Healthy Howard Health Plan: a Summary of Health Care Utilization in 2009

RESEARCH REPORT #2

Healthy Howard Health Plan: A Summary of Health Care Utilization in 2009

RESEARCH REPORT #2

Prepared for Healthy Howard, Inc. by the Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health

November 2010

RESEARCH REPORT #2

ACKNOWLEDGEMENTS

Healthy Howard, Inc. is a 501(c)(3) organization created to administer the Healthy Howard Health Plan. It provided funding to the Department of Health, Behavior and Society (HBS) at the Johns Hopkins Bloomberg School of Public Health (JHSPH) to conduct a formal evaluation of the Healthy Howard Health Plan.

This report was prepared by the evaluation team. Members of the evaluation team and their affiliations are listed below. The evaluation plan for HHHP was reviewed by the JHSPH Institutional Review Board (IRB) and deemed not human subjects research.

The authors wish to thank Healthy Howard, Inc., Johns Hopkins HealthCare LLC, and the Howard County Health Department (including Keyuri Joshi, the Health Department’s summer intern) for their assistance in providing the data needed for this report.

Report Authors Elizabeth Edsall Kromm, PhD, MSc Adjunct Assistant Professor, HBS and Senior Advisor to the Health Officer, Howard County Health Department

David R. Holtgrave, PhD Professor and Chair, Health, Behavior and Society (HBS)

Eileen M. McDonald, MS Associate Scientist, HBS

Shannon Frattaroli, PhD, MPH Assistant Professor, Department of Health Policy and Management (HPM)

A copy of Research Report #2 is available for download from the Department of Health, Behavior and Society’s website at http://www.jhsph.edu/dept/hbs

Suggested Citation: Edsall Kromm E, Holtgrave DR, McDonald EM, Frattaroli S. Healthy Howard Health Plan: A Summary of Health Care Utilization in 2009. Research Report #2. Baltimore, MD: Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, November 2010.

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TABLE OF CONTENTS

EXECUTIVE SUMMARY 5

PART I: HEALTHY HOWARD HEALTH PLAN SERVICE NETWORK 7

PART II: MEMBER ENROLLMENT AND UTILIZATION TRENDS 13

Time Spent Active in HHHP 13

Member Cost Profile 15

PART III: TYPE AND VOLUME OF HEALTH CARE, CY 2009 17

In-Patient Hospital Care 18

Emergency Department (ED) Care 19

Primary Care Services 21

Out-of-Network Care 23

PART IV: DISCUSSION 24

REFERENCES 26

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LIST OF TABLES AND FIGURES

Table 1: HHHP Service Network, CY 2009 8

Table 2: 2009 HHHP Members, Status as of 7/10 and Net Active Months 14

Table 3: Submitted Claims, Volume and Type, CY 2009 17

Table 4: HHHP Network Providers, Claims Submitted, CY 2009 18

Table 5: Nature of In-Patient Hospital Care, CY 2009 19

Table 6: CY 2009 Actual ED Use Compared to Member Self-Report and National Estimates of U.S. Adults 18-64 with Incomes Greater than or Equal to 100% Federal Poverty Level (FPL), by Insurance Status 20

Table 7: CY 2009 ED Visits by CPT Code 20

Table 8: CY 2009 Primary Care by ICD-9-CM Categories 22

Table 9: Out-of-Network Care Compared to Total Care Costs for Nine Members, CY 2009 23

Figure 1: Average Monthly Covered Cost per Member, per Member Month in Program, CY 2009 15

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EXECUTIVE SUMMARY

The Healthy Howard Health Plan (HHHP) is a public-private health care program designed to connect uninsured residents of Howard County, Maryland, to an affordable and comprehensive network of HEALTHY HOWARD HEALTH PLAN health care services. To our knowledge, it is the first plan in the nation to couple health care services with compulsory health WHO’S ELIGIBLE? coaching. To qualify, a person must meet all of the criteria listed below: - A Howard County resident HHHP was designed to fill an important gap for thousands of working - A US citizen or legal permanent families who find themselves without affordable health care options. resident These are people who do not have access to an employer-sponsored - Between the ages of 19 & 64 health plan and cannot afford to purchase private family coverage, - Not eligible for & not enrolled in but make too much money to qualify for state or federal health other health care programs such as insurance programs. Data from the 2008 American Community Medicaid, Medicare, MCHP or PAC Survey indicate between 11,800 and 19,300 Howard County - Currently uninsured & without health insurance for at least six residents are uninsured (U.S. Census, 2008). months (unless lay off resulted in

involuntary loss of coverage) The Plan is administered by a non-profit organization – Healthy - Annual income ≤ 300% of the Howard, Inc. Operating costs are supported by member fees, county Federal Poverty Level (FPL) funding and private foundation grants. In addition, strong partnerships with local providers have translated into in-kind WHAT SERVICES ARE INCLUDED? support and an expanded network of services for HHHP members. Members have access to the following HHHP is the vision of the Howard County Executive and Health services in Howard County: - Primary care visits Officer and is part of a larger initiative to build a model public health - Free or discounted prescriptions community. - Diagnostic & lab tests - Urgent care About the Research Report Series - Emergency room care - In-patient hospital care An evaluation team was assembled prior to HHHP’s implementation. - Mental health care In consultation with Healthy Howard, Inc. staff, several evaluation - Substance abuse treatment aims were developed that serve to guide the ongoing evaluation of - Specialty care the Plan. The formal evaluation is being conducted by researchers - Reduced cost dental & vision care from the Johns Hopkins Bloomberg School of Public Health. - Rehabilitation services - Physical & occupational therapy In order to provide timely information to funders and community - Personalized health coaching partners, the evaluation team committed to producing a series of HOW MUCH DOES IT COST? Research Reports. These reports provide results from analyses of Monthly fee is based on income & different aspects of the program and are intended to inform whether the person joins alone or with a assessments of program performance and to facilitate specific plan partner. Monthly fees: improvements. - Individual ≤ 200% FPL $50 - Couple ≤ 200% FPL $80 Research Report #1, released in March 2010, presented findings - Individual 201%-300%FPL $85 - Couple 201%-300%FPL $130 regarding inaugural members’ living and working conditions, health status, health behaviors and priority health goals. Source: Healthy Howard, Inc., 2010

