Chartbook on Care Affordability: Slide Presentation

Slide 1

National Healthcare Quality and Disparities Report

Chartbook on Care Affordability
August 2016

Slide 2

National Healthcare Quality and Disparities Report

• Annual report to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129).
• Provides a comprehensive overview of:
  • Quality of health care received by the general U.S. population.
  • Disparities in care experienced by different racial, ethnic, and socioeconomic groups.
• Assesses the performance of our health system and identifies areas of strengths and weaknesses along three main axes:
  • Access to health care.
  • Quality of health care.
  • Priorities of the National Quality Strategy.

Slide 3

National Healthcare Quality and Disparities Report

• Based on more than 250 measures of quality and disparities covering a broad array of health care services and settings.
• Includes data generally available through 2013.
• Produced with the help of an Interagency Work Group led by the Agency for Healthcare Research and Quality and submitted on behalf of the Secretary of Health and Human Services.

Slide 4

Key Findings of the 2015 QDR

• Access to care has improved dramatically.
• Quality of care continues to improve, but wide variation exists across the National Quality Strategy (NQS) priorities:
  • Effective Treatment measures indicate improvements in overall performance and reductions in disparities.
  • Care Coordination measures have lagged behind other priorities in overall performance.
  • Patient Safety, Person-Centered Care, and Healthy Living measures have improved overall, but many disparities remain.
• Despite progress in some areas, disparities related to race and socioeconomic status persist among measures of access and all NQS priorities.

Notes:

• Improvements in access were led by sustained reductions in the number of Americans without health insurance and increases in the number of Americans with a usual source of medical care.
• Care Affordability measures are limited for summarizing performance and disparities.
• Disparities in access tend to be more common than disparities in quality.

Slide 5

Chartbooks Organized Around Priorities of the National Quality Strategy

1. Making care safer by reducing harm caused in the delivery of care.
2. Ensuring that each person and family is engaged as partners in their care.
3. Promoting effective communication and coordination of care.
4. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
5. Working with communities to promote wide use of best practices to enable healthy living.
6. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

Note:

• Care Affordability is one of the six national priorities identified by the National Quality Strategy (http://www.ahrq.gov/workingforquality/index.html).

Slide 6

Priority 6: Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models

Long-Term Goals:

1. Ensure affordable and accessible high-quality health care for people, families, employers, and governments.
2. Support and enable communities to ensure accessible, high-quality care while reducing waste and fraud.

Notes:

• The National Quality Strategy recognizes that while this will be a challenge, the goal of reducing health care costs is important to everyone because of the impact of rising costs on families, employers, and State and Federal governments.
• Reducing costs must be considered hand in hand with the aims of better care, healthier people and communities, and affordable care.

Slide 7

Chartbook on Care Affordability

• This chartbook includes:
  • Summary of trends across measures of Care Affordability from the QDR.
  • Figures illustrating select measures of Care Affordability.
• Introduction and Methods contains information about methods used in the chartbook.
• A Data Query tool provides access to all data tables (http://nhqrnet.ahrq.gov/inhqrdr/data/query).

Slide 8

Care Affordability Trends

• Few measures of Care Affordability can be tracked over time.
• One measure of Care Affordability showed worsening over time from 2002 to 2013:
  • People without a usual source of care who indicate a financial or insurance reason for not having a source of care.

Slide 9

Care Affordability Trends

• One measure of Care Affordability achieved 95% performance and was removed from the report this year:
  • People under age 65 with private insurance whose family’s out-of-pocket medical expenditures were more than 10% of total family income.
• No measures of Care Affordability improved quickly, defined as an average annual rate of change greater than 10% per year.

Note:

• For more information, refer to the Introduction and Methods.

Slide 10

Care Affordability Measures for Which Disparities Were Eliminated

• For the measure people under age 65 whose family’s health insurance premiums and out-of-pocket medical expenses were more than 10% of total family income, disparities were eliminated for three groups:
  • Less than high school vs. at least some college.
  • Micropolitan vs. large fringe metropolitan areas.
  • Noncore vs. large fringe metropolitan areas.

