Gaining Influence Through Transparency & Pricing: The Colorado Experience SCHA Annual Executive Leadership Summit July 22, 2014 Steven Summer | President & CEO | Colorado Hospital Association

South Carolina and Colorado 100 hospitals and health systems Exploring ways to increase transparency What we have in common

South Carolina and Colorado What we have in common Population: 4.7 millionPopulation: 5.1 million

South Carolina and Colorado Population centers clustered around interstate corridors. Population growth between 2000 and 2010:  South Carolina: 15.3%  Colorado: 16% What we have in common

Percent of population age 65 and older:  Colorado: 12.3%  South Carolina: 15.2% South Carolina and Colorado What we have in common Growth in population age 65 and older between 2000 – 2030:  South Carolina: 133%  Colorado: 218%

South Carolina and Colorado What we have in common One party holds a majority in the state senate, house and governor’s office.

Colorado’s Road to the APCD Journey began in State lawmakers passed legislation calling for a Blue Ribbon Commission on Health Care Reform. Commission tasked with studying and establishing health care reform models.

Colorado’s Road to the APCD Specific commission tasks included: Examining health reform models to expand coverage, especially for the underinsured and uninsured. Evaluating reform proposals. Holding meetings around the state. Final report due to lawmakers by Jan. 31, 2008.

Colorado’s Road to the APCD Create a multi-stakeholder entity “Improving Value in Health Care Authority” to promote reform recommendations. Reduce health care costs and improve the quality of care. Make information on insurer and provider price and quality available to all Coloradans. Final report included recommendations to:

Center For Improving Value In Health Care (CIVHC) Created by executive order as an entity within Colorado’s Medicaid agency – transitioned to 501(c)3. Triple Aim focus:  Improving health  Improving health care quality  Reducing costs

Center For Improving Value In Health Care (CIVHC) Recommendation to provide public information about cost and quality led to 2010 legislation creating Colorado’s APCD. APCD to include side-by- side comparisons of quality and cost information and out-of pocket expenses.

APCDs in 12 States

Colorado APCD Unique Resides outside state government Data available to providers researchers 2 hospital representatives on governing board Health plans mandated to submit data No state funding – APCD data sales

Member Concerns CHA members accepted the transparency train had left the station; however, CHA and members had several concerns regarding:  CIVHC and APCD governance  Access to and reliability/validity of the data  Input regarding public reporting It was essential that CHA have a leadership role in the process that would ultimately lead to the Colorado APCD.

Protections CIVHC exists outside of state government. Hospitals have representation on the governing board. Hospitals are represented on APCD advisory committees. Recommendations related to the APCD go through the CIVHC board.

Hospital Considerations The APCD is available to hospitals and other providers – as providers have the most influence on driving changes in cost and quality. Hospitals are involved in determining what information is publicly reported.

Hospital Considerations Hospitals also provide input on the reliability of reporting metrics and methodologies. Advance access to public reports. Hospitals directly involved in data review and validation.

Challenges and Barriers Medicare has publically committed to making data available to APCDs, but the process has been slow. Self-insured private employer plans are not required to submit claims. Small group mental health claims excluded until Small Volumes.

Benefits For Colorado Hospitals Potential to be valuable tool for:  Hospitals – access to information across multiple care settings  Advocacy  Care improvement  Practice variations Hospitals are at the table and in a position to influence the development and evolution of the APCD.

Timeline of Claims Availability APCD 2013 APCD 2014

CIVHC Database Database is evolving and will continue to do so.  Pricing structure (single-use or subscription or consulting for data analytics)  Conditional on data level provided, data use and time period  Affordability and access to complete data is an issue  On going commitment to improve data: o Incomplete claims o Data elements missing within claims o Provider data deficient Sustainability of APCD.

Colorado Launch of APCD Consumer Portal Includes hospital- specific data on four procedures Compare price, complexity and quality of care Launch scheduled June 30, 2014 Hospitals provided 30 days to review the data

Colorado Launch of APCD Consumer Portal

CHA Concerns with APCD Consumer Portal Does not include sufficient data to provide defensible results. Half the fully insured commercial market is missing from the data set. Data on hospital volumes not included. Median calculations skew the data so that the vast majority of hospitals appeared above the median. Hospitals meeting the data requirements for inclusions were excluded.

CHA Concerns with APCD Consumer Portal The APCD provides consumers will one lump cost estimate that includes the facility price, ancillary costs and the specialist. Claims for Kaiser Permanente did not include physician charges placing other hospitals at a disadvantage.

APCD Consumer Portal What’s Next CIVHC agreed to postpone the launch. CHA and CIVHC continue to have productive talks. CIVHC is working individually with CHA and hospitals to validate the data. Information on hospital volumes will be added to the Consumer Portal. Hospitals with larger volumes of Kaiser Permanente data will be listed as “under review.” Statewide median information will be removed.

CHA Data Analytics Develop and implement data analytics capacity for financial risk modeling and payment models. Maximize the use of existing and emerging data sources to advocate on behalf of members. Identify opportunities for CHA to analyze the underlying factors contributing to geographic variations in cost and quality.

CHA Data Analytics Utilize discharge and trauma registry data to analyze acute injury care in the state trauma system. Seek to reduce health care disparities (race, language and ethnicity). Support efforts to ensure the transparency of meaningful and relevant health care quality and pricing information.

Priority Analytics Bundled payments for episodes of care. Develop an analytic framework to identify state and peer group variations within an episode of care:  Readmission trends  Hand-offs to post-acute settings  Cost differences across continuum of care Understand volume and utilization trends of hospitals.

Impact of ACA Expansion -- Colorado Hospital Peer Group Jan-Feb 2013Jan-Feb 2014% Change Average Charity Care Charges per Hospital Urban $4.7 million $2.8 million-39.6% Rural $939,000 $664, % Critical Access $224,000 $145, % % Medicare Charges Urban36.1%35.2%-2.4% Rural35.7%35.3%-1.2% Critical Access43.1%42.0%-2.7% % Medicaid Charges Urban14.9%18.9%27.3% Rural13.2%16.8%26.9% Critical Access15.3%16.8%9.9% % Self Pay Charges Urban5.8%4.9%-14.5% Rural7.5%5.8%-22.0% Critical Access8.5%7.7%-10.2% 30 = outside normal variation = within normal variation

Colorado Payer Mix % 20.4% 21.8% 8.1% 6.8% 1.9% 39.7% 26.1% 21.2% 4.8% 6.4% 1.9%

For Rural and Critical Access Hospitals 32 For Urban Hospitals Colorado Uncompensated Care Volumes Rural CAH

Closing Thoughts Transparency of information and accountability to the public are a reality, but focus must be across continuum of care. Public and government are demanding more openness. Hospitals’ credibility with their communities will increasingly relate to public availability of information. Access to reliable data across all care settings will be a key resource for hospitals and associations. Associations must take a leadership role in shaping the nature of transparency and advocating on behalf of their members. Data analytics is new core competency for SHAs.

Questions