Quarterly Quality Call Seton Health Plan Texas Health and Human Services Commission Health Policy and Clinical Services Division Healthcare Quality Analytics, Research and Coordination Support September 14, 2015
Agenda Overview 1. SETON initiatives for value-based contracting - 15 min 2. SETON identification/integration of high value DSRIP projects - 10 min 3. SETON super-utilizer program and intervention(s) - 10 min 4. Focused quality measure discussion - 20 min 2
Agenda Item no. 2 SETON's efforts towards identification of high value DSRIP projects and steps towards integration of these projects into an SETON value based payment model RHPs active: • Travis – 7, 8 4
Agenda Item no. 3 SETON's super-utilizer targeting and intervention strategies. This could include value based payments as a means to finance such activities To discuss: • EQRO Health Forum • CMS IAP BCN Program • “Top 10” highest cost, ED use, inpatient stay 5
Agenda Item no. 4 Focused discussion on a specific SETON quality measure Quality Measures collected by HHSC • Quality of Care • PPEs 6
PPEs Definition Potentially preventable emergency room visit (PPV) Emergency treatment for a condition that could have been, treated or prevented by a physician or other health care provider in a nonemergency setting. Potentially preventable readmission (PPR) A return hospitalization within a set time period that might have resulted from problems in the care during a previous hospital stay or from deficiencies in a post-hospital discharge follow-up. NOTE : For the report, PPRs are expressed as PPR chains (one or more PPRs within a readmission window). Potentially preventable admission (PPA) A hospital admission or a long-term care facility stay that might have been reasonably prevented with adequate access to ambulatory care or health care coordination. 7
SETON PPR on Website $2,000 2.50 SETON Health Plan, POTENTIALLY PREVENTABLE READMISSIONS (PPRs), $1,800 CALENDAR YEARS 2012-2014 $1,600 2.00 $1,400 PPE costs per 1,000 member months (MM) $1,200 1.50 Actual-to-expected (A/E) ratio $1,000 $800 1.00 $600 $400 0.50 $200 $0 0.00 Travis Travis Travis Travis Travis Travis Seton Health Plan TOTAL Seton Health Plan TOTAL Seton Health Plan TOTAL STAR STAR STAR PPR PPR PPR CY12 CY13 CY14 Costs per 1,000 MM $715 $1,465 $515 $832 $1,827 $1,341 A/E Ratio 0.94 1.02 1.73 0.87 2.01 1.1 PPEs per 1,000 MM 0.18 0.16 0.16 0.14 0.31 0.18 8
SETON PPEs PPA PPR PPV 2.5 2.01 2 1.73 1.5 1.2 1.14 1.04 1 0.98 1.03 0.94 0.94 0.5 0 2012 2013 2014 9
SETON Cost per PPE $256.64 2014 $5,894.94 $6,476.89 $480.14 PPV 2013 $3,220.75 PPR $5,837.67 PPA $510.67 2012 $3,971.11 $6,476.69 $0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 10
SETON PPE Cost per 1,000 MM $25,000 $23,251 $20,382 $20,000 $15,000 PPA PPR $9,598 $10,000 PPV $5,699 $4,378 $5,000 $4,016 $1,827 $715 $515 $0 2012 2013 2014 11
SETON Health Plan Quality Measure of Interest Potentially Preventable Readmissions PPRs 12
SETON PPR Profile 2014 Actual Actual to Number of Actual PPR Total Actual Expected PPRs Chains Expenditures Type Admissions Number Ratio for Per 1,000 Per 1,000 Area at Risk for of PPR PPR Member Actual PPR Member Plan PPR Chains Weight Months Expenditures Months 298,826 5,612 1.00 0.19 $45,681,840.23 $1,403.60 STAR 11,658 260 1.10 0.18 $2,181,561.23 $1,341.24 TRAVIS 1,138 47 2.01 0.31 $307,327.32 $1,827.43 SETON 13
Cost per PPR STAR and SA $5,894.94 2014 $7,451.33 $7,387.37 $3,220.75 SETON 2013 $5,939.71 STAR Travis SA $7,596.65 STAR TOTAL $3,971.11 2012 $9,154.19 $7,181.60 $0 $2,000 $4,000 $6,000 $8,000 $10,000 14
PPR A/E Ratios in Travis SA STAR Travis SA SETON 2.5 2.01 2 1.73 1.5 1.02 1 1.1 0.94 0.87 0.5 0 2012 2013 2014 15
