Healthcare Payments Data (HPD) Measures: Health Conditions, Utilization, and Demographics
Introduction
The Healthcare Measures Report presents a series of visualizations that allow users to explore the care and characteristics of Californians within the HCAI Healthcare Payments Database (HPD).
The visualizations cover three measurement categories: Health conditions, Utilization, and Demographics. The health conditions measurements quantify the prevalence of long-term illnesses and major medical events, such as diabetes, asthma, and heart failure, in California’s communities. Utilization measures convey rates of healthcare system use through visits to the emergency department and different categories of inpatient stays, such as maternity or surgical stays. The demographic measures describe the health coverage and other characteristics (e.g., age group) of the Californians included in the data.
Each visualization presents the data in a different format to show geographic variation, changes over time, and comparisons to the statewide average. Filters and grouping options allow users to sort information by age group, sex (assigned sex at birth), or location and to select specific populations. The combination of filtering options, visualization displays, and the collection of measures can answer a range of specific questions such as:
- What percentage of Californians in my age group have a diabetes diagnosis?
- Is the number of surgical inpatient stays increasing or decreasing over time?
- How does the share of the population enrolled in Medi-Cal in my county compare to the statewide average?
The underlying data is available for download.
The Healthcare Measures Dashboards follows the California Health and Human Services Agency’s Data De-Identification Guidelines.
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Glossary
Record Types
HPD uses monthly enrollment records (related to membership or coverage) and service records (service lines from an encounter or on a claim that detail services provided) to calculate healthcare measures. Enrollment records establish the population for counts and proportion calculations and service records are used to determine the presence of conditions or the utilization of health services.
Measure Descriptions
- Demographic measures describe the characteristics of individuals represented in the data. Individuals with at least one enrollment record in a given year are included.
- Health conditions are identified based on diagnosis codes and defined using the criteria outlined by the Centers for Medicare & Medicaid Services (CMS) in the Chronic Conditions Data Warehouse.
- Utilization rates are defined and identified by the criteria outlined by Healthcare Effectiveness Data and Information Set (HEDIS) guidelines and are represented as the number of visits per 1,000 member-years. The unadjusted member month counts are shown in the denominator.
- Emergency department (ED) visits are designated as potentially avoidable when the visit could have been prevented with access to high-quality outpatient care, such as ED visits for an ear infection or conjunctivitis (pink eye).
Payer Types
Payers are the companies, programs, and organizations that oversee insurance plans and reimburse healthcare providers. Three main types of payers make up the majority of the insurance market.
- Commercial: Insurance products for which the coverage premium is paid by a private party, such as an employer, individual, or other entity.
- Medicare: A federal health insurance program funded by the Centers for Medicare & Medicaid Services under the Social Security Amendments of 1965 that provides healthcare benefits to those aged 65 years and over or to disabled beneficiaries of any age. The Medicare data includes Fee-For-Service and Managed Care grouped together.
- Medi-Cal: A public health insurance program that provides free or low-cost medical services and healthcare benefits to low-income individuals, financed from state and federal funds; California’s version of Medicaid. The Medi-Cal data includes Fee-For-Service and Managed Care grouped together.
How HCAI Created This Product
This product was built using Healthcare Payments Data (HPD) Program data. For more information on HPD – California’s All-Payer Healthcare Claims Database (APCD) – visit the HPD Program Overview webpage.
- Each individual is assigned one primary payer type each year. If an individual changes to a different payer type within a calendar year, they will be assigned to the payer type with the longest duration of enrollment during that year. Individuals enrolled in multiple plans at the same time will be assigned to the primary payer. In cases where there is discrepancy in the reported data on which payer is primary, the order of assignment is: commercial payers, followed by Medicare, and then Medi-Cal. Because Medi-Cal is the payer of last resort, dual-eligible individuals (those with both Medicare and Medicaid coverage) will typically be assigned to the Medicare primary payer type.
- The Healthcare Measures Report follows California Health and Human Services Agency’s Data De-Identification Guidelines. Data from any group with less than 11 individuals are removed from the analyses and suppressed in the visualizations. This will result in some error in the reported rates, especially in counties with small populations or measures that generally have lower rates. Use caution when interpreting results for counties with less than 30,000 residents.
- Measures of health condition prevalence are calculated using information in claims and encounter records and therefore only capture instances of a condition that has been treated during the specified time period. Results here may differ from other reports on chronic condition prevalence that use other methods such as medical record sampling or surveys.
- Measure rates are calculated based on the primary payer only. Since Medi-Cal is treated as the payer of last resort, Medi-Cal enrollment numbers used for calculations in this report may be lower than those reported by the Department of Health Care Services (DHCS) and healthcare measures will be calculated using slightly different populations and using data from additional sources outside of DHCS. Please visit the DHCS Data and Statistics page for information on the different methods DHCS uses to identify the Medi-Cal population and calculate measures.
- Users can select two different versions of the county level filter. One lists California’s 58 counties only while the second replaces Los Angeles County with its eight constituent Service Planning Areas (SPAs), because of LA County’s large population. More information on the LA County SPAs is available in the technical notes.
- The HPD Program identifies and tracks the unique identity of individuals across different payers over time. The approach is continually refined to ensure an accurate count of unique individuals. As these methods improve, the HPD Program expects to identify more linkages – cases in which two or more records are determined to belong to a single individual. Therefore, the count of unique individuals is likely to decrease over time as linkages are incorporated.
- Additional information on how HCAI created this product is available in the data’s Technical Note.
Additional Information
Topic: Cost Transparency / Healthcare Utilization
Source Link: Cost Transparency – Healthcare Payments Database
Citation: HCAI – Healthcare Payments Database – Healthcare Payments Data (HPD) Healthcare Measures, 2023
Temporal Coverage: 2018-2021
Spatial/Geographic Coverage: Statewide
Frequency: Annually