Findings from CCS Administrative Data Lee M. Sanders, MD, MPH Lisa J. Chamberlain, MD, MPH Stanford Center for Policy, Outcomes and Prevention (CPOP) CCS Redesign Stakeholder Advisory Board
Analytic Guidance for CCS Program Reform To use data to help protect the health of children with serious chronic illness. 1. To provide CCS and its stakeholders with data-driven analytic guidance to improve the quality and efficiency of care for children served by the CCS program. 2. To implement a coordinated strategy that bridges the gap between analytic activities and innovative care strategies in CCS subspecialty care centers. 2
Essential Questions How do we protect the health and well-being of a large population of children with serious chronic illness? 1. How do these children use health care services? 2. What is the quality (or appropriateness) of care received by this population? 3. What is the distribution of costs for that care? 3
Analytic Design Retrospective, population-based analysis of all paid claims for the CCS Program (2007-2012) Total capture of all care episodes Inpatient bed days Outpatient visits (primary, subspecialty, non-MD) ED visits Home health and Durable Medical Equipment (DME) Residential care Pharmacy Total capture of all CCS-related costs Partial capture of non-CCS-related costs (FFS) N = 323,922 children 4
Stanford CPOP CCS Analytics Advisory Board Ted Lempert Children Now Dr. Tom Klitzner UCLA Complex Care Laurie Soman CRISS Dr. David Bergman Stanford Complex Care Bernardette Arrellano CCHA Advocacy Rich Cordova CHLA Out-Patient Hospitals Dr. Fran Kaufman CHLA Dr. Robert Dimand State Care Systems Dr. Bert Lubin CHORI Dr. Louis Girling Alameda County Dr. Mark Pian San Diego Advisory Dr. Mary Doyle LA County CCS Policy Richard Pan CA Assembly Board Maya Altman Health Plan San Mateo Dr. Melissa Aguirre Fresno John Barry, OTR Shasta Christy Bethell PhD OHSU County Families Research Neal Halfon PhD UCLA Moira Inkelas PhD UCLA Foundations Teresa Jurado CCS, Health Plan San Mateo Dylan Roby PhD UCLA Eileen Crumm PhD Family Voices Meg Okumura, MD, UCSF Chris Perrone CHCF Dr. Ed Schor LPFCH CCS Redesign Stakeholder Advisory Board 5
CCS-enrolled Children: Social and Clinical Characteristics % Age – mean (SD) 7.3 (6.5) years Sex - Female 43.0 Race/Ethnicity White 16.6 Black 8.7 Hispanic 56.4 Insurance Medicaid Managed care 47.6 Medicaid Fee for Service 19.6 CHIP 7.5 Mixed / Other 25.3 Medical complexity > 2 organ Complex Chronic 51.4 systems, or Non-complex Chronic 25.3 progressive Non-Chronic 23.3 Diagnostic category Neurology 14.6 Cardiology 12.6 ENT / Hearing Loss 11.6 * Simons TD, et al. Pediatric Medical Complexity Algorithm (PMCA), Trauma / Injury 10.8 Pediatrics 2014 Endocrine 6.8 CCS Redesign Stakeholder Advisory Board 6
Patterns of Care Visits per child per year Children Visits per child with > 1 visit per year Mean (SD) per year 94% 7.6 (8.6) Outpatient Visits (MD) 87% 18.7 (28.7) Outpatient Pharmacy Visits 49% 1.6 (1.8) ED Visits 31% 14.8 (30.5) Hospitalizations (Bed Days) 29% 10.2 (13.7) Outpatient visits (Non-MD) 16% 5.8 (13.3) Home health visits CCS Redesign Stakeholder Advisory Board 7
Patterns of Care by Age 100000 80 90000 70 80000 year 60 per� 70000 children rate� 50 60000 encounter� of� 50000 40 Number� 40000 30 Median� 30000 20 20000 10 10000 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Age� at� first� visit Hospital� Bed� Days Emergency� Department� Visits Early� Periodic� Screening,� Diagnosis� &� Treatment Dental� Visits Home� Health� Visits Outpatient� clinic� visits Other� outpatient� visits Pharmacy� prescriptions� filled � Number� of� children CCS Redesign Stakeholder Advisory Board 8
Patterns of Care by Medical Complexity 50 45 Mean encounter rate per year 40 35 Outpatient pharmacy fills 30 Other outpatient visits 25 Home health visits ED visits 20 Outpatient physician visits 15 Bed days 10 5 0 Complex Chronic Non-Chronic CCS Redesign Stakeholder Advisory Board 9
Patterns of Care by Diagnostic Category 100 90 80 % of total visits 70 60 50 40 30 20 10 0 y y y y y y y y g g g g g g r r a u o o o o o o n j l l l l l l n o o o o o o o I r t c i g r m d u a e n n r e m t l O y a n u N r e C e P a H l o o r t t O s a G CCS eligible diagnosis Inpatient Home health Pharmacy Outpatient clinic Other outpatient DME % total expenditures % children CCS Redesign Stakeholder Advisory Board 10
