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Total Cost of Care Clinic Comparison Reports

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HealthInsight Utah and the Utah Department of Health Office of Health Care Statistics (OHCS) are committed to supporting Utah clinicians with data and information that can improve their ability to succeed in current and future payment models under Medicare, Medicaid and commercial payer contracts. Using Utah's All Payer Claims Database (APCD), we have developed a private report that includes costs of care for commercially insured patients attributed to primary care physicians at your practice.

The first round of Total Cost of Care Clinic Comparison Reports were mailed to clinic administrators in 12 physician office practices on October 31, 2016. By the end of 2016, 111 more reports will be mailed to primary care practices.

What are the goals of the Clinic Comparison Report?

The goal of this Clinic Comparison Report is to show variation in health care cost and resource use for commercially insured patients attributed to your clinic and compared to averages for patients attributed to other clinics across Utah. It includes basic demographic characteristics, Total Cost of Care and Resource Use Indices, total cost and resource use breakouts for inpatient, outpatient, professional and pharmacy claims, inpatient admissions and emergency use for patients attributed to primary care providers at your clinic.

For more information, visit the Johns Hopkins Adjusted Clinical Groups® (ACG®) System for details on their approach to measuring morbidity that improves accuracy and fairness in evaluating provider performance, identifying patients at high risk, forecasting health care utilization and setting equitable payment rates.

How to Use the Report

report screenshot

Here's how you can use this report:

Consider places where your clinic's total cost index (TCI), price index and resource use index (RUI) differ from the state average.

  1. Look for places where your clinic report has a substantially higher price index than RUI.
  2. Look for places where your clinic report has a substantially higher RUI than price index.
  3. Based on the Centers for Medicare & Medicaid Services (CMS) Quality and Resource Use Reports (QRUR) or other payer reports, are there service areas where you see higher cost consistently?
  4. Look at emergency department use and inpatient admission index. If your retrospective clinic risk score is low but use of these facilities is higher than average, consider ways to minimize non-indicated use of these facilities.
  5. If you are looking at reports for different facilities within the same physician group, where do you see variation? What might be the causes of variation.

Report Resources and Definitions

Service Category Definitions of Report Terms

Inpatient Facility: Includes only services billed by a hospital facility for an inpatient stay. Professional services that are billed by a medical group are included in the Professional Service category.

Outpatient Facility: Includes the facility (hospital) payment for services provided in a hospital outpatient setting. Does not include physician (professional) fees.

Professional: Includes all costs for professional services delivered in any setting, including outpatient, inpatient, clinic, and lab or imaging centers. Ancillary services (lab, radiology, etc.) delivered outside a hospital facility are also included.

Pharmacy: Includes all drugs covered by a patient's pharmacy benefit.

Patient Attribution

Patients are assigned to a primary care provider (PCP) listed in the HealthInsight and Office of Health Care Statistic's (OHCS) Provider Directory based on having specific types of primary care visits (evaluation and management) with that PCP. PCPs and their patients are then assigned to a clinic based on a Clinic Provider List maintained by HealthInsight and OHCS.

Attribution: Using evaluation and management visits as a reference, patients were attributed to the primary care physician (service provider) they visited the most during the measurement year. For ties, the primary care physician most recently seen was chosen.

Additional Information, Assumptions and Limitations

The report represents a first-ever effort to use Utah's All Payer Claims Database to calculate the Health Partners (HP) National Quality Forum (NQF) endorsed Total Cost of Care (TCoC) Indices. The first step of the process was a careful vetting of data quality and completion using a quality assurance process developed especially for claims data before performing the calculations according the HP TCoC specifications. Claims data submitted by several of Utah's commercial payers was found to be incomplete, or incorrectly formatted during this process.

There are two important consequences of this finding. The first is that it disqualified claims submitted by those payers for inclusion in this year's effort and resulting reports. The second consequence is more important. As a result of the careful assessment, these payers have been notified and consulted to provide complete and correctly formatted claims data going forward. We expect to be able to include most of the APCD claims data during the next round of TCoC calculations. Nevertheless, this first year's effort is limited by the fact that only six of the potential 15 payers' claims data is represented in the TCoC indices. We look forward to providing a much more complete picture of Utah's annual TCoC going forward. It is important to note that a number of other states have recently been able to provide cost of health care trend reports after a few years of this kind of quality process for their claims data.

Example: Medical spending is up 5.6% in Minnesota, but clinic costs vary widely

The following is a summary of the quality assurance process and outcome for this inaugural effort to calculate TCoC using the APCD.

  • Claims data from 15 payers representing 1,905,847 insured members.
  • Quality Control process: Data assessed for stability, consistency, expected distributions by type of service, number of orphan claims, standardized MS-DRGs and diagnosis code fields.
  • 640,000 members' claims data eligible for inclusion in calculations.
  • Screened for evaluation and management claims, attributed to primary care provider, attributed to primary care practice with > 600 eligible patients, resulting in 212,052 patients attributed to 123 primary care practices with an average patient panel of 1473.

We have not included any quality process numbers in the clinic report. Earlier this year the Office of Health Care Statistics publicly reported A1c Testing for Diabetics and Avoidance of Antibiotics for Adults with Acute Bronchitis quality measures at the physician office level, based on APCD claims data.

In future years we are planning to include both cost and quality measures for commercial claims data in these physician office reports. You will always be given an opportunity to review information for your clinic prior to public reporting.

For More Information Contact:

Norman K Thurston, Ph.D.
Director, Office of Health Care Statistics
Utah Department of Health
Phone: 801-538-7052
Email: nthurston@utah.gov

Sarah Woolsey, M.D.
Medical Director
HealthInsight Utah
Phone: 801-892-6622
Email: swoolsey@healthinsight.org