advancing new jersey safety net acos: new findings on ...inpatient and treat -and-release ed high...

Center for State Health Policy

Advancing New Jersey Safety Net ACOs: New Findings on Opportunities for Better Care

and Lower Costs

State House Seminar March 26, 2013

Sujoy Chakravarty, Ph.D. Joel C. Cantor, Sc.D.

Jian Tong, M.S. Derek DeLia, Ph.D.

Presented by Rutgers Center for State Health Policy Hosted by the New Jersey Office of Legislative Services

Research Supported by The Nicholson Foundation


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Acknowledgements

The following individuals contributed expertise and assistance… Ping Shi of the NJ Dept. of Health, Center for Health Statistics Daisuke Goto, Jose Nova, Oliver Lontok, Bram Poquette and Dorothy Gaboda

of CSHP Colleagues across the state working toward better care at lower cost


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Objective • Identify opportunities to save hospital costs by improving care in

candidate ACO regions within New Jersey

Approach • Select candidate ACO regions with at least 5,000 Medicaid

beneficiaries - Camden, Greater Newark, and Trenton - 10 other low-income communities

• Examine patterns of hospital utilization • Estimate potential cost savings from improving care in the community


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13 Candidate ACO Regions Camden* Greater Newark** Trenton*** Asbury Park-Neptune Atlantic City-Pleasantville Elizabeth-Linden Jersey City-Bayonne New Brunswick-Franklin Paterson-Passaic-Clifton Perth Amboy-Hopelawn Plainfield, North Plainfield Union City-W. NY- Guttenberg-N. Bergen Vineland-Millville *Camden zip codes (08102, 08103, 08104 & 08105)

**Newark zip codes (07102, 07103, 07104, 07105, 07106, 07107,07108, 07112, & 07114) East Orange zip codes (07017, 07018) Irvington zip code (07111) Orange zip code (07050)

***Trenton zip codes (08608, 08609, 08611, 08618, 08629 & 08638)

Source: Kathe Newman, Rutgers University


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Measures • New Jersey Uniform Billing Hospital Discharge Data: 2008-2010 • Five measures of potentially avoidable hospital use among adults

living in the 13 regions – Avoidable inpatient admissions – Avoidable treat-and-release emergency department (ED) visits – Inpatient high use – ED treat-and-release high use – 30-day all-cause readmissions

• Potential cost savings estimated by comparing each community to the region among them with the best cost performance


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Findings: Performance Across 13 NJ ACO Regions

Regions are arranged in order of worst to best performance based on average of individual measure rankings. Rates of avoidable hospitalizations and ED visits are calculated per 100,000 population and are age-sex adjusted. High inpatient use is defined as 4 or more stays over 2008-10 and high ED use is 6 or more visits over 2008-10. High-user rates denote number per 100 hospital users. Readmission rates are 30-day all-cause, age-sex adjusted per 100 index (initial) hospitalizations.

Rankings: Red Worst three Yellow: Next three Green: Best three

ACO Regions Avoidable

Hospitalizations Avoidable ED

Visits Inpatient High

Use ED High

Use Hospital

Readmissions Atlantic City 3,207 40,876 5.0 12.0 14.2 Greater Newark 3,098 30,104 4.8 9.0 16.4 Trenton 2,858 34,124 4.6 11.4 15.4 Camden 3,754 51,871 3.9 16.8 14.5 Asbury Park 2,185 21,486 5.2 8.1 14.2 Perth Amboy 2,587 23,582 4.0 6.3 13.9 Jersey City-Bayonne 2,549 18,423 4.6 5.9 14.8 Vineland 2,268 18,912 3.9 6.5 12.4 Paterson 2,262 19,472 3.9 6.0 13.7 Elizabeth-Linden 1,830 20,478 3.3 6.2 12.6 Plainfield 1,839 19,684 3.1 6.3 12.1 Union City-W. NY - N. Bergen 2,215 15,028 4.0 3.6 12.5 New Brunswick 1,658 16,827 3.1 5.9 12.5 13 ACO regions combined 2,504 23,836 4.2 7.7 14.4 All NJ 1,727 14,177 4.3 5.0 12.7


3,754

3,207 3,098

2,858

2,587 2,549

2,268 2,262 2,215 2,185

1,839 1,830 1,658 1,727

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Rates of Avoidable Inpatient Hospitalizations

