Download Issue Description to RRT Members (PDF: 80KB/4 pages)

 Protecting, maintaining and improving the health of all Minnesotans Date:
September 22, 2010
To:
Provider Peer Grouping Rapid Response Team members
From:
Katie Burns, Health Economics Program
Subject:
Third issue for your consideration
Thank you for participating in the Rapid Response Team. In preparation for our third
meeting, I wanted to distribute the attached memo from Mathematica Policy Research,
Inc. It describes the next issue for which we would like your input:
1) Should all hospitals be included in one peer group or should separate peer groups be
created for certain types of hospitals?
We will review the memo at our meeting this afternoon to ensure you have an
opportunity to clarify your understanding of the issues and to ask questions.
Response deadline: We will need your feedback on these issues by Tuesday,
September 28 at 4:00 pm. Responses may be provided via email to
[email protected].
MEMORANDUM
955 Massachusetts Avenue, Suite 801
Cambridge, MA 02139
Telephone (617) 491-7900
Fax (617) 491-8044
www.mathematica-mpr.com
TO:
Katie Burns, MDH
FROM:
Jeffrey Ballou, Mary Laschober, and Nyna Williams,
Mathematica
SUBJECT:
Recommendations for Peer Groups for Total Care and
Condition-Specific Care
DATE: 9/21/2010
Overview and Summary of Recommendations
This memo focuses on peer groups for hospitals. It also explains our considerations in
determining peer groups for physician clinics/medical groups in the future. We present a set of
options, discuss the relative advantages of each, and make a recommendation based on our
judgment regarding which option represents the most methodologically sound approach. While
this memo focuses on peer groups for hospitals, many of the issues raised here also apply to
determining appropriate peer groups for physician clinics/medical groups.
In making explicit comparisons among providers, it is important to ensure meaningful
comparisons are being drawn. The Provider Peer Grouping Advisory Group recommended
keeping all hospitals in a single peer group and all physician clinics/medical groups in a single
peer group. Whether it is possible to build meaningful peer groups as inclusive as these hinges
on our ability to adequately adjust for differences in severity of illness among patient populations
and for differences in the types of services provided to patients.
Guided by the principles that peer groups should be more rather than less inclusive for ease
of consumer use and to promote high standards of care across all types of hospitals, we
recommend grouping all hospitals other than critical access hospitals (CAHs) into a single peer
group, with CAHs included in a separate peer group.1 We are not making a specific
recommendation at this point with respect to peer groups for physician clinics/medical groups,
but instead, outline our considerations in determining physician clinic peer groups in the future.
1
In year two, when more quality metrics are available for pediatric services, we may also consider peer
grouping separately for pediatric and adult care.
An Affirmative Action/Equal Opportunity Employer
MEMO TO: Katie Burns
FROM:
Jeffrey Ballou, Mary Laschober, and Nyna Williams
DATE:
9/21/2010
PAGE:
2
1.
Should a Hospital’s Peer Group for the Total Care and Condition-Specific Measures
Include All Other Hospitals or Only Other Hospitals of the Same Type?
A single all-hospital peer group would be the most simple for consumers to understand and
would place a clear focus on providing high quality care efficiently, regardless of facility type,
while type-specific peer groups would result in more meaningful comparisons in the presence of
imperfections (real or perceived) in the process of adjusting for differences related to severity
and service mix.
Relative Advantages of a Single Peer Group. Including all hospitals in the same peer
group would make it easiest for consumers to compare hospitals. It would also emphasize the
importance of delivering high quality care efficiently, regardless of facility type, and highlight
any unwarranted variation in quality or resource use across hospital types. In addition, the large
size of a single all-hospital peer group should increase the precision of the benchmarks.
Relative Advantages of Type-Specific Peer Groups. Patterns of resource use might differ
meaningfully across different types of hospitals—such as rural versus urban hospitals—for
reasons unrelated to the efficiency of care delivery. If risk adjustment models cannot control
adequately for important differences across hospitals in the populations treated, higher cost
facilities might be incorrectly judged as inefficient when compared to all other hospitals.
Moreover, comparing a facility to similar institutions might have greater face validity with
hospital administrators who believe (correctly or not) that their patients’ cost or quality measures
were not adequately risk-adjusted. Adjustments related to differing service mixes across facilities
may also not adequately adjust for differences between rural and urban hospitals. Finally, legal
restrictions for certain types of hospitals could also distort patterns of resource use in ways
unrelated to the efficiency of care. For example, CAHs’ patterns of treatment and resource use
will likely differ from those of other hospitals because of the length-of-stay restrictions on CAH
acute care admissions. Also noteworthy is that participation in the Hospital Consumer
Assessment of Healthcare Providers and Systems (HCAHPS) is voluntary for Minnesota
hospitals with fewer than 500 admissions per year. These smaller hospitals are most often CAHs.
That many CAHs in Minnesota choose not to report these data is an additional argument for peer
grouping CAHs and non-CAHs separately, provided that the number of CAHs is sufficiently
large to accommodate the computation of reliable CAH-specific benchmarks.
Recommendation: Because a primary objective of peer grouping hospitals is to encourage
facilities of all types to provide high quality care, we recommend including all non-CAHs in a
single peer group when evaluating performance for total care. Because CAHs are subject to
length-of-stay restrictions and reimbursed differently from other acute care hospitals, their costs
are likely to differ in meaningful ways from those of non-CAHs. In our opinion, adjustments
related to severity of illness and service mix do not adequately account for fundamental
differences between these types of hospitals. Consequently, we recommend that CAHs be
included in a separate peer group for total care analyses.
MEMO TO: Katie Burns
FROM:
Jeffrey Ballou, Mary Laschober, and Nyna Williams
DATE:
9/21/2010
PAGE:
3
For the analyses of condition-specific care, CAHs would be compared with all other CAHs,
(similarly for non-CAHs) for pneumonia. When analyzing total knee replacement, the peer group
would consist of all orthopedists regardless of whether they are affiliated with a CAH or a nonCAH, with performance measured at the hospital level. Similarly, in the future, if there are other
specific conditions for which care is provided in similar ways at all hospitals, we may consider
including CAHs and non CAHs in the same peer group for these specific conditions.
2.
Considerations in Determining Peer Groups for Physician Clinics/Medical Groups
MDH and Mathematica are still determining whether the unit of analysis for the physician
total care and specific condition analysis will be physician clinics or medical groups. Consistent
with the Provider Peer Grouping Advisory Group’s recommendations, our goal is to peer group
at the clinic rather than the medical group level, as information at this level is most informative
to consumers. Whether or not we can peer group at the clinic level depends on whether available
data can support this unit of analysis. Regardless of whether peer grouping occurs at the clinic or
medical group level, it is also our goal to have as inclusive a peer group for physicians as
possible. In order to have one peer group for physician clinics or medical groups, it will be
necessary to adequately adjust for differences in severity of illness of patient populations as well
as for differences in the types of services offered to patients. We will provide an update to
stakeholders on this important issue after we have conducted some related analysis of the data.
Summary
In summary, we recommend that peer groups for hospital reporting include one peer group
for CAHs and one peer group for all other non-pediatric hospitals.
cc: Provider Peer Grouping Project Team