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Quarterly Quality Call Superior Health Plan
Texas Health and Human Services Commission
Health Policy and Clinical Services Division Healthcare Quality Analytics, Research and Coordination Support
July 13, 2015
STAR PPEs
2
1.13
1.23
1.08 1.12
1.07
0.98 1.01
1.04
1.38
1.13
1.06 1.07
0.8
0.9
1
1.1
1.2
1.3
1.4
1.5
2011 2012 2013 2014
A/E
Rat
io
PPA PPR PPV
PPEs definition
Potentially preventable events analyzed by HHSC include:
• 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.
• 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.
• Potentially preventable complication (PPC): A harmful event or negative outcome, such as an infection or surgical complication, that occurs after a hospital admission or a long-term care facility stay and might have resulted from the care, lack of care, or treatment provided during the admission or stay.
3
STAR PPV
4
* NOTE: Calendar year 2014 is a partial year of data.
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
45.00
50.00
$7,900
$8,000
$8,100
$8,200
$8,300
$8,400
$8,500
$8,600
$8,700
$8,800
$8,900
CY11 PPV STAR SuperiorHealthPlan TOTAL
CY12 PPV STAR SuperiorHealthPlan TOTAL
CY13 PPV STAR SuperiorHealthPlan TOTAL
CY14 PPV STAR SuperiorHealthPlan TOTAL
Costs per1,000 MM 8649.43 8227.77 8515.09 8776.49
A/E Ratio 1.38 1.13 1.06 1.07PPEs per1,000 MM 40.28 44.22 43.64 44.33
Actu
al-to
-exp
ecte
d (A
/E)
ratio
PPE
cost
s pe
r 1,
000
mem
ber
mon
ths
(MM
)
MEDICAID / CHIP MANAGED CARE ORGANIZATION (MCO), POTENTIALLY PREVENTABLE EVENTS (PPE) DATA, CALENDAR YEARS 2011-2014 *
PPV A/E Ratio
5
1.37
1.25
1.36 1.42
0.99
0.83 0.89
1.09
1.69
1.15
1.25 1.21
0.6
0.8
1
1.2
1.4
1.6
1.8
2011 2012 2013 2014
A/E
Ratio
Bexar El Paso Lubbock Nueces Travis
PPV A/E Ratio
6
0.54 0.42 0.43
1.36 1.35 1.29
1.6
1.4 1.32
1.4
1.27 1.25
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2012 2013 2014
A/E
Rat
io
Hidalgo MRSA Central MRSA Northeast MRSA West
Cost per PPV Statewide
7
$214.73
$186.06 $195.12 $197.98
$336.61
$277.13 $261.70 $256.51
$100.00
$150.00
$200.00
$250.00
$300.00
$350.00
$400.00
2011 2012 2013 2014
PPV Superior PPV STAR Total
Service Area Cost per PPV
8
$211.33 $192.22
$217.89
$234.77
$203.32 $184.92
$173.28 $173.46
$142.24 $133.76
$152.13 $155.49
$336.31
$310.49 $319.71
$310.92
$214.20 $215.11 $218.56
$215.02
$100.00
$150.00
$200.00
$250.00
$300.00
$350.00
2011 2012 2013 2014
Bexar El Paso Lubbock Nueces Travis
Service Area Cost per PPV
9
$209.36
$224.99 $221.78
$168.78
$187.18 $196.61
$156.83 $163.29 $166.98
$151.97 $160.41 $160.63
$120.00
$140.00
$160.00
$180.00
$200.00
$220.00
$240.00
2012 2013 2014
Hidalgo MRSA Central MRSA Northeast MRSA West
PPV Reasons Overall Plan (74.8%) Number Frequency
Infections Of Upper Respiratory Tract 80,212 25.80%
Non-Bacterial Gastroenteritis, Nausea & Vomiting 21,385 6.88%
Signs, Symptoms & Other Factors Influencing Health Status 20,114 6.47%
Other Skin, Subcutaneous Tissue & Breast Disorders 16,933 5.45% Contusion, Open Wound & Other Trauma to Skin & Subcutaneous Tissue 16,422 5.28%