Rates calculated per 100,000 population

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2.3 Fold Variation

Med

ian

Reg

ion


Rates of Avoidable Emergency Department Visits

Rates calculated per 100,000 population 8

51,871

40,876

34,124

30,104

23,582 21,486 20,478 19,684 19,472 18,912 18,423

16,827 15,028 14,177

0

10,000

20,000

30,000

40,000

50,000

60,000

3.5 Fold Variation

Med

ian

Reg

ion


Rates of Inpatient High Use

Rates calculated per 100 hospital users

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5.16 5.03 4.84

4.62 4.58

4.00 3.96 3.93 3.91 3.90

3.28 3.15 3.12

4.27

0.0

1.0

2.0

3.0

4.0

5.0

6.0 1.7 Fold Variation

Med

ian

Reg

ion


Rates of Treat-and-Release ED High Use

Rates calculated per 100 hospital users

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16.81

11.96 11.45

9.04 8.08

6.48 6.28 6.27 6.20 6.02 5.87 5.85

3.59

4.96

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0 4.7 Fold Variation

Med

ian

Reg

ion


30-Day All-Cause Readmission Rates

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Age-sex adjusted rates per 100 ‘index’ (initial) hospitalizations

16.41 15.35

14.82 14.54 14.19 14.18 13.94 13.75 12.55 12.49 12.47 12.39 12.12

12.69

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

1.4 Fold Variation

Med

ian

Reg

ion


Inpatient and Treat-and-Release ED High Users

High users per 100 hospital users with high inpatient use (IP), high ED use, or both high IP and ED use. High inpatient use is defined as 4 or more stays over 2008-2010. High ED use is 6 or more visits over 2008-2010. The worst performing regions for these three measures are Asbury Park, Camden and Atlantic City. The best performing regions for the first measure is New Brunswick, and for the remaining two is Union City.

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5.2

3.1 4.2 4.3

16.8

3.6

7.7

5.0

1.8 0.5 1.0 0.8

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

Worst Regions Best Regions 13 ACO Regions All NJ

Inpatient (IP) ED IP and ED


Payer Mix of Inpatient and ED High Users

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Medicare, 51.7% Medicare, 60.6%

Medicaid, 10.3%

Medicaid, 5.3%

Private, 20.9% Private, 22.9%

Charity Care, 10.9% Charity Care, 6.1%

Self Pay, 4.8% Self Pay, 3.4%

Medicare, 10.6% Medicare, 14.7%

Medicaid, 16.8% Medicaid, 13.5%

Private, 29.8% Private, 33.3%

Charity Care, 18.4% Charity Care, 14.5%

Self Pay, 21.5% Self Pay, 20.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

13 ACO Regions All NJ 13 ACO Regions All NJ

Inpatient High Users ED High Users


Demographic Distribution within the 13 ACO Regions

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White 28.1%

Black 42.7%

Hispanic 20.2%

Other 9.0%

18-39 13.9%

40-64 39.5%

65+ 46.5%

Male, 45.7% Female, 54.3%

0% 20% 40% 60% 80% 100%

Race/Ethnicity

Age Group

Gender

Inpatient High Users

White 13.9%

Black 53.0%

Hispanic 26.0%

Other 7.1%

18-39 60.0%

40-64 34.4%

65+ 5.6%

Male, 35.4%

Female, 64.6%

0% 20% 40% 60% 80% 100%

ED High Users

High ED users are more likely to be women, younger, and minority compared to high inpatient users


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Most Common Principal Diagnoses Inpatient High Users ED High Users

Heart failure Other symptoms involving abdomen

and pelvis

Septicemia Symptoms involving respiratory

system and other chest symptoms

Diabetes mellitus Other and unspecified disorders of

back

Other forms of chronic ischemic heart disease

Asthma

Symptoms involving respiratory system and other chest symptoms

General symptoms


High Users with Mental Health and Substance Use Disorders

Percentages represent proportion of high use inpatient stays or ED visits Category of Mental health diagnoses includes substance use diagnoses

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38.6%

22.5% 20.2%

15.4%

0%

10%

20%

30%

40%

50%

Inpatient High Users ED High Users

Mental health Substance use disorder

13 ACO Regions Combined


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Potential Savings if Performance on par with Best Region

Mill

ions

of 2

010

Dol

lars

Potential savings (for the 13 regions combined) if each of them achieved rates of best performing region in each of the 5 measures above. Based on 2008-2010 data for area residents regardless of hospital visited. Figures are annualized and adjusted to 2010 dollars using the CPI-Medical Care. Savings should not be aggregated across all measures due to overlap of populations.

