High Cost Users for LHINs & Health Links Health Analytics Branch, HSIMI September 2013

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Distribution of Costs, 2010/11

Proportion of Ontario Patients Proportion of Costs

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Defining the “high cost user” • In the following analyses, high cost users are the 10% of patients with the highest

combined cost in 2010/11 for the following health care services:

Acute Care Day Surgery Emergency Rooms Inpatient Rehabilitation Inpatient Mental Health Complex Continuing Care Home Care Long-Term Care Physician Claims

• The analysis is based on cost alone. • This group of patients may include those with a single very expensive event (e.g.

transplants) or multiple events with high combined cost (e.g., care for chronic conditions).

These sectors account for approximately 74% of the Ministry/LHIN operating expenses

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Purpose of Current Analyses • Upon the establishment of the Early Adopter Health Links, the

ministry received requests for high cost user analyses for these areas.

• The following describes analyses of the high cost users at the LHIN and Health Link levels (22 Health Links approved as of February 2013); the analysis focuses on the 10% of patients who reside within each Health Link area who had the highest combined cost in 2010/11. • Due to the small size of some Health Link areas the analysis has

been done only for the Top 10% patients. • The analysis was done separately for each geographic area. Note

that LHIN/Health Link High Cost Users may not be within the Ontario high cost users.

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Key Findings Regardless of whether we focus on the high cost users at the Health Link, LHIN or provincial level, the following key findings are applicable: 1. A patient who is a high cost user in one fiscal year may not continue to be

a high cost user in future years.

2. Rare conditions, such as transplants, low birth weight babies, and burns have the highest average acute care cost, while chronic conditions, hip fracture, hip replacement and palliative care have the highest total cost. Health Links have the potential to impact certain groups of high cost users.

3. High cost users are a diverse group, but typically have two key characteristics: • They receive treatment from multiple health care sectors • and/or have long lengths of stay in inpatient settings.

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Key Findings (continued) 4. For most sectors, the average number of episodes and cost per episode is

similar for high cost users and all users. However, high cost users access a larger number of health care sectors.

5. The characteristics of patients and patterns of health care utilization among high cost users are similar across geographic areas. • Seniors represent the largest percentage of patients/expenses and

have the highest average cost per patient. • Acute care, physician visits, and long-term care represent the largest

percentage of expenses. 6. The profile of high cost users is consistent with the population structure of

the area. • Areas with more seniors will have more seniors among the high cost

user patients. • Areas with more young families will have more children and young

adults among the high cost user patients.

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Understanding the High Cost User, 2010/11

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High Cost User Patients – Example Profiles

Female, age 25-39 yrs (cost: $1 million)

Male, age 50-64 yrs (cost: $570,000) Male, age 80+ yrs (cost: $240,000)

Acute inpatient care : 5 discharges 190 acute days + 60 ALC days Emergency: 5 visits Day surgery: 1 visit CCC: 1 episode, 340 days Homecare: 62 services Nursing, physiotherapy, OT and personal support Physician visits\claims: 105 Problems\Conditions: Heart transplant, congestive heart failure, digestive symptoms, cellulitis, cardiovascular screening, transplant rejection

Acute inpatient care: 2 discharges 70 acute days + 90 ALC days CCC: 1 admission, 80 days Inpatient Rehab: 1 discharge, 130 days Physician visits\claims: 170 Problems\Conditions: Respiratory failure, traumatic brain injury, craniofacial bone intervention

Acute inpatient care: 3 discharges 75 acute days Emergency Dept: 3 visits Day Surgery: 2 visits Homecare: 12 services Nursing, Physiotherapy Physician visits\claims: 105 Problems\Conditions: AMI\angina, AMI\shock arrest\with cardiac cath., respiratory intervention, gastrointestinal intervention, screening exam, cardiac study, endoscopic inspection digestive tract

High cost users access multiple types of care and have long lengths of stay

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Once a high cost user not necessarily always a high cost user

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Conditions in Acute Care – Highest Average Cost

• List includes relatively rare events with very high acute care cost.