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Research Report # 2 – Overview and Key Findings

Research Report #2 examines the health care utilization and costs incurred by members during HHHP’s first year of operation. Part I begins with an overview of the HHHP’s service network. Part II describes member enrollment activity over the past 19 months. A description of the type and volume of care provided during the plan’s first year of operation based on available administrative data follows in Part III. Part IV provides a complete discussion of the report findings. This analysis expands our understanding for what it means to transition out of uninsured status and the likely types of care and costs newly insured will incur upon entry into a formal health access network.

A bulleted list of key findings appears below.

 HHHP service network is complex and comprehensive o Primary care home and large hospital system serve as cornerstones of network and provide majority of health care to members. o Community investment – pro bono care by local providers drives service network. o Estimated cost of health care services delivered in 2009 is $727,629 based on available data. o Network appears to be a good fit to member needs with 94.5% of known health care costs accrued from in-network services.

 HHHP may effectively function as a temporary access program o Disenrollment rate for Plan’s inaugural members is stable over time at 35%. o As of July 2010, the average period of enrollment is 9.8 months for those who first became active in 2009. o Health care utilization concentrated in members’ first four months. o Disenrollment occurs not long after period of highest service use.

 HHHP members had unmet needs at time of enrollment o High volume of immunizations and preventive screenings/tests administered by primary care provider. o Claims data indicate 14.2% prevalence of essential hypertension and 6.8% prevalence of diabetes among members with at least one primary care encounter in 2009. Both conditions are amenable to modifications in health-related behaviors. o Two percent of members required at least one in-patient hospital stay in 2009.

 HHHP members demonstrated low utilization of Emergency Department (ED) services o An estimated 8.5% (44) of HHHP members made at least one trip to the ED in 2009. o ED utilization among HHHP members is lower than national averages. Twenty percent of uninsured and 19% of insured U.S. adults reported at least one ED visit in the past 12 months (NCHS, 2010). o Analysis of evaluation and management codes from ED encounter found the majority of visits to be appropriately urgent.

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PART I: HEALTHY HOWARD HEALTH PLAN’S SERVICE NETWORK

HHHP is not health insurance. It is a county-based public-private health care program. The Plan’s design had not previously been seen in Maryland and therefore required legislation at the state level to define operation requirements, appropriate regulatory structure and ensure consumer protections. At the end of Maryland General Assembly’s 2009 Legislative Session, a new subtitle was inserted into the Insurance Article of the Annotated Code of Maryland.1 While an analysis of HHHP’s network development is beyond the scope of this report, an overview of service scope provides essential context for understanding members’ utilization and health care costs.

There are two provider cornerstones to the HHHP network – Chase Brexton Health Services (Chase Brexton) and Howard County General Hospital (HCGH). Chase Brexton is a private, non-profit Federally Qualified Health Center (FQHC) that offers a range of medical services in four locations in Maryland (Chase Brexton, 2010). Their medical campus in Howard County serves as the primary care home for all Plan members. HCGH is a 238 bed acute care medical center (HCGH, 2010) and the only hospital within Howard County lines. As a member of Johns Hopkins Medicine, HCGH offers comprehensive services on site as well as access to care at other Hopkins institutions such as Johns Hopkins Hospital (JHH) and Johns Hopkins Bayview (JHB).

Beyond primary and hospital care, the architects of HHHP considered specialty care needs based on leading chronic conditions among U.S. adults and solicited information from local primary care providers regarding type and frequency of specialty referrals. The network also includes laboratory, radiology, and physical therapy services. HHHP prioritized recruitment of providers willing to offer pro bono services and sought to limit members’ out-of-pocket expenses to the required monthly fee. A three- tiered system was created to provide access to prescription drugs for free or reduced cost, making use of Pharmacy Assistance Programs, generic substitutions and Plan subsidies of 340B pricing through the Chase Brexton pharmacy.2 There are limits on where members can receive services and on the level of services provided. Members are responsible for the cost of care received outside of the network. The Plan does work with out-of-network providers to reduce or eliminate fees. Table 1 outlines the calendar year (CY) 2009 HHHP Service Network.

1 Subtitle 7. Public Private Health Care Programs, §14-703, Insurance Article, Annotated Code of Maryland. 2 The 340B pricing program allows certain entities, such as FQHCs the ability to purchase prescriptions at a significantly reduced cost. This program is administered through the Office of Pharmacy Affairs of the Health Resources and Services Administration (HRSA, 2010).

