Measuring Clinical Outcomes in HMO Report Cards

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Measuring Clinical Outcomes in HMO Report Cards

• Joe Martin, Director of Communications and
  Education
• Pennsylvania Health Care Cost Containment Council
• 225 Market Street, Suite 400
• Harrisburg, PA 17101
• [phone]
• www.phc4.org

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About PHC4

• Independent state agency established in 1986
• 21 Council members provide direction and
  represent business, labor, consumers, insurers,
  and providers
• Mission

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What data do we collect?

• 1.8 million inpatient hospital and 1.5 million
  ambulatory
• More than 40 fields of data are available
• UB 92
• Severity Scores Atlas Outcomes

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PHC4 Reports

• Coronary Bypass Report
• Hospital Performance Report
• The Role of HMOs in Managing Diabetes
• Diabetes Hospitalization Report

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PHC4s Top Priority

• Comprehensive Reporting About Managed Care Plans

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Expanding HMO enrollment
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HMO Report
Combines clinical outcomes, prevention measures
and member satisfaction information.
DOES NOT INCLUDE MEDICARE OR MEDICAID HMO PLANS
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In this report...

• Prevention measures (HEDIS)
• Member satisfaction information (CAHPS)
• PLUS

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Clinical Outcome Measures

• Heart Attack
• Heart Failure
• Asthma
• Non-cancerous Hysterectomies

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Selection of clinical conditions

• Present health issues important to purchasers and
  consumers
• Degree of manageability by an HMO
• Prevention Asthma, Heart Attack, Heart Failure
• Appropriateness Hysterectomy
• Significant risk and cost factors

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Traditional PHC4 Measures

• Mortality Rates (Risk-adjusted)
• Average Length of Stay (Risk-adjusted)
• Hospitalization Rates (Age and Sex-adjusted)

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New Measures

• Readmission rates
• Asthma
• Heart Failure
• Complication rates
• Hysterectomy (Abdominal and Vaginal)

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Episodes

• Care management is provided over a period of
  time, or is on-going
• Clinical outcomes result from a series of
  encounters and types of care
• Measures the outcome of a series of events

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Episodes

• Linked hospitalizations using a unique encrypted
  patient identifier
• Associated payor with episode of care
• Sex and age-adjusted
• Risk-adjusted

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State council report finds HMOs approve too many
hysterectomiesPittsburgh Post-Gazette
Report on HMOs in Pa. findsconsiderable
treatment variationPhiladelphia Inquirer
Pa. Study HMOs are OKAssociated Press
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• When you get to the fork in the road, take it.

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Visit PHC4s Web Site www.phc4.org

• Download free public and
• technical reports