Separations/Discharges

Total Expense ($) Average Expense

($) 160 Heart or Lung Transplant 65 11,360,000$ 169,600$ 710 Extensive Burn with Skin Graft 35 5,320,000$ 161,100$ 571 Newborn/Neonate 1500+ gm with Major

Cardiovascular Intervention145 20,830,000$ 145,700$

110 Lung Transplant 60 7,520,000$ 121,300$ 578 Newborn/Neonate <750 grams 200 21,420,000$ 108,200$ 131 Failure/Rejection Lung Transplant 10 890,000$ 98,400$ 570 Newborn/Neonate 1500+ gm with Major

Gastrointestinal/Diaphragm Intervention170 16,420,000$ 95,500$

579 Newborn/Neonate 750-999 grams, Gestational Age <29 Weeks

305 27,720,000$ 90,900$

270 Liver/Pancreas/Duodenum Transplant 195 15,910,000$ 81,200$ 581 Newborn/Neonate 1000-1499 grams, Gestational

Age <29 Weeks375 25,420,000$ 68,100$

Case Mix Group

Top 10% Patient Segment

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Conditions in Acute Care – Highest Total Cost

• List includes chronic conditions with moderate to high acute care costs.

• Patients with vaginal delivery are among the high cost users because they have numerous physician visits, and other types of care in addition to the cost of the birth.

Separations/Discharges

Total Expense ($) Average Expense

($) 139 Chronic Obstructive Pulmonary Disease 23,520 187,110,000$ 8,000$ 545 Vaginal Delivery, No Other Intervention 64,505 179,670,000$ 2,800$

196 Heart Failure without Cardiac Catheter (CHF) 19,100 170,380,000$ 8,900$

321 Unilateral Knee Replacement 19,335 163,560,000$ 8,500$ 138 Viral/Unspecified Pneumonia 19,220 142,940,000$ 7,400$

810 Palliative Care 12,660 134,050,000$ 10,600$ 221 Colostomy/Enterostomy 4,315 127,420,000$ 29,500$ 162 Cardiac Valve Replacement 3,150 119,620,000$ 38,000$

175 Percutaneous Coronary Intervention with MI/Shock/Arrest/Heart Failure (Angioplasty)

9,410 118,920,000$ 12,600$

727 Fixation/Repair Hip/Femur (Hip Fracture) 7,285 115,300,000$ 15,800$

Case Mix Group

Top 10% Patient Segment

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• 3% used a single sector. • 89% used 2 - 4 sectors. • 7% used 5 or more sectors. • The average number of sectors used was 3.0. • The average number of sectors used by LHIN of

patient residence ranged from 2.8 to 3.4.

Number of Sectors Used

Perth County 3.3Huron 3.4Guelph 3.0Hamilton Central 3.3N. Etobicoke-Malton-W. Woodbridge 2.9Dufferin 3.1South East Mississauga 2.9Mid Toronto West 2.8Don Valley/Greenwood 2.8North Toronto East 2.8S. Simcoe and Northern York 2.9North York Region 2.9Peterborough 3.3Rural Hastings 3.3Quinte 3.3Rural Kingston 3.0Kingston 3.1Thousand Islands 3.3Barrie Community 3.0South Georgian Bay 3.2Temiskaming 3.4Timmins 3.4

Health Link Area of ResidenceAverage # of Sectors

Used

The average number of sectors used ranged from 2.8 to 3.4.

Top 10% patients for Ontario Top 10% patients by Health Link

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Proportion of patients by sector type

If we compare all Ontario users to the top 10% : • Nearly 100% of patients had a physician visit. • 26% of all users and 63% of high cost users had an emergency visit • 7% of all users and 61% of high cost users had an acute care discharge • 9% of all users and 33% of high cost users had a day surgery visit • 4% of all users and 27% of high cost users received a homecare service • 1% of all users and 9% of high cost users spent time in long-term care

While the magnitude varied, the patterns of utilization for both groups were similar at the Health Link and LHIN of residence level.