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Table 1: HHHP Service Network, CY 2009 a

Service Category Service Terms and Limits b Member Cost Sharing Plan Responsibility Primary - 6 visits per CY - % of monthly fee - $50 per member/per Care - +1 visit for women (GYN - Fee scale based on month exam) income for visits - Cost of lab fees for tests - Lab tests administered over yearly limit administered on-site on-site - Podiatry available (counts toward visit limit) - Provider: Chase Brexton Urgent Care - 3 visits per CY - $50 per visit - $25 per visit - Provider: AllCare of MD - Full cost for visits - $0 for visits over yearly over yearly limit limit Emergency - Facility and professional - $100 co-payment if - $0 Department fees waived kept for Care (ED)c - Locations: HCGH, JHH, “observation” JHB In-patient - Facility fees waived - Fees may apply for - $20,000 administration (In-PT) - Professional fees for consultations fee per CY Hospital Hospitalists and provided by out-of- Care Intensivists waived network specialists - Locations: HCGH, JHH, - Plan works to JHB eliminate or reduce - Professional fees for fees incurred from staff specialists waived out-of-network at JHH, JHB specialist consultation

Laboratory - Facility and professional - $0 - $0 and fees waived Pathology - Locations: ED, Out-PT – HCGH In-PT – HCGH, JHH, JHB Radiology - Facility and professional - $0 - $0 fees waived - Provider 1: American Radiology - Locations: ED, Out-PT, In-PT– HCGH - Provider 2: JH Radiology - Locations: In-PT at JHH, JHB

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Table 1 (cont.): HHHP Service Network, CY 2009

Service Category Service Terms and Limits Member Cost Sharing HHHP Responsibility Cardiology - Fees waived for office - $0 - $0 visits - Provider: Cardiology Specialists of Central Maryland - Diagnostic tests performed at HCGH, fees waived Physical - Facility and - $0 - $0 Therapy/ professional fees Occupational waived Therapy - Locations: In-PT, Out- PT – HCGH OB/GYN - Fees waived for office - $0 - Cost of diagnostic tests visits - Pregnant women - Provider: Drs. Esposito, <250% FPL qualify Mayer, Hogan and for and transferred Associates to MD Children’s Health Program Ophthalmology - 4 members per month - $0 - Cost of diagnostic tests max - Fees waived for office visits - Provider: Wilmer Eye Institute at Columbia Gastroenterology - 7 members per month - $0 - $0 max - Fees waived for office visits - Provider: Maryland Digestive Disease Center - Screening tests performed at HCGH, fees waived In-PT Psychiatry - Professional fees - $0 - $0 waived - Provider: Humanim - Location: HCGH Out-PT Psychiatry - 2 members per - $0 - $0 treatment cycle max - Fees waived for office visits - Provider: THRIVE

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Table 1 (cont.): HHHP Service Network, CY 2009

Service Category Service Terms and Limits Member Cost Sharing HHHP Responsibility Behavioral - Professional fees - $0 - $20,000 administration Counseling waived fee per CY - Provider: Pro Bono Counseling Project of Maryland coordinates referrals to their provider network Substance Abuse/ - Discounted visit fees - $10 co-payment for - $0 Addiction - Provider: Howard initial assessment Counseling County Health - $10 co-payment for Department non-intensive Out-PT visit - Discounted rate for intensive Out-PT visit Oncology - Fees waived for office - $0 - $0 visits - Provider: Maryland Oncology Hematology, PA - Diagnostic tests performed at HCGH, fees waived Otolaryngology - 10 members per - Fees apply for allergy - $0 month max and audiology - Fees waived for office services visits - Excludes allergy and audiology services - Provider: ENTAA Care Orthopedics - 6 members per month - $100 for epidural - $0 max injections - Fees waived for office - $50 for peripheral visits and certain pain joint injections management services - $50 for - Discounted rates for electromyogram other services - $30 per nerve for - Provider: Maryland nerve conduction Spine and Sports study Medicine Durable Medical - Discounted rates - Fees vary - $0 Equipment available, negotiated case-by-case basis Provider: Pharmaquip

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Table 1 (cont.): HHHP Service Network, CY 2009

Service Category Service Terms and Limits Member Cost Sharing HHHP Responsibility General Surgery - Professional fees waived - $0 - $0 for emergency surgeries - Provider 1: Maryland Surgeons - Location: In-PT, Out-PT – HCGH - Provider 2: JH Surgeons - Location: In-PT surgeries – JHH Anesthesiology - Professional fees waived - $0 - $0 - Provider: Howard County Anesthesia Associates - Location: In-Pt, Out-Pt – HCGH Dental Care - Option 1: Fee scale - Fees vary - $0 based on income at Chase Brexton Dental Clinic - Option 2: Member pays $19.80 annual fee to join “Aetna Vital Savings” – for access to discounts on dental care from Aetna providers Urology - 6 members per month - $0 - $0 max - Fees waived for office visits - Provider: Chesapeake Urology Associates Long-Term - $50,000 max per CY - $0 - $0 Care/ - Provider: Lorien Health Rehabilitation Systems a This table reflects service terms for CY 2009. Terms and providers may be different in CY 2010. In order to obtain the information for provided in Table 1, the evaluation team developed a worksheet for Healthy Howard, Inc. to complete on the status of the Plan’s network in CY 2009. Remaining questions/clarifications were handled via email communication. b Fees for services administered in an in-patient or out-patient hospital setting are typically billed separately. A facility fee is a facility site charge. A professional fee (also known as “pro fee”) is the charge for care rendered by a physician or other allied health professional. c Members requiring emergency care are instructed to go to the nearest hospital. Once stabilized, a member can request to be transferred to HCGH.

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Prior to joining HHHP, each eligible individual is required to attend an orientation session and sign a member agreement. This session provides an overview of the Plan’s network. The member agreement describes the services offered and limitations in detail. As Table 1 illustrates, HHHP’s network is large and complex. To assist in member navigation, Healthy Howard, Inc. employs a full-time care coordinator on-site at Chase Brexton, the Plan’s primary care home. The care coordinator assists with specialty and service referrals as well as the three-tiered system for prescription drugs.

For both internal plan management and evaluation purposes, efforts were made to require all providers, even those waiving charges, to submit encounter data to the Plan’s third-party administrator (TPA) – Johns Hopkins HealthCare, LLC. When a formal agreement was executed between Healthy Howard, Inc. and a provider, claim submission terms were included in the contract. The submission standards are the same as those that providers follow to receive payment from Medicaid.3 Not all providers entered into a formal agreement with Healthy Howard, Inc.

