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Comparison of Resource Use and Quality for Adults with Diabetes Enrolled in a Commercial Health Maintenance Organization Open Access

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Objective: (1) Examine geographic variation in resource use (inpatient, outpatient, and pharmacy resource use) among adult patients who have diabetes and who have been enrolled in the same commercial health maintenance organization (HMO) for at least 22 months (the study population). Commercial HMOs and U.S. states are the unit of analysis. (2) Examine, at the state level, the value-based relationship between resource use and intermediate quality outcomes for the study population.Background and Previous Results: Health care costs in the United States continue to escalate at a rate that far outpaces inflation. Expenditures on health care surpassed $2.4 trillion in 2009--more than three times the amount spent in 1990. In 2011, the average annual premium cost for family coverage was $15,073; on average, employees paid $4,129 of that amount, representing a more than 130 percent increase in the past 10 years alone. Approximately, 30 million people, or 8.3 percent of the United States population, have diabetes; in 2007, the total estimated cost of diabetes was $174 billion. The affordability of health care continues to challenge policy makers, purchasers, and consumers. Slowing the rate of health care cost increases while preserving high-value, high-quality care presents a formidable policy challenge.There is a complex relationship between resource use and quality. Substantial variation exists at the health plan level for both quality and resource use. Previous research has indicated that medical service resource use has a significant negative relationship to quality for diabetes (0.20, p=0.008), but no apparent relationship to quality for cardiovascular care (0.007, p=0.940). In contrast, pharmacy resource use has a significant positive relationship to quality for diabetes (0.16, p=0.033), and a borderline positive relationship for cardiovascular care (0.17, p= .057). Differences in resource use with no net gain in health outcomes represent opportunities for improving the value that the health care system delivers.This is the first study to examine geographic variation in inpatient, outpatient, and pharmacy services, separately, for patients with diabetes enrolled in a commercial HMO (aggregated at the individual HMO and state level), as well as the value-based relationship between inpatient or outpatient resource use and intermediate quality outcomes among their adult patients with diabetes enrolled in a commercial HMOs.Policy Implications: The demand for information on quality and cost is fueled by evidence of serious performance gaps in the health care system and the demand of purchasers for valid data to aid their buying decisions. Numerous provisions in the Affordable Care Act of 2010 require the implementation of certain performance measures, including measures of resource use. Such initiatives include value-based payment or pay-for-performance programs that create a stronger link between provider payments and performance across a full range of indicators (quality, safety, and cost) as well as demonstration projects that will test new payment models, such as bundled payments for patient-focused episodes, and shared savings programs. As the United States health care system moves to more integrated delivery systems, such as medical or health care homes and accountable care organizations (ACOs), it is critical to examine and understand variation in resource use and the value of care delivered prior to full ACA implementation. This will allow policy makers and purchasers to better assess changes in performance as a result of the implementation of ACA and identify best practices as various demonstration projects and payment models are implemented.Methods: In 2010, approximately 200 commercial HMOs reported resource use and quality of care Healthcare Effectiveness Data and Information Set (HEDIS®) measures for their members with diabetes to the National Committee for Quality Assurance (NCQA) in 2010 for services rendered during calendar year 2009 and 2008. Aggregated data are submitted to NCQA at the HMO level and are aggregated at the state level; the resource use measure data are further submitted in aggregated patient cohorts, allowing for stratification and risk adjustment.The analysis includes three types of analysis: univariate, bivariate, and multivariate. First, a univariate analysis was performed, which examined the statistical dispersion, specifically, the range, interquartile ranges, and standard deviation values of the resource use (inpatient, outpatient, and pharmacy resource use) among adults with diabetes who were enrolled in a study commercial HMO. Second, a bivariate analysis was conducted. Differences in mean results between the highest and lowest performing state study populations for both diabetes total relative resource use and diabetes quality against the other model variables were examined. Using the Pearson product-moment correlation, the relationship of the diabetes total relative resource use, inpatient, outpatient, pharmacy, and emergency department relative resource use for the study population and diabetes quality outcomes within a state was examined. The correlation coefficient was estimated for the resource use and quality variables, including an evaluation of the direction (positive or negative) and strength of relationship among the four variables. Third, a linear regression analysis was conducted, examining the predictive ability of the explanatory variables: state diabetes quality outcomes; per capita inpatient staffed hospital beds; median household income; proportion of primary care physicians; and HMO penetration, on total relative resource use for adults who have diabetes and were enrolled in a commercial HMO.

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