Other Ear, Nose, Mouth, Throat & Cranial/Facial Diagnoses 15,379 4.95%
Musculoskeletal System & Connective Tissue Diagnoses 15,292 4.92%
Abdominal Pain 13,570 4.37%
Viral Illness 10,827 3.48%
Cellulitis & Other Bacterial Skin Infections 8,029 2.58%
Acute Lower Urinary Tract Infections 7,938 2.55%
Splint, Strapping and Cast Removal 6,470 2.08% 10
Discussion • Potentially Preventable Emergency (PPV)
Department Visits • Overall 16% average above state level • Wide variation in utilization
• Low: Hidalgo and El Paso • High: Nueces, Lubbock, MRSA West, Travis,
MRSA Central, Bexar, MRSA Northeast • Variation in cost:
• High in Nueces; Low in Lubbock
11
STAR+PLUS
0.81 0.9
0.84 0.87
0.95 1 1.01 1.01
0.88
0.99 0.97 0.99
0
0.2
0.4
0.6
0.8
1
1.2
2011 2012 2013 2014
A/E
Ratio
s
PPA* PPR PPV
12
* Methodology used by 3M excludes several Behavioral Health conditions
PPA
13
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
CY11 PPA STAR+PLUSSuperior HealthPlan TOTAL
CY12 PPA STAR+PLUSSuperior HealthPlan TOTAL
CY13 PPA STAR+PLUSSuperior HealthPlan TOTAL
CY14 PPA STAR+PLUSSuperior HealthPlan TOTAL
Costs per1,000 MM 50390.29 35249.78 29770.28 29905.98
A/E Ratio 0.81 0.9 0.84 0.87PPEs per1,000 MM 5.9 6.52 6.17 6.26
Actu
al-to
-exp
ecte
d (A
/E)
ratio
PPE
cost
s pe
r 1,
000
mem
ber
mon
ths
(MM
)
MEDICAID / CHIP MANAGED CARE ORGANIZATION (MCO), POTENTIALLY PREVENTABLE EVENTS (PPE) DATA, CALENDAR YEARS 2011-2014 *
PPA A/E Ratios
14
0.69 0.7 0.7
0.78
1.2
1.02
1.11 1.11 1.09
0.71
0.63
1.71
1.08
1.28
0.77 0.88
0.90 0.92
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2011 2012 2013 2014
Axis
Titl
e
Bexar Dallas* Hidalgo Lubbock Nueces
* Behavioral Health services are carved-out in Dallas Service Area
Cost per PPA
15
$8,465.76
$5,784.37 $5,094.26 $5,063.88
$8,540.73
$5,406.41 $4,825.00 $4,777.31
$0.00
$1,000.00
$2,000.00
$3,000.00
$4,000.00
$5,000.00
$6,000.00
$7,000.00
$8,000.00
$9,000.00
2011 2012 2013 2014
TOTAL Superior HealthPlan
Cost by Service Area
16
$7,826.44
$9,676.14
$6,117.80
$5,070.54 $4,916.36
$4,344.61 $4,424.96 $4,357.44
$8,686.57
$5,507.83 $4,822.86
$2,000.00
$3,000.00
$4,000.00
$5,000.00
$6,000.00
$7,000.00
$8,000.00
$9,000.00
$10,000.00
$11,000.00
2011 2012 2013 2014
Bexar Dallas* Hidalgo Lubbock Nueces
* Behavioral Health services are carved-out in Dallas Service Area
PPA Conditions
PPA Reason (APR DRG) [95.1%] Number Percent Bipolar Disorders 1,097 63.26% Major Depressive Disorders & Other/Unspecified Psychoses 214 12.34% Seizure 60 3.46% Other Pneumonia 56 3.23% Diabetes 42 2.42% Asthma 36 2.08% Cellulitis & Other Bacterial Skin Infections 35 2.02% Depression Except Major Depressive Disorder 23 1.33% Kidney & Urinary Tract Infections 23 1.33% Childhood Behavioral Disorders 22 1.27% Schizophrenia 21 1.21% Infections of Upper Respiratory Tract 20 1.15%
17
Discussion • Potentially Preventable Admissions (PPA) • Overall 15% average below state level • Wide variation
• Low: Bexar, Nueces, Hidalgo • High: Dallas, Lubbock
• Cost • Low in Hidalgo and Lubbock
• Did you find similar results?