3 HHHP’s TPA operates Priority Partners Health Choice as a separate line of business. Priority Partners is a Medicaid managed care organization operating in the state of Maryland and is therefore set up to receive encounter data for Medicaid patients.

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PART II: MEMBER ENROLLMENT AND UTILIZATION TRENDS

HHHP began clinical services on January 1, 2009. During the Plan’s inaugural year, there were 515 active members. 4 A person becomes “active” or eligible to receive services at the beginning of each month. As Research Report #1 found, members reside in all parts of the county, with enrollments by age, family size, marital status and ethnicity mirroring county demographics. The largest percentage of members and county residents are White. Higher percentages of Blacks or African Americans and Asians are found in HHHP compared to the overall county population (Edsall Kromm et al, 2010).

Time Spent Active in HHHP

Given this report’s focus on health care utilization and costs during the plan’s first year of operation, it is important to note that the enrollment rate (new members per month) for the second half of 2009 was greater than the first half of the year. A total of 194 new members joined between January and June compared to 321 new members between July and December of 2009. Therefore, all 515 members did not have the same period of time in which to receive services. One explanation for the low initial numbers may be that HHHP’s early enrollment activities served to identify those who were eligible for other programs. Although interest in joining HHHP brought county residents to the Health Department5 or Healthy Howard, Inc., many were found to be likely eligible for existing health care programs such as Medicaid for Families (MA for Families) or the Primary Adult Care Program (PAC).

In addition, it is important to note that HHHP does not offer continuous eligibility. A member must pay each month in order to remain active and eligible to receive services. This means that periods of disenrollment or “inactivity” may occur. As of July 2010, or 19 months into service operation, sixty-five percent (333) of those who first became active in 2009 were still active members.6 Thirty-five percent (182) of individuals who became active during CY 2009 were not active as of July 2010. Table 2 presents the Plan’s inaugural members by current status and net active time spent as members.

4 Research Report #1 reported 512 active members. At the time the analysis was conducted, the Plan’s eligibility determining system – Health-e-Link – listed 512 active members in CY 2009. A subsequent system report of CY 2009 members identified three individuals incorrectly categorized as first active in CY 2010. These three members were then added to the total member count for CY 2009. 5 The Howard County Health Department assisted in outreach and enrollment efforts during HHHP’s initial launch period – October to December 2008. 6 A member becomes active at the beginning of each month and remains active for the entirety of that month. A member active as of 7/1/10 is active until 7/31/10. The enrollment roster from the Plan’s TPA reviewed for this report listed member status as of 7/1/10. The roster reflects member activity to and including month 19 of the program.

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Table 2: 2009 HHHP Members, Status as of 7/10 and Net Active Months

1st Active New Members Avg. Net Members Avg. Net Month HHHP Still Active Active Monthse Not Active Active Monthse (2009) Membersd (% of Month’s for Members (% of Month’s for Members New Members) Still Active New Members) Not Active Jan 44 23 19 21 7.2 (52%) (48%) Feb 21 15 18 6 6.2 (71%) (29%) Mar 21 14 16.8 7 6.8 (67%) (33%) Apr 26 17 15.5 9 4 (65%) (35%) May 43 25 14.9 18 7.1 (58%) (42%) Jun 39 26 14 13 7.5 (67%) (33%) Jul 21 13 12 8 5 (62%) (38%) Aug 60 39 11.8 21 6.3 (65%) (35%) Sep 62 40 10.7 22 5 (65%) (35%) Oct 51 38 9.9 13 5.2 (75%) (25%) Nov 64 45 8.9 19 2.9 (70%) (30%) Dec 63 37 7.8 26 3.8 (59%) (41%) Total 515 333 13.3 182 5.6 (65%) (35%) d The numbers in this column reflect only the number of individuals who became active members at the start of each month in CY 2009. It is not the total membership per month. e Net Active Months equals the total number of months a member is active minus any period of disenrollment. For example, if a member’s experience is – Active (1/1-3/31/09), Disenrolled (4/1-5/31/09), Active (6/1/09-7/31/10) – the net active months as of 7/10 equals 17.

For disenrolled members as of 7/10, the average net active months in HHHP is 5.6. For those who remain active, the average time spent in the Plan is a little over a year, at 13.3 months. While the number of new members per month increased during the year, the rate of activity in terms of remaining enrolled or disenrolling, appears stable over time. Further inferences are not made regarding the stable rate of activity over time given that reasons for disenrollment are not known. There are a number of potential reasons a member may disenroll. Anecdotal reports from Plan staff indicate that members who disenrolled found other coverage, got a job or spouse got a job with benefits, had a need that could

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not be met by the Plan’s network, or could not afford to make the payment each month.7 HHHP does administer an exit survey to those who disenroll. The method of survey administration has changed over time and the response rate is very low.

Member Cost Profile

There is an indication of a pattern of utilization during members’ time spent active in the Plan. While Part III examines in detail the type and volume of health care delivered during CY 2009, Figure 1 below demonstrates a concentration of health care costs early in members’ HHHP active status. Based on claims data submitted for in-network services, this graph charts the average monthly cost of care provided per member per each member’s time spent active in 2009. These costs are for care provided within HHHP’s network (refer to Table 1 for network services and cost sharing information).

Figure 1: Average Monthly Covered Cost Per Member, Per Member Month in Program, CY 2009 f

f The graph charts the average monthly cost for covered services per member per each member’s month in the program in 2009. Month 1 is every member’s first active month, regardless of the actual month in which (s)he joined HHHP. A person active 1/1-12/31/09 has 12 member months; a person active 10/1-12/31/09 has three member months.