336.3

161.7

1,131.1

117.9

427.8

242.5

100.4

846.8

47.8

334.0

0

200

400

600

800

1,000

1,200

Avoidable IP costs Avoidable ED costs IP High User Costs ED High User Cost Readmission Costs

Best Region: Best Region: Best Region: Best Region: Best Region:

Elizabeth-Linden Jersey City-Bayonne Elizabeth-Linden UC-WNY-NB Vineland

Actual Cost

If Performed as Best Region

$93.8m

$61.3m

$284.3m

$70.1m

$93.8m


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Regions with Highest Savings Potential

Greater Newark $35.7

Jersey City, $14.5 Trenton, $9.4

Other Regions $34.2


Trenton, $10.7 Camden, $9.4

Other Regions $17.3


Jersey City, $51.9

Trenton $27.7

Other Regions $85.4


Trenton, $11.9 Camden, $10.5

Other Regions $24.2


Jersey City, $17.6 Trenton, $7.8

Other Regions $31.6

$0

$50

$100

$150

$200

$250

$300

Avoidable Hospitalizations $93.8 million

Avoidable ED Visits $61.3 million

Inpatient High Use $284.3 million

ED High Use $70.1 million

Readmissions $93.8 million

Mill

ions

of 2

010

Dol

lars


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Potential Medicaid Savings if Performance on par with Best Region

Mill

ions

of 2

010

Dol

lars

Potential savings if Newark achieved rates of best performing NJ ACO region in each of the 5 measures reported above. Based on 2008-2010 data, age-sex adjusted, annualized and adjusted to 2010 dollars using the CPI-Medical Care. Savings should not be aggregated across measures (except IP and ED avoidable use) due to overlap of populations.

Potential inpatient, ED high use, and readmission savings (for the 13 regions combined) if each of them achieved rates of best performing region . Based on 2008-2010 data for area residents regardless of hospital visited. Figures are annualized and adjusted to 2010 dollars using the CPI-Medical Care. Savings should not be aggregated across measures due to overlap of populations.

128.9

22.1

47.1

58.6

7.8

31.7

0.0

20.0

40.0

60.0

80.0

100.0

120.0

140.0

IP High User Medicaid Costs ED High User Medicaid Costs Readmissions Medicaid Cost

Best Region: Best Region: Best Region:

Vineland UC-WNY-NB Vineland

Actual Cost

If Performed as Best Region

$70.4m

$14.3m

$15.4m


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Regions with Highest Medicaid Savings Potential


Jersey City-Bayonne $11.5

Trenton, $6.2

Other Regions $19.2

Greater Newark, $4.9 Trenton, $3.0 Camden, $2.0

Other Regions, $4.4

Greater Newark, $7.5

Jersey City-Bayonne , $3.1 Trenton, $1.5

Other Regions, $3.2

$0

$10

$20

$30

$40

$50

$60

$70

Inpatient High Use $70.4 million ED High Use $14.3 million Readmissions $15.4 million

Mill

ions

of 2

010

Dol

lars


How do the ACO communities compare? • Best performing ACO regions do about as well as overall NJ average

• Compared to NJ overall, on average ACO regions perform worse in… – Avoidable ED visits (68% higher) – ED high users (56% higher) – Avoidable inpatient stays (45% higher) – Readmissions (14% higher) – Inpatient high use not substantially different from statewide average

• Wide variation in performance across ACO regions – shows potential for improvement – ED high users (4.7 fold variation) – Avoidable ED visits (3.5x) – Avoidable inpatient stays (2.3x) – Inpatient high use (1.7x) – 30-day readmissions (1.4x)

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How do the ACO communities compare? • Substantial savings potential from achieving best performance

– Highest potential savings from inpatient high users • $284 million in 2010 cost reductions across 13 regions overall • Cost reductions for Medicaid patients of $70.4 million • Greatest potential in Newark, Jersey City, Trenton, Camden

– But, high behavioral health co-morbidities underscore challenges

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Thank You Complete Findings at

http://www.cshp.rutgers.edu/MedicaidACO

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