18
STAR Health PPEs
19
TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTALSuperiorHealthPl
an
SuperiorHealthPl
an
SuperiorHealthPl
an
SuperiorHealthPl
an
SuperiorHealthPl
an
SuperiorHealthPl
an
SuperiorHealthPl
an
SuperiorHealthPl
an
SuperiorHealthPl
an
SuperiorHealthPl
an
SuperiorHealthPl
an
SuperiorHealthPl
anSTARHealth
STARHealth
STARHealth
STARHealth
STARHealth
STARHealth
STARHealth
STARHealth
STARHealth
STARHealth
STARHealth
STARHealth
PPA PPR PPV PPA PPR PPV PPA PPR PPV PPA PPR PPVCY11 CY12 CY13 CY14
Costs per 1,000 MM $25,562 $21,977 $8,579 $24,530 $18,551 $9,102 $29,758 $16,254 $10,284 $39,881 $22,485 $10,068A/E Ratio 1 1 1 1 1 1 1 1 1 1 1 1PPEs per 1,000 MM 4.1 1.9 30.67 3.84 1.78 40.96 5.09 1.75 42.86 6.43 2.05 43.92
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
45.00
50.00
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
Actu
al-to
-exp
ecte
d (A
/E)
ratio
PPE
cost
s pe
r 1,
000
mem
ber
mon
ths
(MM
)
MEDICAID / CHIP MANAGED CARE ORGANIZATION (MCO), POTENTIALLY PREVENTABLE EVENTS (PPE) DATA, CALENDAR YEARS 2011-2014 *
STAR Health PPEs
20
4.10 3.84 5.09 6.43
1.90 1.78 1.75 2.05
30.67
40.96 42.86 43.92
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
45.00
2011 2012 2013 2014
Number of PPEs per 1,000 Member Months
PPA PPR PPV
STAR Health PPEs Costs
21
$25,562.00 $24,530.00
$29,758.00
$39,881.00
$21,977.00 $18,551.00 $16,254.00
$22,485.00
$8,579.00 $9,102.00 $10,284.00 $10,068.00
$0.00
$5,000.00
$10,000.00
$15,000.00
$20,000.00
$25,000.00
$30,000.00
$35,000.00
$40,000.00
$45,000.00
2011 2012 2013 2014
PPEs Costs per 1,000 Member Months
PPA PPR PPV
STAR Health Cost per PPE
22
$6,234.75 $6,388.09 $5,846.29 $6,202.32
$11,566.70 $10,421.89
$9,287.77
$10,968.48
$279.74 $222.22 $239.94 $229.24
$13,121.67
$2,909.33
$0.00
$2,000.00
$4,000.00
$6,000.00
$8,000.00
$10,000.00
$12,000.00
$14,000.00
2011 2012 2013 2014
PPA PPR PPV PPC
2013 PIP Score
24
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
75.5
79.0
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Repo
rt S
core
Ave
rage
Health Plan
2013 Final PIP Report Score Averages by Plan
2013 PIP Score by Topic
25
2013 Final PIP Report Scores by Topic 2013 Final PIP Report Topic Count and Scores
Health Plan Program Topic Final Score
Total Count
Average Score
Minimum Score
Maximum Score
Superior STAR Postpartum care 83.3 15 70.3 23.6 100.0 Superior STAR Diabetes HbA1c testing 87.5 3 90.5 87.5 96.4 Superior STAR Well Child Visits (W34) 100.0 8 87.9 74.1 100.0 Superior STAR Health Postpartum care 62.5 15 70.3 23.6 100.0 Superior STAR Health Follow-up Hospital (FUH) 80.6 8 71.7 41.7 84.4 Superior STAR Health Pharyngitis 83.3 4 85.4 75.0 100.0 Superior STAR+PLUS Asthma Medication 80.6 1 80.6 80.6 80.6 Superior STAR+PLUS Cholesterol Management 83.3 2 82.7 82.1 83.3 Superior STAR+PLUS Diabetes HbA1c testing 87.5 3 90.5 87.5 96.4
2014 Performance Improvement Projects Superior STAR Comprehensive Diabetes Management (PPA) Superior STAR Asthma Management, includes all measures, (PPA) Superior STAR+PLUS Comprehensive Diabetes Management (PPV) Superior STAR+PLUS Schizophrenia Medication Management Superior STAR Health Antidepressant Management in Teen and Young Adults
PIP Scores by Plan Type
26
83.3 87.5
100.0
62.5
80.6 83.3
80.6 83.3
87.5
70.3
90.5 87.9
70.3 71.7
85.4 80.6 82.7
90.5
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Postpartumcare
DiabetesHbA1c testing
STAR
W34 Postpartumcare
FUH Pharyngitis AsthmaMedication
CholesterolManagement
DiabetesHbA1c testing
STAR+PLUS
Scor
e
Superior All Plans
Special Populations Baseline: December 1, 2014 Superior Health Plan, Inc. and Superior Health Plan
Network Methodology: Identify super-utilizers: claims, PPEs, clinical
outcomes Resources: predictive modelling on cost, utilization, gaps
in care, dual diagnosis Focus: identify members with highest potential to improve Integrated Care Team with specific responsibilities Intervention: in person visits at clinic and/or home Evaluation: costs, ER visits, admissions, readmissions,
gaps in care
27
Partnership Opportunity Medicaid Waiver Bexar County - RHP 6 El Paso – RHP 15 Lubbock – RHP 12 Nueces – RHP 4 Travis – RHP 7 Hidalgo – RHP 5 MRSAs Central, Northeast & West – multiple
RHPs
28