The costs in Figure 1 represent the charge a provider would bill a typical third-party payer for services rendered and represents only those providers who agreed to submit encounter data to HHHP’s TPA. Even with these limitations, this graph presents members’ general pattern of utilization as if they were part of a traditional health insurance plan. The majority of costs for covered services are incurred during a member’s first three to four months of Plan enrollment. The average time spent in HHHP (as of 7/10) for all inaugural members is 9.8 months. While 2010 cost data are not available, the information from CY 2009 on enrollment and utilization suggests that members stay active in the Plan for a period of time beyond the point of highest service use.

7 personal communication, Healthy Howard, Inc. staff (bi-weekly policy meetings)

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Research has shown that uninsured adults in general are more likely to delay or forgo treatments and prescriptions for chronic conditions and much less likely to receive preventive care (IOM, 2009). Based on Health Risk Assessment (HRA) data, 42% of members completing the HRA reported having a physical exam within the past year with another 41% indicating a check-up within the last two to five years. Prior to joining the Plan, less than 60% of female HHHP members over the age of 40 reported having a mammogram in the past two years (Edsall Kromm et al, 2010). Time since last physical exam is a measure of unmet medical need –therefore costs incurred early in enrollment may in some way be driven by pent-up demand or addressing unmet medical and preventive care needs. In addition, HHHP encourages members to establish care at Chase Brexton and make an initial primary care appointment once they become active.

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PART III: TYPE AND VOLUME OF HEALTH CARE, CY 2009

As mentioned in the Part I discussion of HHHP service network, not all participating providers submit encounter data. Therefore, our description of the type and volume of health care provided during CY 2009 is limited to available administrative data based on submissions to the Plan’s TPA. Providers that agreed to send this information have 180 days from the date of service to submit claims. The monthly claims reports posted by the TPA include the following information: member identification number; provider name; date of service; place of service (e.g. in-patient, out-patient, emergency department, office visit); ICD-9-CM code; CPT code; billed amount; and allowed amount. ICD-9-CM is the International Classification of Diseases, 9th Revision, Clinical Modification, which serves as the official system to assign codes to health care diagnoses and procedures (CDC, 2010). CPT stands for Current Procedural Terminology and is another set of “codes, descriptions and guidelines intended to describe the procedures and services performed by physicians and other health care providers” (AMA, 2009: xiv). The billed amount is the standard charge a provider would submit to a private insurer. The allowed amount is what Medicaid pays for that service. Our analysis utilized ICD-9-CM codes and the billed amount cost estimates.8 Part III describes the type and volume of health care provided during CY 2009, including findings regarding the issues for which members sought care as hospital in-patients, through the emergency room, from the primary care home, and from out-of-network providers.

Claims were organized by the TPA into two groups – covered and uncovered claims. Covered claims represent care provided within the HHHP network, and uncovered claims are bills submitted by out-of- network providers.9 Table 3 gives an overview of claims received for services provided in CY 2009.

Table 3: Submitted Claims, Volume and Type, CY 2009

Covered Claims Uncovered Claims # Claims submitted 6388 179 # Members responsible for claims submitted 369 23 Total billed amount $687,179 $40,451 Total allowed amount $525,198 $16,545

Approximately 72% (369) of 2009 members had at least one health care encounter during the Plan’s first year of operation. Based solely on submitted encounter data, the cost of health care delivered during calendar year 2009 is $727,629. All but 5.5% of this estimate comes from covered claims or in-network services. HHHP does work with out-of-network providers to reduce or eliminate charges and these negotiations can take several months. As of August 2010, it was not possible to ascertain the exact percentage of submitted uncovered claims that is solely the responsibility of the member. Not all out- of-network providers seek payment via the TPA; some may bill the member directly. What is known based on available data is that each member with administrative data evidence of out-of-network care also has at least one covered claim. The nature of submitted uncovered claims is discussed in detail later

8 We did not review member medical records to confirm ICD-9-CM classification. 9 Members have a HHHP card similar to a basic health insurance identification card. Based on the card, a medical billing office may interpret HHHP to be a form of health insurance.

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in this section. Based solely on the billed amount for submitted claims, the average per member cost to provide services to 515 members in CY 2009 was $1,418.

Twenty-three members each accrued more than $5,000 of in-network health care services based on covered claims data. Nine of these members had at least $10,000 each in covered care during the first year of HHHP operation. Given that the highest per member per month cost of covered care in CY 2009 was a little more than $300 (Figure 1), these individuals are outliers in terms of utilization.

The top health care services categories in 2009 are primary care, in-patient and out-patient hospital care and emergency department care. Table 4 lists the in-network providers that submitted more than $3,000 in claims, the total billed amount for services rendered, and the average total billed amount per month, in descending order.

Table 4: HHHP Network Providers, Claims Submitted, CY 2009 g

Service Category Total Billed Avg Total Billed per Month In-PT and Out-PT Hospital Care (HCGH Only) $397,152 $33,096 Primary Care $121,223 $10,102 In-PT Hospital Care (JHH, JHB) $62,330 $5,194 ED, In-PT and Out-PT Radiology $53,855 $4,488 (American Radiology at HCGH only) ED Care (HCGH Only) $16,260 $1,355 In-PT Hospital Professional Fees (HCGH only) $9,505 $792 Anesthesia $6,972 $581 OB/GYN $4,860 $405 Urgent Care $4,332 $361 Urology $3,155 $263 g Providers w/ total covered claims billed less than $3000 are not included in this table. The service categories not listed are the following: In-Patient Psychiatry; Orthopedics; Gastroenterology; and Oncology.

Based on the available claims data, HCGH served as the primary location for health care services obtained by members in 2009. Members were seen in both in-patient and out-patient setting as well as in the Emergency Department. Outpatient care was comprised of lab tests, radiology and physical therapy services. This is not surprising given that fees for most diagnostic tests were waived if performed on-site at HCGH (Table 1).