Outpatient: Inpatient Patterns by Diagnostic Category p 12 ONC Mean outpatient visit rate 10 ENDO 8 HEME GASTRO NEONATAL CARD ORTH DEVT NEUR ENT URO OPTH 6 INJ 0 5 10 15 20 Mean bed day rate CCS Redesign Stakeholder Advisory Board 11
Patterns of Care Regional Variability CCS Redesign Stakeholder Advisory Board 12
Potentially Preventable Hospitalizations Quality of Care: Number of Children Hospitalized Bacterial pneumonia Ambulatory Sensitive Condition 10000 12000 14000 16000 18000 20000 2000 4000 6000 8000 0 Dehydration Asthma Kidney/urinary infection Epilepsy Severe ENT infection CCS Redesign Stakeholder Advisory Board Cellulitis Gastroenteritis Hypoglycemia Immunization preventable conditions Mastoiditis Nutritional deficiency Anemia Pelvic inflammatory disease Tuberculosis Stretococcal meningitis hospitalizations Diabetes of all CCS Seizures Failure to thrive 24.8% 13
Quality of Care: No Care After Hospital Discharge (Overall Readmission Rate: 9.6%) No Outpatient Visit of any kind within 28 days Post-Hospitalization 30.3 No MD visits within 28 days Post-Hospitalization 56.3 No Outpatient Visit of any kind within 21 days Post-Hospitalization 33.6 No MD visits within 21 days Post-Hospitalization 61.1 No Outpatient Visit of any kind within 14 days Post-Hospitalization 39 No MD visits within 14 days Post-hospitalization 67.8 No Outpatient Visit of any kind within 7 days Post-Hospitalization 51.9 78.9 No MD visits within 7 days Post-hospitalization 0 10 20 30 40 50 60 70 80 Percent of hospitalized CCS enrollees CCS Redesign Stakeholder Advisory Board 14
Cost Distribution By Child 100 1 4 5 90 25 80 40 70 60 32 Percent 50 40 15 30 50 20 26 10 2 0 Children Annual expenditures CCS Redesign Stakeholder Advisory Board 15
Cost Distribution By Medical Complexity Among “High Cost” Children* Among All CCS Enrollees Complex Chronic 9% 6% 26% 47% Non-complex Chronic 27% 85% Non-Chronic *Top 10% of annual expenses **Pediatric Medical Complexity Algorithm (PMCA), Mangione-Smith R. 2014 16
Cost Distribution By Type of Care Chart Title 0% DME Emergency Care 2% 14% Outpatient (nonMD) 1% Outpatient (MD) 36% Hospital Residential Facility 17% Pharmacy 9% Home Health 21% 17
Cost Distribution, by Medical Complexity Complex Chronic Non-complex/non-chronic 2.4 0.8 13.9 16.1 31.1 1.2 0.7 6.6 8.4 21.5 67.7 27.7 Inpatient Home health Pharmacy Outpatient clinic Other outpatient DME CCS Redesign Stakeholder Advisory Board 18
Percent of Total Expendituresfor all by Diagnostic Category Cost diagnoses Neurology/Neurosurgery 10.0 15.0 20.0 25.0 30.0 35.0 0.0 5.0 Cardiology/Cardiothoracic Surgery Hematology 31.0 13.8 NICU CCS Redesign Stakeholder Advisory Board 10.7 7.1 Oncology CCS-Eligible Diagnosis 5.9 Gastroenterology ENT 3.9 Pulmonary Gen Peds/BehavDevt 3.3 2.9 External/Injury 2.6 2.5 0 200 400 600 800 1000 1200 1400 1600 1800 2000 Number of Children 19
Costs Distribution by Diagnostic Category $160,000,000 $140,000,000 $120,000,000 Total expenditures $100,000,000 $80,000,000 $60,000,000 $40,000,000 $20,000,000 $0 T y y y y y y y y g g g g r g r g N o o o o a o u o E n l l l l l j l o o o o o n o o r t c i r n I m a d u n e i m r r t e O l a n c u N e o C e P H o d r n t E s a G Inpatient Outpatient pharmacy Residential facility Home health Outpatient physician DME ED Other outpatient CCS Redesign Stakeholder Advisory Board 20
“High Cost Children” Over Time CCS Redesign Stakeholder Advisory Board 21
Cost Distribution by Hospital Type Infants (< 12 months) All Children UC� System� Hospitals County� Hospitals Non-Profit� &� 11% 8% For-Profit� Hospitals 43% Other� Hospitals Non-Profit� &� For- UC� System� 1% Profit� Hospitals Hospitals County� Hospitals � Free-Standing� 25% 13% 6% Children's� Hospitals 37% Other� Hospitals � 1% � Free-Standing� Medically Complex Children Children's� Hospitals Non-Profit� &� For-Profit� UC� System� 55% Hospitals Hospitals 18% 13% County� Hospitals� 5% Other� Hospitals � <1% � Free-Standing� Children's� Hospitals 64% � CCS Redesign Stakeholder Advisory Board 22
Summary • Distinct patterns of care use – particularly by age and medical complexity. • Wide variability in care patterns, particularly before and after hospitalization. • Costs are highly skewed, driven by inpatient and residential care, and persistent over time. 23
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