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Event Frequency by Sector Among the Ontario top 10% patients: • 96% had 6 or more physician

visits in 2010/11. • For all other sectors, among the

patients with activity, the largest proportion had a single event.

• 26% of patients had 1 emergency visit, while 21% had 3 or more visits.

• Less than 10% of patients received treatment in mental health, rehabilitation, CCC, or LTC.

• 27% of patients received homecare with an average of 77 visits/hours per patient.

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Total Length of Stay (LOS)

Patients in the top 10% in Ontario: • Account for 95-100% of the total LOS for all Ontario users within each sector. • Have 6.3 million total days in acute care, including 1 million ALC and 720,000 special

care unit days. • Have 718,000 days in inpatient rehabilitation. • Have 1.4 million days in inpatient mental health. • Have 1.7 million days in complex continuing care. • Have 27.4 million days in long-term care.

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Comparison of Analyses - 2009/10 vs. 2010/11

• With the addition of LTC and Physician visits, the number of patients and

the expense increased among all users and high cost users; however the average cost per patient declined.

• However, regardless of the method, 10% of patients account for just over 75% of the included health care expenditures.

2009/10 2010/11Total Patients 3,901,620 11,160,290Total Expense (Billions) $14.2 $25.2Average Cost per Patient $3,500 $2,300Patients 390,160 1,116,030Total Expense (Billions) $10.6 $19.4Average Cost per Patient $27,000 $17,400% of Total Expense 75% 77%

All Users

Top 10%

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Expense Summary – Early Adopter Health Links

The top 10% patients account for 74-81% of the total expenses for Health Link residents and 74-78% of expenses for LHIN residents, indicating that the proportion of total expenses for high cost users is consistent across Health Links and LHINs.

PatientsTotal

Expense (Millions)

Patients Total

Expense (Millions)

% of Total Expense for

All Users

Average Expense

Perth County 61,045 143$ 6,105 112$ 78 18,300$ Huron 51,860 141$ 5,185 108$ 76 20,800$ Guelph 119,740 246$ 11,975 190$ 77 15,900$ Hamilton Central 123,820 417$ 12,385 336$ 81 27,100$ N. Etobicoke-Malton-W. Woodbridge 189,490 384$ 18,950 287$ 75 15,200$ Dufferin 57,220 118$ 5,720 90$ 76 15,600$ South East Mississauga 159,915 317$ 15,990 237$ 75 14,800$ Mid Toronto West 123,210 350$ 12,320 280$ 80 22,700$ Don Valley/Greenwood 68,075 173$ 6,810 137$ 79 20,100$ North Toronto East 100,605 225$ 10,060 173$ 77 17,200$ S. Simcoe and Northern York 224,990 444$ 22,500 330$ 74 14,700$ North York Region 554,125 1,258$ 55,415 958$ 76 17,300$ Peterborough 118,415 333$ 11,840 254$ 76 21,400$ Rural Hastings 33,875 92$ 3,390 70$ 77 20,800$ Quinte 106,615 283$ 10,660 216$ 76 20,200$ Rural Kingston 27,380 61$ 2,740 47$ 77 17,200$ Kingston 113,440 332$ 11,345 264$ 80 23,300$ Thousand Islands 63,065 185$ 6,305 146$ 79 23,100$ Barrie Community 168,435 343$ 16,845 262$ 77 15,600$ South Georgian Bay 49,795 124$ 4,980 95$ 76 19,000$ Temiskaming 28,185 95$ 2,820 74$ 78 26,300$ Timmins 36,855 99$ 3,685 73$ 74 19,800$

All Users

Health Link Area of Residence

Top 10%

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Average Cost Per Event

Among all users and Ontario patients in the top 10%: • Acute and rehabilitation have the highest average cost per day. • Homecare, physician and ED visits have relatively low costs per event. • The difference in the average cost for the top 10% vs. all users is

relatively small, suggesting that the higher cost is due to a greater number of events rather than more expensive events.