Slide 11

Care Affordability Measures for Which Disparities Were Eliminated

• For the measure people without a usual source of care who indicate a financial or insurance reason for not having a source of care, disparities were eliminated for three groups:
  • Female vs. male.
  • Large central vs. large fringe metropolitan areas.
  • Multiple race vs. White.

Slide 12

Care Affordability Measures for Which Disparities Were Growing

• For the measure people without a usual source of care who indicate a financial or insurance reason for not having a source of care, disparities were growing for two groups:
  • High school vs. at least some college.
  • Uninsured vs. any private.

Slide 13

Care Affordability Measures for Which a New Disparity Was Identified

• For the measure people without a usual source of care who indicate a financial or insurance reason for not having a source of care, a new disparity developed between Blacks and Whites.

Slide 14

Measures of Care Affordability

• Depending on the data source, this chartbook tracks measures of Care Affordability through 2012 or 2013, overall and for populations defined by:
  • Age.
  • Race, ethnicity.
  • Income, education, insurance.
  • Number of chronic conditions.
• Measures of Care Affordability include:
  • Access problems due to health care costs.
  • Inefficient care due to use of services associated with more harm than benefit.

Notes:

• One approach to containing the growth of health care costs and thus making health care more affordable is to improve the efficiency of the health care delivery system by reducing use of unneeded services, often referred to as overuse.
• As noted in the National Strategy for Quality Improvement in Health Care, “Achieving optimal results every time requires an unyielding focus on eliminating patient harms from health care, reducing waste, and applying creativity and innovation to how care is delivered.”

Slide 15

Measures of Access Problems Due to Health Care Costs

• People under age 65 whose family’s health insurance premiums and out-of-pocket medical expenses were more than 10% of total family income.
• People without a usual source of care who indicate a financial or insurance reason for not having a source of care.
• People under age 65 who were in families having problems paying medical bills in the past year.

Note:

• High health care costs can prevent some patients from receiving the care that they need.

Slide 16

People under age 65 whose family's health insurance premiums and out-of-pocket medical expenses were more than 10% of total family income, by chronic conditions (18-64) and family income, 2006-2013

Left Chart:

No. of Conditions	2006	2007	2008	2009	2010	2011	2012	2013
0-1 Conditions	15.4	14.2	14.7	15.6	15.8	15.3	15.4	14.9
2-3 Conditions	30.0	27.9	27.2	25.1	26.9	26.3	29.0	28.2
4+ Conditions	48.3	43.4	38.7	38.4	35.1	37.7	36.0	37.7

Right Chart:

Income	2006	2007	2008	2009	2010	2011	2012	2013
Total	17.5	16.3	17.3	17.4	17.6	17.5	17.9	17.3
High Income	8.2	6.7	6.7	7.3	8.2	7.6	8.3	9.8
Middle Income	18.8	18.7	20.2	19.1	20.5	19.2	20.7	20.2
Low Income	23.6	23.6	25.3	25.1	23.9	25.3	23.1	21.3
Poor	33.9	29.6	29.1	29.2	26.3	26.6	28.1	24.3

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006-2013.
Denominator: Civilian noninstitutionalized population under age 65.

Notes: For this measure, lower rates are better. Total financial burden includes premiums and out-of-pocket costs for health care services.

