Static regions for health policy analysis

Health Policy CommissionDiscussion document

September 20, 2013

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Objectives

▪ Review example geographic regions in use in Massachusetts

▪ Describe Health Policy Commission draft approach to static geographic regions

▪ Discuss key decision points in analytic model

▪ Receive Health Planning Council feedback on draft approach

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Two types of geographic definitions are useful in our policy analyses

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Static geographic regions

▪ Regions to be used for drilling down a level deeper than statewide figures

▪ Statically defined and changed infrequently to allow measurement of trend over time

▪ Should be based on existing region definitions or should provide an easy crosswalk to support analysis linking data with other sources (including national datasets - census, etc)

Dynamic service areas for market analysis

▪ Service area defined with the hospital at the center

▪ Definition based on a consistent rule, but actual geographic boundaries of service areas may vary over time based on market shifts

▪ Should align with ‘real’ market function

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FOCUS FOR TODAY

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Goals for static region definition

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Stable / Rigid

Definitions of health care service regions will be used across:

Understandable

Usable

Meaningful

Effective region definitions will be…

▪ Reflect population distribution and travel patterns▪ Incorporate market-oriented understanding of delivery system and referral

patterns

▪ Anchor in familiar concepts (e.g. cities or political boundaries)▪ Develop through defensible and easily communicated methodology▪ Use existing region definitions where possible

▪ Set up crosswalks for linking to major data sources (e.g. zip codes for linking to APCD, census data, HSAs)

▪ If regions include multiple levels, build hierarchically to enable effective roll-ups and drill-downs

▪ Keep regions consistent over time to allow measurement of trend▪ Define regions based on data which will not change significantly from year-

to-year, so that regions remain meaningful

▪ Cost Trends reports and analyses

▪ Assessments of geographic access/disparities▪ Health resource planning analysis

▪ Policy development – DoN and investments

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Design questions for static regions

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How many levels of regions should there be?

▪ Single set of regions (e.g. at tertiary care level)▪ Two sets of regions (e.g. secondary and tertiary care)▪ Three sets of regions (e.g. to add primary care practice

regions)

How often should region definitions be refreshed?

▪ Every decade▪ Every 5 years▪ Every 3 years▪ Annually

Question

How should size of regions (and therefore number of regions) be determined?

▪ Based on market / competition (e.g. at least 2 hospitals per region)

▪ Based on geographic access (e.g. no more than 45 mins travel time between 2 points in region)

▪ Based on existing patterns of use (e.g. areas built around how far patients currently go for care)

NOT EXHAUSTIVE

Options

Should we use an existing region definition or develop a new one?

▪ Select region definitions from a Massachusetts agency▪ Select region definitions from academic literature, a

nonprofit, or federal agency▪ Develop a new region definition

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Example of regional definitions currently in use in Massachusetts

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Organization

Dartmouth Atlas

Region definition Description

▪ 3 hospital referral regions▪ 64 hospital service areas▪ 105 primary care service

areas

▪ Based on Medicare patients– HRR: Cardiovascular surgery and neurosurgery– HSA: All inpatient admissions– PCSA: Primary care services

EOHHS ▪ 6 EOHHS regions ▪ Used for reporting on health indicators▪ Regions include: Western Mass, Central Mass,

Boston, Metro West, Northeast, Southeast

DPH ▪ 5 regions for emergency medical services

▪ Based on location of trauma centers and geographic proximity / time to reach emergency services

Health Planning Council (Freedman draft)

▪ 4 tertiary regions▪ 16 secondary regions▪ 122 primary regions

▪ To be used for resource planning▪ Based on similar criteria to Dartmouth Atlas▪ Consistent with patient access and referral patterns

DOI ▪ 7 rating regions ▪ Regions defined for area rate adjustments

Network adequacy stds ▪ Highly varied ▪ Varied by payer and services

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Dartmouth Atlas offers the greatest ability to link to existing studies and national benchmarks, but is especially outdated at the secondary care level (HSAs)

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EOHHS publications use 6 regions, 14 counties, and 351 cities/towns

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Western Mass

Central Mass

Northeast

Metro West

Southeast

Boston Region

Barnstable

Berkshire

Bristol

Essex

Hampden

Dukes

Franklin

Hampshire

Middlesex

Nantucket

Norfolk

Plymouth

Suffolk

Worcester

EOHHS regions Counties (alphabetical) Cities/towns

SOURCE: Massachusetts EOHHS/DPH

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Emergency Medical Service regions

8 SOURCE: Massachusetts EOHHS

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Division of Insurance rating regions

9 SOURCE: Division of Insurance

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Map of Massachusetts

10 SOURCE: Division of Insurance

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Health Planning Council draft regions (May 3)

11 SOURCE: Freedman Analytic Plan/Health Planning Council

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Health Planning Council draft - Secondary Service Market (SSM) - 16

SOURCE: Freedman Analytic Plan/Health Planning Council 12

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Dartmouth Atlas region structure

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Primary care service areas (PCSAs)

104 in MA (plus 3 RI PCSAs overlapping MA)

▪ Reflect Medicare patient travel to primary care providers▪ Each includes a ZIP code area with 1+ PCPs and any

contiguous ZIP code areas whose Medicare populations seek the plurality of their primary care from those providers.

