Population Based Healthcare Delivery Design (II): Navy Catchment Area Birth Forecasting Tool Angie Cheng Cheng, MPH CNA, Health Research and Policy Analytics Community| Wednesday June 6, 2012 |11:00am-12:00pm e-mail: il [email protected] h @

C, P, O 1)Context: Inadequate access to system-level perinatal data may lead to misalignment of resources and demand 2)Purpose: CNA created a data data-driven driven analytical tool to help optimize perinatal product line efficiency 3)Outcome: ) Decision-makers can make more informed perinatal resource decisions using the Navy Catchment Area Birth Forecasting Tool to visualize historical birth volume trends, calculate population-based birth forecasts, and set birth volume targets across MTFs and N Navy catchment t h t areas FOR OFFICIAL USE ONLY

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Outline • • • • • • •

Background Tasking and purpose Birth forecast tool contents Data source and methods Walk through the MS Excel tool Case scenarios Conclusions

FOR OFFICIAL USE ONLY

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Background Highest utilization product line is Obstetrics MTF direct inpatient care for Obstetrics constitutes

• • • •

36% of inpatient Navy healthcare costs 50% of inpatient p workload ((admissions))

FOR OFFICIAL USE ONLY

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Background •

Problems identified by Navy Perinatal community: • • •

•

No centralized oversight in practices and resourcing Misalignment of resources and demand S i lt leaders Specialty l d have h diffi difficulty lt accessing i system t level l l workload data

Need data data-driven driven analytical tools that even the playing field and optimize perinatal product line efficiency

FOR OFFICIAL USE ONLY

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Tasking and purpose •

BUMED M81 and the Perinatal Advisory Board tasked k d CNA to ddevelop l a tooll that: h • •

•

•

•

Provides historic trends in birth volume F r Forecasts t annuall birth volume l m b based d on userr entered t r d population changes Helps p users visualize seasonalityy of birth volume and set monthly birth volume targets

Tool was presented to the PAB in August 2011 and disseminated to Obstetrics leaders across Navy MTFs Updated with FY2011 data in May 2012 (version 2.2) FOR OFFICIAL USE ONLY

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Birth forecasting tool contents •

• • • • •

•

Annual Direct Care/Purchased Care Catchment Area Birth Volume Forecast Module Catchment Area Female Beneficiary Population Fertility Module Troop Movement Catchment Area Birth Volume Forecast Module Monthly Catchment Area Birth Volume Target Module Monthly Military Treatment Facility Birth Volume Target Module Annual Military Treatment Facility Birth Volume Module Accompanying p g worksheets and underlyingg data in the Excel document

FOR OFFICIAL USE ONLY

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Data sources •

•

MHS Data Repository • Inpatient I i Admissions Ad i i • Standard Inpatient Data Record (SIDR) FY 2005-2011 • Purchased Care Institutional (PCI) FY 2005-2011 2005 2011 • Population M2 DEERS FY 2005-2011 Births are defined using Diagnosis Related Groups (DRGs) • DRGs 370-375 (prior to 2007) • MS-DRGs 765-768, 774,775 • Births of multiples are counted as one delivery FOR OFFICIAL USE ONLY

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Population concepts •

Catchment Areas| Multi-Service Market Areas (MSMAs) | MTFs

•

National Capital Area (NCA) MSMA • • • •

•

• •

NMC Portsmouth 633rd Med Grp- JB Langley-Eustis McDonald AHC- Ft. Eustis

San Diego MSMA • •

•

NNMC Bethesda (Walter Reed NMMC) 779th Med Grp-Andrews D itt ACHDewitt ACH Ft. Ft Belvoir B l ir Walter Reed AMC

• • • • • •

Tidewater MSMA •

•

• CONUS Catchment Areas

• OCONUS Catchment Areas • • • • • • •

NMC SSan Di Diego NH Camp Pendleton

Puget Sound MSMA • • •

NH Bremerton NH Oak Harbor Madigan AMC- Ft. Lewis

NH Beaufort NH Camp Lejeune NH Jacksonville J k ill NH Pensacola NH Lemoore y Palms NH Twentynine

FOR OFFICIAL USE ONLY

NH Guam-Agana NH G Guantanamo NH Naples NH Okinawa NH Rota NH Sigonella NH Yokosuka

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Birth forecasting method General Fertility Rate= # Births # Female population (15 (15-45) 45) Birth Forecast=Forecasted Female Population x Fertility Rate • • •

•

Annual DC/PC Catchment Area Module uses FY2011 catchment area-specific fertility rates as baseline Forecast error bounds incorporate p variation of rates over time Female population changes based on projected changes in active military end strength1 using catchment area specific gender and martial status statistics Troop Movement Module uses specific beneficiary category and rank population and fertility rates to forecast births 1.

