1. Quality and Use in Managed Care Sarah Hudson Scholle Academy Health Annual Research Meeting Seattle June 26, 2006

2. BackgroundBackground Health care costs continue to increase Greater emphasis on demonstrating value in health care. Evidence about the relationship between utilization/ costs of care and quality is limited. –Studies in ambulatory settings show no relationship –A recent Medicare study found higher spending was correlated with poorer quality of care.

3. PurposePurpose To examine the relationship between quality and utilization of health care among commercial health plan –correlation of HEDIS ® 3.0 effectiveness measures with outpatient and inpatient utilization –regression analyses controlling for patient and plan covariates

4. Data Sources NCQAs Commercial HEDIS/CAHPS data set Includes plans that do not allow public reporting of data Reporting year 2003 (Measurement year 2002)

5. 316 Commercial Plans submit data in 2003 254 included in analysis 62 (excluded: 20%) 29 No data on any of the Dependent variables 10 No data on the patient characteristics 23 Missing 4 or more of the 11 quality measures StudyGroup Study Group Represents 83% of commercial managed care enrollees

6. Utilization Measures Limited to adults age 20-64 Excluded behavioral health, maternity, & surgical care Measures –Outpatient visits per 1,000 members per year –Emergency visits per 1,000 members per year –Medical discharges per 1,000 members per year –Inpatient days per 1,000 members per year

7. Quality Indicators and Composite 67.4%, 5.0%QUALITY COMPOSITE 73.6%, 9.8%Follow-up after Hosp for Mental Illness 44.5%, 7.5%Flu Shots 59.9%, 7.8%Acute phase antidepressant treatment 67.8%, 11.5%Diabetic HbA1c control 62.6%, 12.0%LDL-C control 75.9%, 5.2%Breast Cancer Screening 59.1%, 7.7%Blood Pressure control 93.8%, 7.6%Beta Blocker After Heart Attack 68.8%, 5.6%Asthma medication management 67.8%, 5.1%Advising Smokers to Quit Mean, SDMeasure

8. CovariatesCovariates Plan Characteristics –Public reporting, Profit status, type of plan (HMO vs POS vs both), Geographic location Member Characteristics –Age and gender distribution –CAHPS data on race, education and health status

9. Correlation: Quality Composite and Outpatient Visits

10. Correlation: Quality Composite and Hospital Discharges

11. Correlations between Quality and Utilization Outpt Visits ER visits Medical Discharges Hospital Days Smoking Cessation 0.22***-0.12-0.26***-0.22** Asthma Medication Mgmt 0.19**-0.24***-0.26***-0.30*** Beta Blocker after MI 0.09 0.00-0.21***-0.20** Blood Pressure Control 0.08 0.01-0.06-0.04 Breast Cancer Screening 0.20**-0.07-0.28***-0.30*** Cholesterol LDL Control 0.12-0.20**-0.17**-0.18** Diabetic HbA1c Control 0.10-0.10-0.20**-0.23*** Acute Phase Antidepressant Tx 0.01 0.22***-0.46***-0.42*** Flu Shots 0.09-0.23***-0.29***-0.30*** MH Inpt Follow-up(30) 0.15*-0.06-0.17**-0.16* Quality Composite 0.19*-0.18**-0.36***-0.35***

12. Regression Results: Relationship of Quality to Utilization Based on loglinear regressions using Poisson distributions. Covariates include plan region and profit status as well as plan rates of patient covariates from CAHPS data - age, gender, minority status and health status. 0.0207 - 0.7781Hospital Days 0.0365-0.6900Hospital Admissions 0.12750.5702Outpatient Visits 0.3677-0.4735 Emergency visits P-valueEstimateDependent Measure

13. Summary of Findings Positive Correlation between Quality and Access: Plans with higher quality score have a higher proportion of members with at least one visit. Negative Correlation between Quality and Hospital Use: Plans with higher quality score have lower average admissions and hospital days. There is no correlation between quality and the outpatient visit rate.

14. DiscussionDiscussion Findings are consistent with prior research focusing on the Medicare population. Impact is important: –A 5% improvement in quality is related to a 4% decrease in hospital days. –This translates to $12 per member per month (based on a conservative estimate of hospital costs of $3,000 per inpatient day).

15. LimitationsLimitations This cross-sectional study cannot address causality. Measurement of quality is limited to available measures. Using CAHPS data as a proxy for population socioeconomic and health status is an indirect method of adjustment. Controlling for health plan region may not be sufficient for disentangling impact of supply on utilization.

16. What mechanism links quality to utilization and costs? Quality reduces unnecessary hospitalization. Quality reflects better data collection. Quality is a marker of better organization for managing hospitalization days and HEDIS quality efforts.

17. ImplicationsImplications The IOM envisioned restructuring the health care system to address both quality and costs simultaneously. These data give hope that improvements in effectiveness of care may reduce both the human costs of poor care and their financial implications as well. More research is needed on the relationship between quality and utilization and potential mechanisms affecting that relationship.

18. For More Information… Sarah Hudson Scholle scholle@ ncqa.org 202-955-1726 www.ncqa.org