• Importance: Health care expenses that exceed 10% of family income are a marker of financial burden for families.
• Overall Percentage: In 2013, 17.3% of people under age 65 had health insurance premium and out-of-pocket medical expenses that were more than 10% of total family income.
• Trends:
  • From 2006 to 2013, there were no statistically significant changes in the overall percentage.
  • Among people with 4 or more chronic conditions and poor people, the percentage decreased.
  • Among high-income and middle-income people, the percentage increased.
• Groups With Disparities:
  • In all years, the percentage of adults under age 65 whose family’s health insurance premium and out-of-pocket medical expenses were more than 10% of total family income was higher among those with 2-3 and 4+ chronic conditions compared with those with 0-1 chronic conditions. The gap between people with 4+ chronic conditions and 0-1 conditions narrowed over time.
  • In all years, the percentage was about 3 times as high for poor individuals and low-income individuals and more than twice as high for middle-income individuals compared with high-income individuals.  The gaps between poor and high-income people and between low-income and high-income people were narrowing over time.

Slide 17

People without a usual source of care who indicate a financial or insurance reason for not having a source of care, by insurance (under age 65) and race/ethnicity, 2002-2013

Left Chart:

Insurance Status	2002	2003	2004	2005	2006	2007	2008	2009	2010	2011	2012	2013
Total	15.6	16.3	14.8	16.0	17.0	18.0	17.6	21.1	21.2	19.9	20.2	24.0
Uninsured	28.0	27.0	28.3	30.7	31.9	32.2	31.7	38.7	41.4	40.5	40.8	47.2
Public Only	18.5	19.9	17.3	21.0	21.4	23.6	21.5	24.7	20.0	18.4	20.6	22.8
Any Private	8.9	9.3	6.9	7.2	7.5	8.3	8.5	8.8	8.1	7.4	7.3	9.7

Right Chart:

Race/Ethnicity	2002	2003	2004	2005	2006	2007	2008	2009	2010	2011	2012	2013
White	12.8	14.8	11.6	13.0	15.1	15.6	14.0	17.3	18.0	15.4	16.0	19.6
Black	13.1	15.8	14.8	12.9	14.8	14.3	17.0	18.6	18.7	20.0	21.6	26.0
Hispanic	23.0	19.8	22.1	23.6	24.6	27.0	27.9	33.0	30.6	29.5	30.6	34.4

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2013.
Denominator: Civilian noninstitutionalized population without a usual source of care.

Notes: For this measure, lower rates are better. White and Black are non-Hispanic. Hispanic includes all races.

• Importance: High-quality health care is facilitated by having a regular provider, but some Americans may not be able to afford one.
• Overall Percentage: In 2013, 24.0% of people without a usual source of care indicated a financial or insurance reason for not having a source of care.
• Trends:
  • The overall percentage worsened from 2002 to 2013.
  • The percentage worsened among uninsured people and among Whites, Blacks, and Hispanics.
• Groups With Disparities:
  • In all years, the percentage of people without a usual source of care who indicated a financial or insurance reason for not having a source of care was higher:
    • Among uninsured people and people with public insurance compared with people with any private insurance. The gap between uninsured people and people with any private insurance was growing larger over time.
    • Among Hispanics compared with Whites.
  • From 2011 to 2013, the percentage of people without a usual source of care who indicated a financial or insurance reason for not having a source of care was higher among Blacks compared with Whites. This represents a new disparity that is growing larger over time.

Slide 18

People under age 65 who were in families having problems paying medical bills in the past year, by poverty status and race/ethnicity, 2011-2015 Q2

Left Chart:

Poverty Status	2011	2012	2013	2014	2015 Q1-2
Total	21.3	20.4	19.4	17.9	16.5
Poor	32.1	31	29.3	27.3	24.5
Near Poor	34.6	33.9	32.9	28.4	27.1
Not Poor	15.2	14	13.8	12.8	12.2

Right Chart:

Race/Ethnicity	2011	2012	2013	2014	2015 Q1-2
White	19.8	18.9	17.8	16.3	14.7
Black	27.3	27.5	26	24.1	23.1
Asian	11	8.8	8.8	8.6	6.7
Hispanic	24.3	22.9	22.6	20.7	20

Key: Q = quarter.
Source: Cohen RA, Schiller JS. Problems paying medical bills among persons under age 65: early release of estimates from the National Health Interview Survey, 2011-June 2015. Hyattsville, MD: National Center for Health Statistics; 2015. http://www.cdc.gov/nchs/nhis/releases.htm.