PPR Cost per 1,000 MM STAR and SA $2,000 $1,827 $1,800 $1,600 $1,519 $1,465 $1,436 $1,404 $1,400 $1,341 $1,200 STAR TOTAL $1,000 STAR Travis SA $832 $800 $715 SETON $600 $515 $400 $200 $0 2012 2013 2014 16
PPR A/E Ratios All Plans Travis SA Blue Cross Blue Shield of Texas Sendero Health Plans Seton Health Plan Superior HealthPlan 2.5 2 2.01 1.73 1.5 1 0.94 0.5 0 2012 2013 2014 17
Cost per PPR All Plans Travis SA $5,894.94 2014 Superior HealthPlan Seton Health Plan $3,220.75 2013 Sendero Health Plans Blue Cross Blue Shield of Texas $3,971.11 2012 $0.00 $5,000.00 $10,000.00 $15,000.00 18
PPR Cost per 1,000 MM All Plans Travis SA Blue Cross Blue Shield of Texas Sendero Health Plans Seton Health Plan Superior HealthPlan $3,000 $2,500 $2,000 $1,827 $1,500 $1,000 $715 $515 $500 $0 2012 2013 2014 19
PPRs and Cost Correlation All Plans Travis SA Blue Cross Blue Shield of Texas Sendero Health Plans Seton Health Plan Superior HealthPlan 3 2.5 2 $1.83 1.5 1 0.5 $0.72 $0.52 0.31 0 0.18 0.16 2012 PPR 2012 PPR 2013 PPR 2013 PPR 2014 PPR 2014 PPR per 1,000 Cost per per 1,000 Cost per per 1,000 Cost per MM 1,000 MM MM 1,000 MM MM 1,000 MM * Cost numbers represented in thousands 20
PPR Reasons 2013 Overall Plan Number Frequency 2013 2014 2013 2014 Mental health or substance abuse readmission following an initial admission for a substance abuse or mental health diagnosis 54 81.82% Medical readmission for a continuation or recurrence of the reason for the initial admission, or for a closely related condition 5 7.58% Medical readmission for acute medical condition or complication that may be related to or may have resulted from care during initial admission or in post-discharge period after initial admission 4 6.05% Readmission for mental health reasons following an initial admission for a non-mental health, non-substance abuse reason 3 4.55% Total 66 100 21
PPR 2014 Overall Plan Number Frequency Year 2014 2013 2014 2013 Mental health or substance abuse readmission following an initial admission for a substance abuse or mental 51 54 57.95% 81.82 health diagnosis Medical readmission for acute medical condition or complication that may be related to or may have resulted 18 4 20.45% 6.05 from care during initial admission or in post-discharge period after initial admission All other readmissions for a chronic problem that may be 5 5.68% related to care either during or after the initial admission Readmission for a substance abuse diagnosis reason following an initial admission for a non-mental health, 5 5.68% non-substance abuse reason Readmission for mental health reasons following an initial admission for a non-mental health, non-substance abuse 4 3 4.55% 4.55 reason Medical readmission for a continuation or recurrence of the reason for the initial admission, or for a closely related 3 5 3.42% 7.58 condition Ambulatory care sensitive conditions as designated by 2 2.27% AHRQ 22 Total 88 66 100 00 100
2013 in Travis SA Health Plan Volume Blue Cross Blue Shield of Texas 67 19% Sendero Health Plans 32 9% Seton Health Plan 88 25% Superior Health Plan 162 46% 23
2013 PIP Score 2013 Final PIP Report Score Averages by Plan 100.0 95.8 90.0 94.0 90.3 87.5 86.0 80.0 84.6 82.4 82.4 81.8 80.2 79.9 79.0 Report Score Average 70.0 73.9 73.0 72.3 71.8 70.9 71.0 67.6 60.0 63.3 57.0 56.4 50.0 53.2 40.0 30.0 20.0 21.7 10.0 0.0 Health Plan 24
Agenda Item no. 5 Review meeting Conclusions Contacts James A. Cooley (512) 380-4376 james.cooley@hhsc.state.tx.us Dan Culica (512) 380-4382 dan.culica@hhsc.state.tx.us 25
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