static regions for health policy analysis health policy commission discussion document september 20,...
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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