In-Patient Hospital Care

Ten members had at least one in-patient stay in 2009. This represents approximately 2% of the inaugural HHHP member population. In-patient care was directed at treating medical issues in one or more of seven disease categories (Table 5).

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Table 5: Nature of In-patient Hospital Care, CY 2009

General Disease Categories Requiring In-PT Hospital Care (ICD-9-CM)h Diseases of the Digestive System Diseases of the Genitourinary System Mental Disorders Diseases of the Skin and Subcutaneous Tissue Diseases of the Respiratory System Endocrine, Nutritional, and Metabolic Diseases and Diseases of the Circulatory System Immunity Disorders h (CDC, 2010) To guard against deductive disclosure given the small number of in-patient admissions, only general disease categories linked to the ICD-9-CM codes are provided.

Two categories – diseases of the digestive system and diseases of the respiratory system – were reported for more than one member. In-patient care accounts for the largest portion of health care spending in this country (Hartman et al, 2009). According to national-level data on hospital-based care in 2007, the conditions related to the digestive system, circulatory and respiratory systems were responsible for the majority of in-patient hospital care among adult women and men (Levit et al, 2009).

Emergency Department Care

According to the 2007 National Health Interview Survey, 20% of uninsured and 19.4% of insured U.S. adults regardless of income made at least one trip to the Emergency Department in the past year (NCHS, 2010). Research Report #1 found reported ED utilization by HHHP members prior to joining the Plan to be lower than the national averages, regardless of coverage status. The majority (56%) of inaugural members reported no ED visits in the twelve months prior to joining the Plan (Edsall Kromm et al 2010).10

Encounter data submitted for ED care (CY 2009) indicates members’ actual utilization was less than members’ recall of previous ED visit history. Table 6 lists CY 2009 ED visits based on administrative data, compared to members’ self-reported prior use and national estimates of ED visits by adults ages 18-64 based on insurance status and income. Forty-four members made a total of 56 ED visits in CY 2009.

An estimated 8.5% (44) of HHHP members made at least one trip to the ED in CY 2009; while 1.3% had two or more visits. According to HRA data, in the twelve months prior to joining HHHP, 6.3% of members had two or more ED visits. Both actual and self-report rates are lower than national ED utilization rates.

10 24% of HRAs completed left the ED question blank. See page 18 of Research Report #1 for information on response rate and subsequent HRA data analysis.

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Table 6: CY 2009 Actual ED Use Compared to Member Self-Report and National Estimates of U.S. Adults 18-64 with Incomes Greater than or Equal to 100% FPL, by Insurance Status

# ED Visits 1 or more visits 2 or more visits % HHHP Members i 8.5% 1.4% (Actual visits made in CY 2009) % HHHP Members j 18.8% 6.3% (Self-report of visits made in year prior to joining HHHP) % Uninsured US adults 18-64, between 100% and 200% FPL k 32.6% 14.9% % Insured US Adults k 24.1% 11.2% % Uninsured US adults, 18-64, 200%+ FPLk 21.6% 7.4% % Insured US adults, 18-64, 200%+ FPL k 16.7% 5.0% i Based on submitted claims data (Place of Service Code – 23 – Emergency Department) j Edsall Kromm et al, 2010 k(NCHS, 2010), “uninsured” equals uninsured less than 12 months

Different methods exist in the published literature to determine the urgency and appropriateness of ED visits.11 Brusseau and colleagues (2006) classify approaches into two categories: 1) methods that combine chart review with analysis of comprehensive encounter data and 2) methods that utilize available data sets such as ICD-9 codes and CPT codes. A decision was made to review CPT codes linked to members’ ED visits based on available data and cost. With CPT codes, there are five evaluation and management codes (99281-99285) for emergency room visits (AMA, 2010). The codes indicate the complexity of the visit. Visit complexity is essentially a proxy for visit urgency. Table 7 describes the urgency of CY 2009 ED visits.

Table 7: CY 2009 ED Visits by CPT Code

CPT E/M Code Descriptionl % of ED Visits m Presenting problem(s) are self-limited or minor 3.6% Presenting problem(s) are of low to moderate severity 1.8% Presenting problem(s) are of moderate severity 28.6% Presenting problem(s) are of high severity and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function 53.5% Presenting problem(s) are of high severity and pose an immediate danger to life or physiologic function 12.5% l (AMA, 2009:17) m N=56 visits

11 Urgency and appropriateness are frequently used to describe ED utilization. There are different schools of thought as to whether the terms are synonymous or two distinct constructs. Brusseau et al suggest that urgency relates to “the need for care” while appropriateness “refers to the site where care is received” (2006:638).

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The majority (66%) of ED visits were of high severity based on the applied CPT code. Of the small percentage of active members receiving emergency care in 2009, problems prompting ED visits were relatively urgent. The research literature estimates that non-urgent visits represent between 20 and 40% of U.S. ED care (Buechner and Williams, 2007; Haddy et al, 1987). According to data from the 2007 National Hospital Ambulatory Medical Care Survey, 29.8% of ED visits in 2007 were classified as semi- urgent or non-urgent (Niska et al, 2010).

Primary Care Services

All HHHP members receive primary care services from one provider – Chase Brexton. According to submitted claims, 68% (350) of members had at least one interaction with the Plan’s primary care home in 2009. In Part II, pent-up demand or unmet medical and preventive care needs was posited as one explanation for the early concentration of covered services costs (Figure 1). The nature of primary care services lends additional support to this working hypothesis. The claims data show a large number of vaccine administrations and screening tests.12 Fourteen general disease categories comprise the nature of primary care in the Plan’s first year of operation, based on ICD-9-CM codes. Table 8 provides a snapshot of disease categories tied to primary care encounters prevalent in five percent or more of members. The following five general disease categories each represented less than five percent of members: 1) neoplasms (benign and malignant); 2) injuries and poisoning; 3) blood disorders; 4) diseases of the digestive system; and 5) diseases of the skin and subcutaneous tissues.

