DMV7 in Compliance with Preventive Care Measures WHIO Data for Evaluating Patient-Centered Medical Homes % Non- Of the 3,90,136 beneficiaries in DMV7, 1,661,095 (2%) had at least two E/M visits with either a group or non- group in one public health region. The other beneficiaries are not included because they did not have at least two E/M visits with a group or non- group in at least one public health region. This approach is a blend of two plurality-of-care approaches proposed for attributing beneficiaries to a medical group for the Centers for Medicare & Medicaid Services Accountable Care Organization and Value- Based Modifier programs. 3.7% 2.3% Southern 76.2% 79.8%.9%.% *E/M CPT Codes: , ,

6 Utilization Measures Younger than % 2.8% 0.9% 5.% 9.9% 7.% 28.6% 3.% Non-. 1.5% The percentage of children with emergency department (ED) visits is similar within each of the public health regions but varied across regions, with the Southern having the lowest percent of ED visits for both (28.6%) and non- (3.%) physicians (Figure 8). Except for the Northern, there appeared to be little difference across regions in the average number of hospitalizations for hospitalized beneficiaries (Figure 11) Non Figure 8. Percent of Beneficiaries in WHIO DMV7 with Emergency Department Visits by Public Health Figure 11. Average Number of Hospitalizations for Hospitalized Beneficiaries in WHIO DMV7 by Public Health The average number of ED visits per beneficiary was similar within each of the public health regions. The Southern had significantly lower ED visits per beneficiary for both (2.3) and non- (2.9) physicians (Figure 9). The Southeastern (.5% vs. 6.5%) and Southern (2. % vs. 5.2%) had significantly lower 30-day readmission rates for physicians compared to non- physicians (Figure 12). 7% 6% 5% % 3% 2% 1%.%.6%.3% 5..5% 6.5% 2.% 5.2% 5.5% 5.2% 0 Non- Non- Figure 9. Average Number of Emergency Department Visits per Beneficiary in WHIO DMV7 by Public Health Figure 12. Percentage All-Cause 30-Day Readmission Rates for Beneficiaries in WHIO DMV7 by Public Health 2 15% 1 5% 1.9% 13.5% 17.9% 1.9% 1.2% 13.7% 10.9% 12. Non- 17.7% 1.5% Figure: 10. Percent of Beneficiaries in WHIO DMV7 Hospitalized by Public Health The percentage of beneficiaries hospitalized was higher for physicians in comparison to the non- physicians in the Northern (17.9% vs. 1.9%) and (17.7% vs. 1.5%) (Figure 10). Definitions ED Visit CPT Codes: 99281, 99282, 99283, 9928, Hospitalizations - Number of unique confinements (as defined by WHIO data mart). 30-day readmission - Number of unique confinements marked as 30-day readmit (as defined by WHIO data mart). 10 Using WHIO Data for Evaluating Patient-Centered Medical Homes 11

7 Utilization Measures 18 and Older % 39.8% 36.2% 2.8% 6.2% 2.8% 31.3% 3.9%.9% 0.6% Non- The Southern had the lowest use of emergency department (ED) visits for both the (31.3%) and non- (3.9%) groups (Figure 13). The average number of hospitalizations among hospitalized beneficiaries was significantly lower for the Northeastern, Southeastern and Southern regions. In the Northern (6.6 vs..1) and (.1 vs. 1.9), the average number of hospitalizations was higher for the group compared to the non- group (Figure 16) Non- Figure 13. Percent of Beneficiaries in DMV7 with Emergency Department Visits by Public Health Figure 16. Average Number of Hospitalizations for Hospitalized Beneficiaries in DMV7 by Public Health 6 The Northern (.3 vs. 5.5) and Non Figure 1. Average Number of Emergency Department Visits per Beneficiary by Public Health Southern (2.9 vs..0) have fewer ED visits per beneficiary for the group compared to the non- group (Figure 1). The percent of all-cause 30-day readmissions was lowest for the group in the (6.8%). The range of 30-day readmissions for the non- group varied from 8.7% (Northern group) to 13.3% (Southern non- group) (Figure 17). 1% 12% 1 8% 6% % 2% 12.6% 11.6% 8.7% 9.1% 10.6% 11.5% 11.8% 13.3% 6.8% 9.6% Non- 3 25% 2 15% 1 5% 18.% 18.8% 25.2% 23.5% 21.% 19.5% 17.2% 15.6% % The percentage of beneficiaries hospitalized was slightly higher for the group in all regions except the Northeast (Figure 15). Figure 17. Percentage All-Cause 30-Day Readmission in DMV7 by Public Health 12 Non- Figure 15. Percent of Beneficiaries in DMV7 Hospitalized by Public Health Definitions ED Visit CPT Codes: 99281, 99282, 99283, 9928, Hospitalizations - Number of unique confinements (as defined by WHIO data mart). 30-day readmission - Number of unique confinements marked as 30-day readmit (as defined by WHIO data mart). 13 Using WHIO Data for Evaluating Patient-Centered Medical Homes