FY2013 Defense Budget: http://comptroller.defense.gov/budget.html FOR OFFICIAL USE ONLY

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Annual direct care and purchased care births from FY 2005-2011 and forecasts for FY 2012-2014

Click on cell for a drop down arrow to select catchment

Forecast Results

Select whether you want to use the baseline for % direct care, population change and fertility rate. If FOR OFFICIAL USE ONLY not, select “No” and enter data in blue cells

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Birth volume, population counts, and fertility rates for AD females,, AD family, y, and other Click on cell for a drop p down arrow to select catchment area/ MSMA Forecast results for 2012-2014 based on population change rate from DoD end strength projections

FY2011fertility rate used to forecast

FOR OFFICIAL USE ONLY

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Birth volume and female population data forecasts based on AD enlisted and officer movement

Forecast Results

Select whether you want to use the b baseline li ffor % F Female l and % Married by Rank. If not, select “No” and enter data in blue cells

Enter expected increase or decrease in AD enlisted and officer populations (male and female combined) for the FOR OFFICIAL USE ONLY catchment area/MSMA

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Graph of monthly catchment area birth volume from FY 2005 2005-2011 2011

Enter a target monthly birth volume based on an estimate from the graph where the historical seasonal variation is lowest

Red Target volume line adjusts based on what user enters

Gray dashed line is t ti ll att sett automatically the minimum volume

October 2004-September 2011 FOR OFFICIAL USE ONLY

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Graph of monthly MTF birth volume from FY 2005 2005-2011 2011

Enter a target monthly birth volume based on an estimate from the graph where the historical seasonal variation is lowest

Red Target volume line adjusts based on what user enters

FOR OFFICIAL USE ONLY

Gray y dashed line is set automatically at the minimum volume

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October 2004-September 2011

Graph of annual MTF birth volume from 2005-2011 2005 2011

FOR OFFICIAL USE ONLY

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Case scenarios •

DoD reduction of end strength by 2017 • •

•

202,100 202 100 to t 182,100 182 100 Marines M i andd 570,000 570 000 to t 490,000 490 000 Army A soldiers ldi 1 What impact will a decline of 100,000 troops have on birth volume across the system? • Decline of 6,083 births (~18%) across the system

Marine Corps relocation from Okinawa to Guam by 2014 •

•

9,000 Marines are moving out of Okinawa, where 4,700 Marines are moving to Guam and about 4,300 will be rotated through Australia, the Philippines and Hawaii2 What W at impact pact will w this t s relocation e ocat o have ave on o NH Okinawa O awa and a d NH Guam Gua on perinatal workload? • Okinawa will lose 591 births (~50%), and Guam will gain 260 births ( (~62%) %)

1. FY2013 Defense Budget: http://comptroller.defense.gov/budget.html 2. http://www.military.com/news/article/us-to-remove-9000-marines-from-okinawa.html FOR OFFICIAL USE ONLY

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DoD reduction of end strength

20,000 broken down using 1:8.5 ratio and 80,000 using 1:5 ratio

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Marine Corps relocation from Okinawa

9,000 broken down using 1:8.5 ratio

Use Marine Corp specific marital FOR OFFICIAL USE ONLY status and gender statistics

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Marine Corps relocation to Guam

4,700 broken down using 1:8.5 ratio

Use Marine Corp specific marital status and genderFOR OFFICIAL USE ONLY statistics

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Conclusions •

•

•

Simple and easy to use tool allows decision makers to make k more informed i f d perinatal i l resource decisions d ii based b d on data trends and user knowledge P Potential i l next steps include i l d capturing i andd integrating i i staffing requirements into the tool and creating similar analytic tools for other product lines Most recent version of tool available on the BUMED SharePoint site: https://bumedportal.med.navy.mil/bumed/m8/m81/ BirthForecast/default.aspx FOR OFFICIAL USE ONLY

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Orthopedic surgery: Trends, volume, and quality

1)Context: • •

Orthopedic surgery volume is growing at 5 to 9 percent per annum. Most of this volume is purchased care

2)Purpose: 2)P • •

What is the system in place to do this work? What should Navy be doing in these areas?

