47
HOSPI TALS IN INTEGRATED SYSTEMS
SANOFI / MANAGED CARE DIGEST SERIES
®
/ WHERE INFORMATION BECOMES INTELLIGENCE.
™
HOSPITALS/SYSTEMS DIGEST 2013
HMOs Affiliated With Systems Reduce Utilization Rates
UT I L I ZAT ION
Key Takeaway
Additional members joining HMOs through health insurance exchanges—and other Affordable Care
Act provisions (for example, the elimination of coverage refusal due to pre-existing conditions and
gender)—will certainly impact enrollment and member resources. As a result, physician encounter
ratios and other utilization measures may remain in flux, as payers accommodate newly insured
members whose required medical needs are potentially more complex.
• Between 2010 and 2011, HMOs in systems
reduced medical utilization rates for the
majority of the profiled measures for
Medicare and non‑Medicare members alike.
• However, average length of stay (ALOS)
increased over this time at system HMOs for
both Medicare (to 5.9 days from 5.6) and
non‑Medicare (to 4.0 from 3.9) members.
Annual utilization rates of HMOs
1
HMOs in Systems
HMOs Not
in Systems
ALL HMOs
Utilization measure
2010
2011
2010
2011
2010
2011
Number of HMO Enrollees per Plan
255,880 269,270 159,251 161,828
175,027 179,816
Hosp. Days per 1,000 Non-Medicare Members
232.8
224.3
239.6
238.9
238.2 235.9
Hosp. Days per 1,000 Medicare Members
1,551.9 1,559.9 1,617.8 1,659.0
1,608.9 1,643.1
Hosp. Admissions per 1,000 Non-Medicare Members
56.7
55.3
59.2
57.9
58.7
57.4
Hosp. Admissions per 1,000 Medicare Members
282.2
254.6
275.1
269.3
276.1 266.9
Physician Encounters per Non-Medicare Member
4.2
4.3
4.9
4.6
4.7
4.6
Physician Encounters per Medicare Member
9.2
9.0
10.9
9.7
10.6
9.6
Ambulatory Visits per Non-Medicare Member
1.7
1.6
1.6
1.5
1.6
1.5
Ambulatory Visits per Medicare Member
4.9
4.2
4.3
4.3
4.4
4.3
ALOS per Non-Medicare Hospital Admission
3.9
4.0
4.1
4.2
4.1
4.1
ALOS per Medicare Hospital Admission
5.6
5.9
6.0
6.2
6.0
6.1
Data source: IMS Health © 2013
• After annual growth between 2006 and
2010, the number of physician encounters
per non‑Medicare member of nonsystem
HMOs dropped by 6.1% in 2011, to 4.6.
• Meanwhile, HMOs in systems reported modest
growth in the number of physician encounters
per non-Medicare member in 2011, to 4.3
from 4.2 the prior year (an increase of 2.4%).
Physician encounterS PER NON-MEDICARE MEMBER, 2006–2011
1
3.0
3.5
4.0
4.5
5.0
Physician Encounters
per Non-Medicare Member
2006
2007
2008
2009
2010
2011
HMOs in Systems
HMOs Not in Systems
3.2
3.8
3.9
4.0
4.2
4.3
3.4
3.9
4.1
4.3
4.9
4.6
1
HMOs are considered to be in highly integrated health systems if they are part of a system by virtue of ownership or contractual arrangements.
HMOs are not considered to be in integrated health systems if they hold only provider network contracts with systems. All data are as of
December 31, 2011. Preoperational HMOs are excluded.
Non-Medicare Physician Encounter Ratio Declines at Nonsystem HMOs
LONG-TERM TREND
I...,37,38,39,40,41,42,43,44,45,46 48,49,50,51,52,53,54,55,56,57,...IV