8 1 Technical Appendix Figure 18. Percentage of Female Physicians in WHIO DMV7 by Public Health Figure 19. Average Age of Physicians in WHIO DMV7 by Public Health % 35.% 39.6% 33.5% % 33.3% 2.1% % 76.9% % 80.% Non- 8.1% Non- Non- 3.3% 96.7% 2.% 3.2% % 88.7% Figure 20. Percent of Physicians in WHIO DMV7 by Public Health Physician Attribution Methodology Primary care physicians (N=5,57) in DMV7 of the WHIO database were attributed to a public health region based on their practice ZIP code and the county to which it belongs. Counties were attributed to one of five state public health regions as identified by the Department of Health Services 9. Physicians were assigned to a or non- group based on their NCQA designation. 10 National Provider Identification (NPI) numbers for the primary care physicians in WHIO DMV7 were matched with the Wisconsin Medical Society membership database for,653 physicians (83%) to determine demographic characteristics of the physicians included in this report. There were higher percentages of female physicians in the groups in the Southeastern and regions and lower percentages of female physicians in the group in the Southern (Figure 18). There was no difference in the average age of the physicians in the and non- groups (Figure 19). The Northeastern and Northern regions had the highest percentages of physicians, 23.1% and 19.6% respectively. The Southern had the lowest percentage of physicians with 3.3% (Figure 20). Next Steps The Wisconsin Medical Society offers physicians and health care organizations several opportunities to learn how they can use the WHIO database to improve the quality and efficiency of care they provide. These opportunities include the following: WHIO Orientation Sessions: The Wisconsin Medical Society offers free webinars that provide an overview of WHIO and insight into how the data are used by various stakeholders. Call or visit to learn more about these and other learning opportunities through the Society. Buck E. Badger Report: Available at the individual physician and clinic levels, the Buck E. Badger Report provides standard information about a physician s practice in comparison to his/her peer group for 19 specialties. Episode Treatment Group (ETG) Analyzer Report: The Society s ETG Analyzer Report provides a comparison of all of a clinic s ETGs (with at least 30 episodes) to a regional group. The regional group may be a public health region, an economic development region, a county or a combination of counties. ETG Drill-Down Report: The ETG Drill-Down Report provides detailed information about the average standard costs for one ETG for each physician in a medical group, for a clinic overall and in comparison to a regional group. Five service categories are used to present the cost analysis for each ETG: facility inpatient, facility outpatient, pharmacy, professional services and ancillary. Custom Analytics: The Society s Data Analytics team of WHIO experts is available to work with physicians and health care leaders to address specific areas of concern or interest. To learn more, call the Wisconsin Medical Society at Wisconsin Medical Society Staff involved in creating this report Cindy Helstad, PhD, RN, Director of Research Raju Vadapalli, MCA, Systems Architect Susan Wiegmann, PhD, Director of Quality Tara Gessler, Project Manager Mary Kay Adams-Edgette, Senior Graphic Designer Kendi Parvin, Communications Director Lisa Hildebrand, Communications Specialist We wish to thank F. Bradford Meyers, MD, FAAFP, and Linda Syth, CEO, Wisconsin Medical Society Holdings Corporation, for their helpful comments on draft versions of this report. In-text references 1. Robert Wood Johnson Foundation Aligning Forces for Quality. Lessons Learned Physicians Views of Comparative Information on Costs and Resource Use. October Patient-Centered Medical Homes, Health Affairs, September 1, AAFP, AAP, ACP, AOA. Joint Principles of the Patient-Centered Medical Home. February AAFP, AAP, ACP, AOA. Guidelines for Patient-Centered Medical Home Recognition and Accreditation Programs. February Medical Group Management Association. The Patient-Centered Medical Home Guidelines: A Tool to Compare National Programs Patient-Centered Primary Care Collaborative. Payment Reform to Support High-Performing Practice: Report of the Payment Reform Task Force. July Williams JW, Jackson GL, Powers BJ, et al. The Patient- Centered Medical Home. Closing the Quality Gap: Revisiting the State of the Science. Evidence Report/ Technology Assessment No (Prepared by the Duke Evidence-based Practice Center under Contract No I.) AHRQ Publication No. 12-E008- EF. Rockville, MD. Agency for Healthcare Research and Quality. July Wagner EH, Coleman K, Reid RJ, Phillips K, Sugarman JR. Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes. The Commonwealth Fund. February (Accessed November 15, 2012) WI-PDMH-Network/paractices -ncqarecognized.html (Accessed January 23, 2012). Using WHIO Data for Evaluating Patient-Centered Medical Homes 15

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