1. Static regions for health policy analysis Health Policy Commission Discussion document September 20, 2013

2. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION Objectives ▪ Review example geographic regions in use in Massachusetts ▪ Describe Health Policy Commission draft approach to static geographic regions ▪ Discuss key decision points in analytic model ▪ Receive Health Planning Council feedback on draft approach 1

3. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION Two types of geographic definitions are useful in our policy analyses 2 Static geographic regions ▪ Regions to be used for drilling down a level deeper than statewide figures ▪ Statically defined and changed infrequently to allow measurement of trend over time ▪ Should be based on existing region definitions or should provide an easy crosswalk to support analysis linking data with other sources (including national datasets - census, etc) Dynamic service areas for market analysis ▪ Service area defined with the hospital at the center ▪ Definition based on a consistent rule, but actual geographic boundaries of service areas may vary over time based on market shifts ▪ Should align with ‘real’ market function AB FOCUS FOR TODAY

4. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION Goals for static region definition 3 Stable / Rigid Definitions of health care service regions will be used across: Understandable Usable Meaningful Effective region definitions will be… ▪ Reflect population distribution and travel patterns ▪ Incorporate market-oriented understanding of delivery system and referral patterns ▪ Anchor in familiar concepts (e.g. cities or political boundaries) ▪ Develop through defensible and easily communicated methodology ▪ Use existing region definitions where possible ▪ Set up crosswalks for linking to major data sources (e.g. zip codes for linking to APCD, census data, HSAs) ▪ If regions include multiple levels, build hierarchically to enable effective roll- ups and drill-downs ▪ Keep regions consistent over time to allow measurement of trend ▪ Define regions based on data which will not change significantly from year- to-year, so that regions remain meaningful ▪ Cost Trends reports and analyses ▪ Assessments of geographic access/disparities ▪ Health resource planning analysis ▪ Policy development – DoN and investments A

5. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION Design questions for static regions 4 How many levels of regions should there be? ▪ Single set of regions (e.g. at tertiary care level) ▪ Two sets of regions (e.g. secondary and tertiary care) ▪ Three sets of regions (e.g. to add primary care practice regions) How often should region definitions be refreshed? ▪ Every decade ▪ Every 5 years ▪ Every 3 years ▪ Annually Question How should size of regions (and therefore number of regions) be determined? ▪ Based on market / competition (e.g. at least 2 hospitals per region) ▪ Based on geographic access (e.g. no more than 45 mins travel time between 2 points in region) ▪ Based on existing patterns of use (e.g. areas built around how far patients currently go for care) NOT EXHAUSTIVE Options Should we use an existing region definition or develop a new one? ▪ Select region definitions from a Massachusetts agency ▪ Select region definitions from academic literature, a nonprofit, or federal agency ▪ Develop a new region definition A

6. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION Example of regional definitions currently in use in Massachusetts 5 Organization Dartmouth Atlas Region definitionDescription ▪ 3 hospital referral regions ▪ 64 hospital service areas ▪ 105 primary care service areas ▪ Based on Medicare patients – HRR: Cardiovascular surgery and neurosurgery – HSA: All inpatient admissions – PCSA: Primary care services EOHHS ▪ 6 EOHHS regions ▪ Used for reporting on health indicators ▪ Regions include: Western Mass, Central Mass, Boston, Metro West, Northeast, Southeast DPH ▪ 5 regions for emergency medical services ▪ Based on location of trauma centers and geographic proximity / time to reach emergency services Health Planning Council (Freedman draft) ▪ 4 tertiary regions ▪ 16 secondary regions ▪ 122 primary regions ▪ To be used for resource planning ▪ Based on similar criteria to Dartmouth Atlas ▪ Consistent with patient access and referral patterns DOI ▪ 7 rating regions ▪ Regions defined for area rate adjustments Network adequacy stds ▪ Highly varied ▪ Varied by payer and services A Dartmouth Atlas offers the greatest ability to link to existing studies and national benchmarks, but is especially outdated at the secondary care level (HSAs)

7. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION EOHHS publications use 6 regions, 14 counties, and 351 cities/towns 6 Western Mass Central Mass Northeast Metro West Southeast Boston Region Barnstable Berkshire Bristol Essex Hampden Dukes Franklin Hampshire Middlesex Nantucket Norfolk Plymouth Suffolk Worcester EOHHS regionsCounties (alphabetical)Cities/towns SOURCE: Massachusetts EOHHS/DPH

8. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION Emergency Medical Service regions 7 SOURCE: Massachusetts EOHHS

9. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION Division of Insurance rating regions 8 SOURCE: Division of Insurance

10. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION Map of Massachusetts 9 SOURCE: Division of Insurance

11. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION Health Planning Council draft regions (May 3) 10 SOURCE: Freedman Analytic Plan/Health Planning Council

12. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION Health Planning Council draft - Secondary Service Market (SSM) - 16 SOURCE: Freedman Analytic Plan/Health Planning Council 11

13. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION Dartmouth Atlas region structure 12 Primary care service areas (PCSAs) 104 in MA (plus 3 RI PCSAs overlapping MA) ▪ Reflect Medicare patient travel to primary care providers ▪ Each includes a ZIP code area with 1+ PCPs and any contiguous ZIP code areas whose Medicare populations seek the plurality of their primary care from those providers. Hospital service areas (HSAs) 64 in MA (plus 2 RI HSAs overlapping MA) ▪ Local health care markets for hospital care ▪ Based on assigning ZIP codes to hospital area where the greatest proportion of zip code’s Medicare residents were hospitalized (adjusted to ensure contiguity) Hospital referral regions (HRRs) 3 in MA (Boston, Worcester, Springfield) ▪ Regional health care markets for tertiary medical care that generally requires the services of a major referral center ▪ Based on where patients were referred for major cardiovascular surgical procedures and for neurosurgery ▪ Each HRR has at least one city where both major cardiovascular surgical procedures and neurosurgery are performed SOURCE: Dartmouth Atlas web site

14. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION The Health Policy Commission is exploring an approach based on a three-level hierarchy 13 Primary Proposed approach ▪ Use 108 Dartmouth Atlas PCSAs Secondary Proposed approach ▪ ~10-20 regions, built as roll-up of 64 Dartmouth Atlas HSAs to allow use of nationally reported data ▪ Roll up based on “Dartmouth-like” logic, including e.g.: – Merge small HSAs based on where residents of those HSAs are sent for IP stays – Ensure regions ‘balanced’ in size (e.g. no region > 30% of total MA discharges) Tertiary/Quaternary Proposed approach ▪ Use 3 Dartmouth Atlas HRRs for alignment with Medicare and other national analyses Example analytical uses ▪ Regional segmentation for descriptive statistics (e.g. health status, TME growth) ▪ Regional variation in prices and provider input costs ▪ Ongoing description of competitive landscape Example analytical uses ▪ Monitoring access to primary care Example analytical uses ▪ Comparisons of Massachusetts regions to national data on cost, service intensity, health status ▪ Analysis of specialized services (e.g. neurosurgery, CV surgery) A

15. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION Region sets modeled/reviewed 14 Access-based secondary regions Service-based secondary regions ▪ Merge Dartmouth HSAs to obtain 10-20 regions for which all residents are within 15 mi or 30 min travel time of an “anchor” hospital offering secondary services ▪ Constrained to roll up to Dartmouth HRRs ▪ Merge Dartmouth HSAs to obtain regions which contain at least 2 providers of: – Labor and delivery – Inpatient surgical services – Inpatient mental health services – SNFs and home health care services ▪ Constrained to roll up to Dartmouth HRRs Principles for modeling scenario In addition to map outlining region boundaries, summary outputs for each region should include: ▪ Population of region ▪ Maximum travel time to center of region from any point in region ▪ Provider landscape: – # of hospitals and inpatient beds – # of physicians – # of mental health providers and IP facilities – # of SNFs Adapted Health Planning Council regions ▪ Draft regions defined by Health Planning Council, adjusted to roll up to Dartmouth HRRs Health Planning Council regions ▪ Draft regions as defined by Health Planning Council team, based on following principles: – At least two Community Hospitals – Either 20 or 45 minute driving time (density) from Market center – Organized along major traffic routes – Not contradictory to Dartmouth Atlas HSAs – May require sub-division for ED 1 2 3 4

16. Health Policy Commission | PRELIMINARY WORKING DRAFT – FOR DISCUSSION Next steps 15 ▪ Develop secondary regions – Aim to meet following principles: ▫ ~10-20 regions ▫ At least 2 hospitals per region ▫ Regions should be defined by roll-up of Dartmouth Atlas HSAs to allow use of nationally reported data ▫ Regions should be ‘balanced’ in size (e.g. no region > 30% of total MA discharges) – Need to define logic for merging: ▫ Merge a small HSA into a larger HAS only if at least X% of discharges sent to larger HAS ▫ Any HSA which sends at least Y% of its residents’ discharges to hospitals contained within its region should not be merged ▫ ‘Greedy merge’ (merge into HSA receiving largest % of discharges from the smaller HAS) vs. ‘Merge for ‘balance’ (merge into smallest HSA receiving at least X% of discharges) – Model several options based on various thresholds ▪ Review with Health Planning Council, CHIA, AGO, DPH, and other agencies doing geographic breakdowns of health care analysis – Review Regions and Descriptive Statistics at September Health Planning Council meeting – Discussion with other agencies in parallel ▪ Use regional cuts for APCD analyses in December cost trends report from Health Policy Commission