Quarterly Quality Call Seton Health Plan Texas Health and Human - - PowerPoint PPT Presentation

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

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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

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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

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Agenda Item no. 4 Focused discussion on a specific SETON quality measure Quality Measures collected by HHSC

• Quality of Care
• PPEs

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PPEs Definition

Potentially preventable emergency room visit (PPV)

Emergency treatment for a condition that could have been, treated

• r 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.

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SETON PPR on Website

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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 0.00 0.50 1.00 1.50 2.00 2.50 $0 $200 $400 $600 $800 $1,000 $1,200 $1,400 $1,600 $1,800 $2,000 Actual-to-expected (A/E) ratio PPE costs per 1,000 member months (MM)

SETON Health Plan, POTENTIALLY PREVENTABLE READMISSIONS (PPRs), CALENDAR YEARS 2012-2014

SETON PPEs

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0.98 1.03 0.94 0.94 1.73 2.01 1.14 1.2 1.04

0.5 1 1.5 2 2.5 2012 2013 2014 PPA PPR PPV

SETON Cost per PPE

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$6,476.69 $5,837.67 $6,476.89 $3,971.11 $3,220.75 $5,894.94 $510.67 $480.14 $256.64

$0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 2012 2013 2014 PPV PPR PPA

SETON PPE Cost per 1,000 MM

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$5,699 $4,378 $4,016 $715 $515 $1,827 $23,251 $20,382 $9,598

$0 $5,000 $10,000 $15,000 $20,000 $25,000 2012 2013 2014 PPA PPR PPV

SETON Health Plan Quality Measure of Interest

Potentially Preventable Readmissions PPRs

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SETON PPR Profile 2014

Type Area Plan Total Admissions at Risk for PPR Actual Number

• f PPR

Chains Actual to Expected Ratio for PPR Weight Actual Number of PPRs Chains Per 1,000 Member Months Actual PPR Expenditures Actual PPR Expenditures Per 1,000 Member Months STAR 298,826 5,612 1.00 0.19 $45,681,840.23 $1,403.60 TRAVIS 11,658 260 1.10 0.18 $2,181,561.23 $1,341.24 SETON 1,138 47 2.01 0.31 $307,327.32 $1,827.43

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Cost per PPR STAR and SA

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$7,181.60 $7,596.65 $7,387.37 $9,154.19 $5,939.71 $7,451.33 $3,971.11 $3,220.75 $5,894.94

$0 $2,000 $4,000 $6,000 $8,000 $10,000 2012 2013 2014 SETON STAR Travis SA STAR TOTAL

PPR A/E Ratios in Travis SA

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1.02 0.87 1.1 0.94 1.73 2.01 0.5 1 1.5 2 2.5 2012 2013 2014 STAR Travis SA SETON

PPR Cost per 1,000 MM STAR and SA

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$1,436 $1,519 $1,404 $1,465 $832 $1,341 $715 $515 $1,827

$0 $200 $400 $600 $800 $1,000 $1,200 $1,400 $1,600 $1,800 $2,000 2012 2013 2014 STAR TOTAL STAR Travis SA SETON

PPR A/E Ratios All Plans Travis SA

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0.94 1.73 2.01

0.5 1 1.5 2 2.5 2012 2013 2014 Blue Cross Blue Shield of Texas Sendero Health Plans Seton Health Plan Superior HealthPlan

Cost per PPR All Plans Travis SA

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$3,971.11 $3,220.75 $5,894.94

$0.00 $5,000.00 $10,000.00 $15,000.00 2012 2013 2014 Superior HealthPlan Seton Health Plan Sendero Health Plans Blue Cross Blue Shield of Texas

PPR Cost per 1,000 MM All Plans Travis SA

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$715 $515 $1,827

$0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 2012 2013 2014 Blue Cross Blue Shield of Texas Sendero Health Plans Seton Health Plan Superior HealthPlan

PPRs and Cost Correlation All Plans Travis SA

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* Cost numbers represented in thousands

0.18 $0.72 0.16 $0.52 0.31 $1.83

0.5 1 1.5 2 2.5 3 2012 PPR per 1,000 MM 2012 PPR Cost per 1,000 MM 2013 PPR per 1,000 MM 2013 PPR Cost per 1,000 MM 2014 PPR per 1,000 MM 2014 PPR Cost per 1,000 MM Blue Cross Blue Shield of Texas Sendero Health Plans Seton Health Plan Superior HealthPlan

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 health diagnosis 51 54 57.95% 81.82 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 18 4 20.45% 6.05 All other readmissions for a chronic problem that may be related to care either during or after the initial admission 5 5.68% Readmission for a substance abuse diagnosis reason following an initial admission for a non-mental health, non-substance abuse reason 5 5.68% Readmission for mental health reasons following an initial admission for a non-mental health, non-substance abuse reason 4 3 4.55% 4.55 Medical readmission for a continuation or recurrence of the reason for the initial admission, or for a closely related condition 3 5 3.42% 7.58 Ambulatory care sensitive conditions as designated by AHRQ 2 2.27% Total 88 66 100 00 100 22

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%

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2013 PIP Score

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56.4 90.3 73.0 53.2 67.6 71.8 72.3 95.8 79.9 82.4 82.4 80.2 87.5 63.3 57.0 70.9 21.7 84.6 86.0 94.0 81.8 73.9 71.0 79.0 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Report Score Average Health Plan

2013 Final PIP Report Score Averages by Plan

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

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