The top two specific conditions among members were essential hypertension and diabetes. Of the 350 members with at least one visit to Chase Brexton in CY 2009, the “Essential Hypertension”(ICD-9-CM code 401) and “Diabetes Mellitus” (ICD-9-CM code 250) code were linked to 14.2% and 6.8% of the 350 members with at least one visit to Chase Brexton in CY 2009, respectively.

Research Report #1 shows that inaugural HHHP members are a population at risk. While members’ prevalence rates of leading chronic conditions were similar to estimates for Howard County and Maryland adult populations, HHHP members exhibited significantly higher rates of tobacco use, poor diet and physical inactivity (Edsall Kromm et al, 2010). The rate of essential hypertension appears to support members’ self-reported behaviors that affect health status. Essential hypertension, also called primary hypertension, has no known cause but is believed to be linked to a number of factors such as poor diet, lack of exercise, obesity and genetics (NHLBI, 2010). It accounts for 95% of all cases of hypertension (Carretero and Oparil, 2000) and is a modifiable risk factor for cardiovascular disease. Further inferences cannot be made without a review of member medical charts to confirm ICD-9-CM classification.

12 A review of medical record/chart data in combination with complete claims data is necessary to provide a robust analysis regarding the specific preventive and medical care services provided to HHHP members.

RESEARCH REPORT #2

Table 8: CY 2009 Primary Care by ICD-9-CM Categories General % of Disease Category Related ICD-9-CM 3-Digit Categoriesn Memberso Diseases of the Acute respiratory infections 18.2% respiratory system Chronic obstructive pulmonary disease Other diseases of respiratory system Other diseases of the upper respiratory tract Pneumonia and influenza Diseases of the Diseases of veins and lymphatics, and other diseases 17.4% circulatory system Hypertensive disease Ischemic heart disease Other forms of heart disease Endocrine, Diseases of other endocrine glands 13.1% nutritional, metabolic Disorders of thyroid gland diseases, immunity disorders Nutritional deficiencies Other metabolic disorders and immunity disorders Diseases of the Arthropathies and related disorders 10.6% musculoskeletal Dorsopathies system and connective tissue Osteopathies, chondropathies, acquired muscoskeletal deformities Rheumatism, excluding the back Diseases of the Diseases of male genital organs 7.7% genitourinary system Disorders of breast Inflammatory disease of female pelvic organs Other diseases of urinary system Other disorders of female genital tract Mental disorders Neurotic disorders, personality disorders, non-psychotic disorders 7.4% Other psychoses Infectious and Mycoses 6.3% parasitic diseases Other bacterial diseases Other diseases due to viruses and Chlamydiae Other infectious and parasitic diseases Syphilis and other venereal diseases Viral diseases accompanied by exanthem Diseases of the Diseases of the ear and mastoid process 5.4% nervous system and Disorders of the eye and adnexa sense organs Disorders of the peripheral nervous system Hereditary and degenerative diseases of central nervous system Other disorders of the central nervous system n(CDC, 2010)

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o (N=350). Members may have more than one ICD-9-CM code per visit and multiple visits. The percentages listed are by disease category. Out-of-Network Care

There were a total of 179 claims for out-of-network care provided to 23 members in CY 2009, totaling $40,451. As of August 2010, $10,939 is known to be truly out-of-network and the members’ responsibility and $18,346 is still pending. HHHP was able to work with providers to waive fees for $11,165 worth of out-of-network services; negotiation outcomes are still pending for another $18,346.

Charges known to be the member’s responsibility – $10,939 – are linked to care provided to nine people or 1.7% of 2009 HHHHP membership. Seven of these members each also accrued more than $5000 worth of in-network care. Table 9 considers the uncovered costs for these nine members compared to their total known utilization.

Table 9: Out-of-Network Care as Percentage of Total Care Costs for Nine Members, CY 2009

Appox. % of Total Cost of Care Total Cost Out-of-Network of Care Member 1 $83,885 0.9% Member 2 $9,521 3.8% Member 3 $9,839 5.8% Member 4 $16,618 6.6% Member 5 $19,484 8.5% Member 6 $2,912 12.9% Member 7 $16,611 16.3% Member 8 $13,515 24.4% Member 9 $198 42.1%

An estimated 14% of personal health expenditures in the U.S. are paid out-of-pocket (NCHS, 2010). For comparison, if we consider the total cost of care from Table 9 to be members’ personal health expenditures and uncovered claims to be out-of-pocket costs, the out-of-pocket costs for these nine members averages 13.5% of their personal health expenditures.13

All but five claims in this subgroup were for specialist consultations during an in-patient hospital stay. HCHG utilizes hospitalists and intensivists to oversee patient care during an in-patient stay and contracts with private practitioners to provide specialty care. While HCGH agreed to waive professional fees for their hospitalists and intensivists, it is up to each individual specialty provider to decide whether or not to participate in the HHHP network.

13 Total cost of care in this scenario does not include the monthly fee or out-of-pocket payments for prescriptions.

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PART IV: DISCUSSION

Research Report #2 describes the type and cost of health care provided to previously uninsured individuals during the first year of the Healthy Howard Health Plan. This utilization profile combined with the findings from Research Report #1 regarding member demographics, health behaviors and priority health goals contributes to an expanded understanding of what it means to transition into and participate in a health care access program. The findings from Research Report #2 are discussed below.

