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).

• Visit the HPD Public Reporting Webpage
• Visit the HPD Program Overview Webpage

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 present 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?

Note: These measures do not include 2021 Medicare Fee-for-Service (FFS) data. The missing data result in an undercount of Medicare payer type enrollment and an overcount of Medi-Cal payer type enrollment for reporting year 2021, with indeterminant effects on measure rates. The overcount of Medi-Cal enrollment occurs because Medicare is considered to be the primary insurer for individuals with both Medicare and Medi-Cal eligibility (“dual eligibles”), but dual-eligibles with missing Medicare FFS data in 2021 will appear in the data as Medi-Cal only. The implications for measure rates are indeterminate because the effect on the measure calculation depends on the rate for the specific measure in the included and excluded populations. For example, in the absence of the Medicare FFS population, the measure rate for payer type Medicare will be based on the Medicare Advantage population. If the measure rate in the Medicare Advantage population is higher than the rate in the Medicare FFS population, the result will be an overestimate (since the Medicare FFS population is missing). Please use caution interpreting results for groups with a high proportion of Medicare members in 2021, or conducting comparisons that rely on payer type and include the year 2021.

The Healthcare Measures Dashboards follows the California Health and Human Services Agency’s Data De-Identification Guidelines.

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.

Payer Types

Each individual is assigned one primary payer type each year. 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.

• 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.
• 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.
• Commercial: Insurance products for which the coverage premium is paid by a private party, such as an employer, individual, or other entity.

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. In 2021, however, dual-eligible individuals using Medicare FFS are instead assigned to the Medi-Cal payer type, because Medicare FFS data is not included.

How HCAI Created This Product#

This product was developed using the HCAI Healthcare Payments Database, California’s All-Payer Healthcare Claims Database (APCD).

• 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 the 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.
• 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 where rates are generally lower. Use caution when interpreting results for counties with less than 30,000 residents.
• Medicare Fee-for-Service (FFS) records are collected from the Centers for Medicare & Medicaid Services (CMS) later than other sources and so Medicare FFS data from 2021 is not included in this report. The missing data result in an undercount of Medicare payer type enrollment and an overcount of Medi-Cal payer type enrollment for reporting year 2021, with indeterminant effects on measure rates. The overcount of Medi-Cal enrollment occurs because Medicare is considered to be the primary insurer for individuals with both Medicare and Medi-Cal eligibility (“dual eligibles”), but dual-eligibles with missing Medicare FFS data in 2021 will appear in the data as Medi-Cal only. The implications for measure rates are indeterminate because the effect on the measure calculation depends on the rate for the specific measure in the included and excluded populations. For example, in the absence of the Medicare FFS population, the measure rate for payer type Medicare will be based on the Medicare Advantage population. If the measure rate in the Medicare Advantage population is higher than the rate in the Medicare FFS population, the result will be an overestimate (since the Medicare FFS population is missing). Furthermore, the measure rates for payer type Medi-Cal will be based on a larger population, combining Medi-Cal only individuals and dual-eligible individuals, who were included in payer type Medicare in earlier years (based on the inclusion of Medicare FFS data). Use caution when interpreting results for groups with a high proportion of Medicare members in 2021 or conducting comparisons that rely on payer type and include the year 2021.
• Measures of health condition prevalence are calculated using information in claims and encounter records and therefore only capture instances of a condition that have 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 primary payer only and Medi-Cal is recognized as the payer of last resort. As a result, Medi-Cal enrollment numbers may be lower than 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.
• 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 report’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, County
Frequency: Annual