Hospital service areas (HSAs)

64 in MA (plus 2 RI HSAs overlapping MA)

▪ Local health care markets for hospital care▪ Based on assigning ZIP codes to hospital area where the

greatest proportion of zip code’s Medicare residents were hospitalized (adjusted to ensure contiguity)

Hospital referral regions (HRRs)

3 in MA (Boston, Worcester, Springfield)

▪ Regional health care markets for tertiary medical care that generally requires the services of a major referral center

▪ Based on where patients were referred for major cardiovascular surgical procedures and for neurosurgery

▪ Each HRR has at least one city where both major cardiovascular surgical procedures and neurosurgery are performed

SOURCE: Dartmouth Atlas web site

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The Health Policy Commission is exploring an approach based on a three-level hierarchy

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Primary

Proposed approach

▪ Use 108 Dartmouth Atlas PCSAs

Secondary

Proposed approach

▪ ~10-20 regions, built as roll-up of 64 Dartmouth Atlas HSAs to allow use of nationally reported data

▪ Roll up based on “Dartmouth-like” logic, including e.g.:– Merge small HSAs based on

where residents of those HSAs are sent for IP stays

– Ensure regions ‘balanced’ in size (e.g. no region > 30% of total MA discharges)

Tertiary/Quaternary

Proposed approach

▪ Use 3 Dartmouth Atlas HRRs for alignment with Medicare and other national analyses

Example analytical uses

▪ Regional segmentation for descriptive statistics (e.g. health status, TME growth)

▪ Regional variation in prices and provider input costs

▪ Ongoing description of competitive landscape

Example analytical uses

▪ Monitoring access to primary care

Example analytical uses

▪ Comparisons of Massachusetts regions to national data on cost, service intensity, health status

▪ Analysis of specialized services (e.g. neurosurgery, CV surgery)

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Region sets modeled/reviewed

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Access-based secondary regions

Service-based secondary regions

▪ Merge Dartmouth HSAs to obtain 10-20 regions for which all residents are within 15 mi or 30 min travel time of an “anchor” hospital offering secondary services

▪ Constrained to roll up to Dartmouth HRRs

▪ Merge Dartmouth HSAs to obtain regions which contain at least 2 providers of:

– Labor and delivery

– Inpatient surgical services

– Inpatient mental health services

– SNFs and home health care services

▪ Constrained to roll up to Dartmouth HRRs

Principles for modeling scenario

In addition to map outlining region boundaries, summary outputs for each region should include:

▪ Population of region

▪ Maximum travel time to center of region from any point in region

▪ Provider landscape:

– # of hospitals and inpatient beds

– # of physicians

– # of mental health providers and IP facilities

– # of SNFs

Adapted Health Planning Council regions

▪ Draft regions defined by Health Planning Council, adjusted to roll up to Dartmouth HRRs

Health Planning Council regions

▪ Draft regions as defined by Health Planning Council team, based on following principles:

– At least two Community Hospitals

– Either 20 or 45 minute driving time (density) from Market center

– Organized along major traffic routes

– Not contradictory to Dartmouth Atlas HSAs

– May require sub-division for ED

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Next steps

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▪ Develop secondary regions– Aim to meet following principles:

▫ ~10-20 regions▫ At least 2 hospitals per region▫ Regions should be defined by roll-up of Dartmouth Atlas HSAs to allow use of nationally

reported data▫ Regions should be ‘balanced’ in size (e.g. no region > 30% of total MA discharges)

– Need to define logic for merging:▫ Merge a small HSA into a larger HAS only if at least X% of discharges sent to larger HAS▫ Any HSA which sends at least Y% of its residents’ discharges to hospitals contained within its

region should not be merged▫ ‘Greedy merge’ (merge into HSA receiving largest % of discharges from the smaller HAS) vs.

‘Merge for ‘balance’ (merge into smallest HSA receiving at least X% of discharges)

– Model several options based on various thresholds

▪ Review with Health Planning Council, CHIA, AGO, DPH, and other agencies doing geographic breakdowns of health care analysis

– Review Regions and Descriptive Statistics at September Health Planning Council meeting

– Discussion with other agencies in parallel

▪ Use regional cuts for APCD analyses in December cost trends report from Health Policy Commission