3)Outcome: •

Recommend rationalization of capability p y at centers of excellence in regions with the beneficiary volume to support an efficient scale of operation

FOR OFFICIAL USE ONLY

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Background Hip Knee Replacements Replacements

Cervical Spinal Fusions

Lumbar / Thoracic Fusions

Year

Population

2006

1,834,000

1,680

2,792

759

1,093

2007

1,873,000

1,803

2,991

916

1,228

2008

1 919 000 1,919,000

1 853 1,853

3 243 3,243

889

1 277 1,277

2009

1,952,000

2,017

3,490

1,024

1,603

2010

1,963,000

2,242

3,783

1,162

1,685

2011

1,965,000

2,256

3,955

1,244

1,649

Increase, 2006-2011

7%

34%

42%

64%

51%

$23-24k $23 24k

$22-$23k $22 $23k

$22k

$46k

$13

$29

$14

$31

Estimated cost per procedure, d 2012* Implied increase in spending (millions)

*Source: healthcarebluebook.com FOR OFFICIAL USE ONLY

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Joint replacement

FOR OFFICIAL USE ONLY

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Who gets a joint replacement?

Hip replacements FY11

Knee replacement FY11

Count

Ave Age

Count

Ave Age

Direct care

362

58.0

603

61.1

Purchased care

1,894

70.5

3,352

70.4

FOR OFFICIAL USE ONLY

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Totals include population of Navy MSMAs and catchment areas

Direct care hip replacement FY11 Not Medicare Eligible MSMA NCA

Tidewater San Diego Puget Sound

MTF Walter Reed Nat’l Military Med Cen 779th Medical Group – Andrews AFB

Enrolled MTF

Enrolled MCSC

Not En olled Enrolled

Medicare

Total

52

1

2

16

71

3

8

18

107

3

13

5

NMC Portsmouth

68

633rd Medical Group JB Langley – Eustis

10

NMC San Diego

11

3

Madigan AMC AMC-Ft Ft. Lewis

41

4

NH Bremerton NH Jacksonville NH Pensacola

14

7

14 1

39

85

25

28

53

7

2

9

14

3

1

Total at these locations

234

25

12

112

383

Percent by category

61%

7%

3%

29%

100%

Share population age >35 Share,

32%

13%

22%

34%

FOR OFFICIAL USE ONLY

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Totals include net referrals

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Direct care knee replacement FY11 Not Medicare Eligible Enrolled MTF

Enrolled MCSC

Not En olled Enrolled

Medicare

Total

Walter Reed Nat’l Military Med Cen

50

0

0

11

61

779th Medical Group – Andrews AFB

39

2

14

55

107

17

32

165

19

6

5

30

102

4

47

153

37

1

43

82

1

10

19

45

6

27

MSMA NCA

Tidewater San Diego Puget Sound

MTF

NMC Portsmouth 633rd Medical Group JB Langley – Eustis NMC San Diego Madigan AMC AMC-Ft Ft. Lewis

9

1

NH Bremerton

9

NH Jacksonville

16

7

NH Pensacola

18

3

Total at these locations

397

40

13

178

628

Percent by category

63%

6%

2%

28%

100%

Share population age >35 Share,

32%

13%

22%

34%

FOR OFFICIAL USE ONLY

3

Totals include net referrals

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Joint replacement quality and volume •

Key references: Hi Hips:

• • •

Knees:

• • •

•

Katz et. al., Journal of Bone and Joint Surgery 83A (11) 2001 Solomon et al., Arthritis & Rheumatism 46(9) 2002 Katz et. al. The Journal of Bone and Joint Surgery (86) 2004 Bozic et. al. The Journal of Bone and Joint Surgery Am. 92 2010

Recommendations for best outcomes: Hips

• • •

Surgeons who perform 50 or more procedures per year Facilities with at least 100 procedures per year

See also the Institute of Medicine workshop on volume and quality and related studies at www.nap.edu

Knees

• • •

Surgeons who perform 50 or more procedures per year Facilities with at least 200 procedure per year FOR OFFICIAL USE ONLY

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Status of recommendations? •

•

•

•

Numerous published studies, both critical and supporting, but generally results have stood up well to scrutiny States publish statistics on facility and surgeon volume and encourage g patients p to use them as qqualityy indicators Insurance companies use volume targets in their “center of excellence” programs C l programs ddo most surgery in h Civilian high h volume l settings