HHHP service network is complex and comprehensive

HHHP’s primary care home and local hospital serve as cornerstones of the network and are responsible for providing the majority of health care services to members. While there are limitations on the level and type of services offered, the majority of participating providers waive their fees. The network appears to be a good fit for member needs with 94.5% of known health care costs accrued from in- network services. Specialty consults called during in-patient stays make up almost all of the out-of- network charges. This situation is an artifact of HCGH structure and is an important consideration for program replication in other county or state settings. HHHP is not able to predict which specialists a hospitalist or intensivist calls for a consult during an in-patient stay. Given this limitation, HHHP may wish to recruit providers based on the HCGH’s list of contracted specialists.

HHHP may effectively function as a temporary access program

Average monthly costs per member appear to peak at month 3 after program enrollment. The disenrollment rate for the Plan’s inaugural members is relatively stable at about one-third of the membership. Further work should explore the possibility that at least some plan members utilize Healthy Howard as a temporary access program to address some key health issues, and when those are addressed, transition out of the plan. This initial indication of how the plan is being used in greater detail and over a longer period of time is a topic for further research.

HHHP members demonstrate low utilization of Emergency Department services and visits appear appropriately urgent

ED utilization among HHHP members is lower than national averages. Twenty percent of uninsured and 19% of insured U.S. adults reported at least one ED visit in the past 12 months (NCHS, 2010). An estimated 8.5% (44) of HHHP members made at least one trip to the ED in 2009. The majority (66%) of ED visits were of high severity. In addition, the actual ED visit rate from CY 2009 is lower than members’ reported ED use in the twelve months prior to joining HHHP. Gaining access to hospital debt forgiveness did not appear toincrease ED visits based on available claims data. Members also had access to urgent care through the HHHP network. The Plan’s cost sharing structure is set up to incentivize use of the primary care home, followed by urgent care. The co-payment for urgent care is half that of going to the ED. There were 19 visits to urgent care by 19 different members in CY 2009.

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The report’s findings and subsequent inferences are limited by the existence, quality and availability of administrative data. Such issues may reflect the realities of real-time evaluation of a naturally occurring experiment. It is not possible to know for certain the total cost and utilization of in-network services or the members’ total responsibility for out-of-network care. HHHP also offers its members access to a variety of community resources – the value, cost and member participation are also needed to determine the Plan’s scope and benefit.

Even with these limitations, this report offers timely and valuable information for those working to implement national health care reform. HHHP members represent who will be served as of 2014, if not before. This population may not immediately exhibit high rates of utilization or incur large health care expenses, but it will likely display high prevalence of modifiable risk factors for chronic disease. The health care system must be set up to emphasize prevention in order to effectively manage the millions of previously uninsured and ultimately reduce their risk profile.

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REFERENCES

American Medical Association. (2009). Current Procedural Terminology, 4th Edition.

Brusseau DC, Rakesh DM, Allessandrini EV. (2006) Methods of categorizing emergency department visit urgency. A survey of pediatric emergency medicine physicians. Pediatric Emergency Care, 22(9), 635- 639.

Buechner JS, Williams KA. (2007). Classification of emergency department visits: how many are necessary? Med Health R.I., 90, 96-97.

Carretero OA, Oparil S. (2000). Essential Hypertension, Part I: Definition and Etiology. Circulation, 101, 329-335.

Centers for Disease Control and Prevention (CDC). (2010). International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Retrieved July 6, 2010 from http://www.cdc.gov/nchs/icd/icd9cm.htm

Chase Brexton Health Services, Inc. (2010). About Chase Brexton. Retrieved, August 8, 2010, from http://www.chasebrexton.org/images/stories/prcontent/missionvisionpr7_1_2010.pdf

Edsall Kromm E, McDonald EM, Frattaroli S, Ma X, Holtgrave D. (2010). Healthy Howard Health Plan: A Summary of Inaugural Members’ Demographics, Health Status and Goals in 2009. Research Report #1. Baltimore, MD: Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health.

Haddy RI, Schmaler ME, Epting RJ. (1987). Nonemergency emergency room use in patients with and without primary care physicians. Annals of Emergency Medicine, 14, 672-676.

Hartman M, Martin A, McDonnell P, Catlin A. (2009). National health spending in 2007: Slower drug spending contributes to lowest rate of overall growth since 1988. Health Affairs, 28, 246-261.

Health Resources and Services Administration (HRSA). (2010). Office of Pharmacy Affairs, Introduction. Department of Health and Human Services. Retrieved August 25, 2010, from http://www.hrsa.gov/opa/introduction.htm

Healthy Howard, Inc. (2010). Healthy Howard Health Plan – Visitors Section. Retrieved August 13, 2010, from http://www.healthyhowardplan.org/visitors.

Howard County General Hospital (HCGH). (2010). Howard County General Hospital – About Us Section. Retrieved August 25, 2010, from http://www.hcgh.org/content/AboutUs.htm.

Levit K, Wier L, Stranges E, Ryan K, Elixhauser A. (2009). HCUP Facts and Figures: Statistics on Hospital- based Care in the United States, 2007. Rockville, MD: Agency for Health Care Research and Quality.

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Institute of Medicine. (2009). America’s Uninsured Crisis: Consequences for Health and Health Care. Washington, DC: The National Academies Press.

National Center for Health Statistics (NCHS). (2010a). Health, United States, 2009. Hyattsville, MD: U.S. Department of Health and Human Services.

National Heart Lung and Blood Institute (NHLBI) (2010). Other names for high blood pressure. National Institutes of Health. Retrieved August 25, 2010, from http://www.nhlbi.nih.gov/health/dci/Diseases/Hbp/HBP_OtherNames.html

Niska R, Bhuiya F, Xu J. (2010). National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary. National Health Statistics Reports, No. 26. Hyattsville, MD: National Center for Health Statistics.

U.S. Census Bureau (2008). American Community Survey. Health insurance coverage status by age for the civilian non-institutionalized population. 2008 American Community Survey 1 yr estimates. Retrieved, July 6, 2010, using American Fact Finder, http://factfinder.census.gov