Average Cost/Event

Average Cost/ Inpatient Day

Average Cost/Event

Average Cost/ Inpatient Day

Acute Separation 7,678$ 1,875$ 8,150$ 2,026$ Rehabilitation Discharge 17,944$ 898$ 17,913$ 888$ CCC Episode 35,775$ 584$ 37,133$ 589$ Mental Health Episode 18,111$ 554$ 21,662$ 575$ LTC Episode 20,750$ 99$ 24,044$ 99$ Day Surgery Visit 981$ 1,407$ Emergency Visit 249$ 391$ Physician Visit 69$ 135$ Home Care Service (Hour/Visit) 54$ 75$

Sector

All Users Top 10%

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Patients and Cost by Age Group

If we compare the Ontario population to patients in the top 10%: • Seniors account for 41% of high cost user patients, but only 14% of the population. • Although infants represent 1% of the population they account for 2.5% of high cost users. Children

and young adults (age 18-44 years) combined account for 58% of the population and 33% of high cost user patients.

• Seniors and infants have the highest average health care costs, while young adults have the lowest.

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High Cost User Profile is Consistent with Population Age Structure

A comparison of Health Links with larger proportions of seniors (Peterborough, South Georgian Bay) to those with smaller proportions of seniors but larger proportions of children/young adults (Guelph, Dufferin) reveals that: • Peterborough and South Georgian Bay have greater proportions of seniors amongst their high cost users

(areas above the red lines – top 10% bars). • In contrast, Guelph and Dufferin have smaller proportions of seniors (areas above the red lines – top 10%

bars), but larger proportions of children/young adults (areas below the green lines) amongst their high cost users.

• The profile of high cost users is consistent with the age structure of the population.

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Average Costs are Similar for LHINs and Health Links

Among the top 10% patients for LHIN and Health Link residents: • North West and North East LHINs had the highest average cost, while Mississauga Halton and Central LHINs

residents had the lowest. • Hamilton Central and Temiskaming Health Links had the highest average cost, while residents of South Simcoe and

Northern York and South East Mississauga Health Links had the lowest. • The average cost for the top 10% within a Health Link is similar to the average cost for the top 10% for the LHIN of

residence.

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Health Links vs. LHINs – Per Cent of Total Expense

Among patients in the top 10% for select Health Links/LHINs: • Although there is variation in the magnitude, the per cent of total expense by sector

for the Health Links is consistent with the overall values for the LHIN. • Acute care accounted for the largest per cent of the expense for all LHINs/Health Links. • Long-term care was the 2nd highest proportion for the South West and North East

LHINs and Health Links, while physician visits accounted for the 2nd highest proportion of expenses for the Toronto Central LHIN and Health Links.

Perth County

Huron South West LHIN

Mid Toronto

West

Don Valley/ Greenwood

North Toronto

East

Toronto Central

LHIN

Temiskaming Timmins North East LHIN

SectorAcute 40.3 43.0 42.8 33.0 36.9 37.4 36.8 53.5 42.9 48.9Long-Term Care 21.6 20.3 16.4 14.7 14.6 10.5 12.7 17.8 14.7 15.1Physician Visits 14.2 13.2 15.4 17.3 19.2 21.2 19.3 10.9 14.1 12.5CCC 5.1 3.7 3.7 5.4 9.4 10.6 8.2 1.6 7.9 3.2Inp. Mental Health 3.5 3.7 6.5 14.4 6.6 4.3 7.3 6.0 6.7 7.4Homecare 5.5 7.4 6.2 7.1 5.0 6.4 6.9 3.8 6.1 5.5Emergency 3.7 4.1 3.4 3.4 3.2 3.3 3.4 2.9 4.0 3.6Day Surgery 3.4 2.9 3.2 2.0 2.4 3.0 2.4 2.0 2.7 2.2Inp. Rehabilitation 2.7 1.6 2.4 2.8 2.7 3.3 3.1 1.4 0.9 1.6

Per Cent of Total ExpenseHealth Link/LHIN of Residence

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Health Links vs. LHINs – Average number of events

Among patients in the top 10% for select Health Links/LHINs: • Although there is variation in the magnitude, the average number of events by sector

for the Health Links is consistent with the overall values for the LHIN. • Homecare and physician visits had the largest average number of events. • Homecare services showed the greatest variation within and between LHIN areas.