See CNA white paper “Hip and knee arthroplasty in Navy MSMAs and catchment areas, FY2010”

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Civilian practice v. MHS

Hips p

Knees

Facility Volume per Year

Navy MTFs, FY2011

Maine 2008

Nevada 2009

Massachusetts 2004

0-10

6%

1%

0%

0%

11-25

12%

6%

2%

1%

26-50

0%

16%

4%

6%

51-100

55%

5%

11%

14%

101+

28%

72%

83%

79%

0 25 0-25

2%

4%

1%

1%

26-100

48%

25%

19%

17%

101-200

51%

4%

11%

29%

200+

0%

67%

69%

53%

FOR OFFICIAL USE ONLY

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Hip replacements by location, location FY2011 Beneficiary volume of hip arthroplasties by catchment area/MSMA, FY2011 700 600 500 400

Medicare Eligible Not Enrolled Enrolled MCSC Enrolled MTF

300 200 100

100 per year

N

CA Ti M de SM w at A er Sa M n SM D A ie Pu go ge M t SM S ou A nd M C SM am A p Le je un Ja e ck so nv ill e Pe ns ac ol a Be au fo rt Le Tw m en oo ty re ni ne Pa lm s

0

Hip replacements cost $23-24k. The implant itself costs $5k.

Knee replacements by location, location FY2011 Beneficiary volume of knee arthoplasties by catchment area/MSMA, FY2011 Medicare Eligible Not Enrolled Enrolled MCSC Enrolled MTF

200 per year

Ti

N

CA

M de SM w at A er Sa M n SM D A ie Pu go ge M t SM S ou A nd M C SM am A p Le je un Ja e ck so nv ill e Pe ns ac ol a Be au fo rt Le Tw m en oo ty re ni ne Pa lm s

1,000 900 800 700 600 500 400 300 200 100 0

Knee replacements cost $22-23k. The implant itself costs $5k.

Spinal fusion

FOR OFFICIAL USE ONLY

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Who gets a spinal fusion?

Cervical

Lumbar / Thoracic

Count

Ave Age

Count

Ave Age

Direct care

292

45.6

1349

43.5

Purchased care

952

55.3

300

57.9

FOR OFFICIAL USE ONLY

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Totals include population of Navy MSMAs and catchment areas

Direct care spinal fusion FY11 Not Medicare eligible Enrolled MTF

Enrolled MCSC

Not Enrolled

Medicare

Total

Walter Reed Nat’l Military Med Cen

224

6

12

28

270

NMC Portsmouth

148

34

12

11

205

NMC San Diego

102

14

3

5

124

14

93

MTF

Madigan AMC-Ft. Lewis

77

2

NH Camp Lejeune

15

1

Total

566

FOR OFFICIAL USE ONLY

54

30

16 58

Totals include net referrals

708

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The largest insurance companies

Who has a preferred provider pprogram g that uses procedure volume as a quality measure?

List of insurers from U. S. News and World Report: http://health.usnews.com/healthplans/national-insurance-companies

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Civilian hospital volume 1 of 2 “Why is this important? Studies have found that surgical teams with experience – that is, routinely performing a sufficient number of cases – get better results.” - Beth Israel Deaconess Medical Center

FOR OFFICIAL USE ONLY

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Civilian hospital volume 2 of 2 Facility volume per year 1-25

MTFs 2011 2%

Nevada 2010 0%

Maine 2009 2%

Kentucky 2010 1%

Utah 2010 0%

26-100

13%

4%

9%

17%

1%

101-300 101 300

85%

19%

43%

50%

12%

301-900

0%

77%

47%

8%

32%

901+

0%

0%

0%

24%

55%

FOR OFFICIAL USE ONLY

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Spinal fusions by location, FY2011 Beneficiary volume of spinal fusions by catchment area/MSMA, FY2011 700 600 500 400

Medicare Eligible Not Enrolled Enrolled MCSC Enrolled MTF

300 200 100

100 per year

Ti

N

CA

M de SM w at A er Sa M n SM D A ie Pu go ge M t SM S ou A nd M C SM am A p Le je un Ja e ck so nv ill e Pe ns ac ol a Be au fo rt Le Tw m en oo ty re ni ne Pa lm s

0

Cervical spinal fusions cost about $22k, lumbar cost about $46k