This may be due to the differences in the age structure of the population and/or different service delivery patterns.

Perth County

Huron South West LHIN

Mid Toronto

West

Don Valley/ Greenwood

North Toronto

East

Toronto Central

LHIN

Temiskaming Timmins North East LHIN

SectorHomecare 50.1 70.8 62.4 108.9 83.5 86.5 94.9 61.8 96.7 84.2Physician Visits 22.9 24.3 26.0 31.2 30.6 28.6 30.7 27.4 25.7 26.6Emergency 2.8 3.9 3.0 2.8 2.5 2.2 2.7 4.2 3.5 3.6Acute 1.4 1.6 1.4 1.3 1.4 1.3 1.4 1.7 1.6 1.6Day Surgery 1.5 1.5 1.5 1.7 1.5 1.5 1.6 1.5 1.4 1.6Inp. Mental Health 1.5 1.4 1.5 1.6 1.6 1.4 1.6 1.3 1.7 1.5Long-Term Care 1.2 1.3 1.3 1.4 1.3 1.3 1.3 1.4 1.4 1.3Inp. Rehabilitation 1.0 1.0 1.1 1.0 1.1 1.1 1.1 1.1 1.0 1.0CCC 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.0 1.1 1.0

Health Link/LHIN of Residence

Average Number of Events

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Summary and Conclusions: • High cost users are a small, but diverse group; however, their patterns of health care

utilization are relatively consistent across geographic areas. • The top 10% account for approximately 75% of all health care expenditures. • They access an average of 3 different health care sectors. • They account for 95-100% of the total LOS in each sector. • Acute care represents the largest proportion of their expenses. • Seniors are more likely to be high cost users than those in other age groups.

• Only 44% of patients who were high cost users in one fiscal (2009/10) year were still high cost users the following fiscal year (2010/11).

• The high cost user analyses will always be retrospective.

• The analysis demonstrates that there is a spectrum of high cost users (from transplant patients to patients with multiple chronic diseases). Health Links have the potential to impact certain groups of high cost users and improve patient care coordination.

• It is important to focus on the features (patient demographics, diagnoses, utilization trends) that are associated with being identified as a high cost user in order to target populations and assist with planning and service coordination for LHINs and Health Links.

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Appendix

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Changes to the High Cost User Methodology - 2009/10 vs. 2010/11

Addition of Long-Term Care and Physician Claims • Increases the # of patients from 3.9 million in 2009/10 to 11.1 million in

2010/11 • Increases the total expense from $14.2 billion in 2009/10 to $25.2 billion in

2010/11

Inclusion of activity and costs from private, federal, and specialty facilities that receive provincial funding

• Increases the total hospital expense by $103 million

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Acute Care by Location of Service - LHIN

• Nearly half, of acute care expenses for Central (49%) and Central West (48%) LHIN residents were for care provided in hospitals outside the LHIN of residence.

• Only 3% of acute care expenses for Champlain residents were incurred in other LHINs.

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Acute Care by Location of Service – Health Link Among the Top 10% of patients by Health Link: • 58% of the acute expense for

North York residents was for care provided outside Central LHIN.

• 53% of the acute expenses for North Etobicoke-Malton-West Woodbridge and 48% of the expenses for Dufferin residents were incurred in hospitals outside the Central West LHIN.

• The large expense for residents of North York Region is due to the large population size of that Health Link.

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Limitations:

The ministry is unable to provide the following information: 1. A summary of health care utilization for actual health card numbers. 2. A summary of information for small geographic areas (postal code, FSA). 3. A summary information for specific health care providers. 4. Information for Top 1% and 5% patient segments. 5. Information for all planned areas.

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