Notes: For this measure, lower rates are better.

• Trends: From 2011 to the first half of 2015, the percentage of people under age 65 in families having problems paying medical bills decreased overall and for all poverty status and racial/ethnic groups.
• Groups With Disparities:
  • In all years, people in poor and near-poor families were more likely to have problems paying medical bills than people in families that were not poor. The gaps between people in poor and not poor families and between near-poor and not poor families have narrowed over time.
  • In all years, compared with Whites, Blacks and Hispanics were more likely to have problems paying medical bills while Asians were less likely to have problems. None of these gaps were changing over time.

Slide 19

Measures of Inefficiency

• Ruptured appendix per 1,000 adult admissions with appendicitis.
• Men age 40+ who had a screening prostate-specific antigen test in the past year.

Note:

• Inefficient care includes delayed care that is more costly and care with risks that exceed benefits. This inefficiency can raise health care costs and make it harder for people to afford care.

Slide 20

Admissions for perforated appendix per 1,000 adult admissions with appendicitis age 18 and over, United States, by race/ethnicity and insurance, 2001-2013

Left Chart:

Year	Total	White	Black	Hispanic	API
2001	332.7	323.8	378.5	334.7	331.1
2002	326.7	322.4	364.1	319.7	289.3
2003	318.1	314.0	353.4	306.9	287.2
2004	309.5	306.8	327.8	304.5	284.0
2005	304.8	301.3	335.5	296.7	284.3
2006	303.6	298.1	342.7	298.0	284.2
2007	295.2	289.8	321.7	287.9	281.4
2008	296.7	294.4	316.1	283.8	275.1
2009	292.4	292.8	309.6	269.4	271.9
2010	300.8	302.6	320.4	273.2	299.3
2011	307.4	311.4	324.9	273.4	298.7
2012	313.6	319.1	316.1	283.9	317.6
2013	338.4	344.4	345.3	310.0	335.8

Right Chart:

Insurance Status	2001	2002	2003	2004	2005	2006	2007	2008	2009	2010	2011	2012	2013
Private Insurance	309.7	305.6	305.0	298.0	288.8	285.0	281.9	274.3	280.3	288.8	290.5	309.9	336.7
Medicare	394.2	361.7	395.9	384.3	347.0	364.5	331.0	299.3	322.8	352.3	303.8	351.4	333.4
Medicaid	348.7	347.8	354.2	344.2	316.5	314.6	314.9	308.9	277.4	310.6	284.7	302.5	312.1
Uninsured	352.0	349.9	346.8	340.9	349.0	348.4	309.7	321.6	308.5	350.5	317.1	330.4	351.5

2008 Achievable Benchmark: 232.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, State Inpatient Databases, disparities analysis file and Nationwide Inpatient Sample, 2001-2013.
Denominator: Adults age 18 and over.

Notes: For this measure, lower rates are better. Annual rates are adjusted for age and gender.

• Importance: Timely assessment of abdominal pain and diagnosis of appendicitis reduces rates of perforated appendix.
• Overall Rate: In 2013, there were 338 perforated appendixes for every 1,000 adult admissions with appendicitis.
• Trends:
  • From 2001 to 2013, there were no statistically significant changes in the overall rate.
  • The rate improved among Blacks and Hispanics and among people with Medicare and Medicaid.
• Groups With Disparities:
  • Until 2007, Blacks tended to have higher rates than Whites, and people with Medicare, Medicaid, or no insurance tended to have higher rates than people with private insurance.
  • Since 2007, only the gap between uninsured and privately insured people has persisted.
  • The disparities between Blacks and Whites and between people with Medicaid and those with private insurance were eliminated.
• Achievable Benchmark:
  • In 2008, the top 4 State achievable benchmark for perforated appendix per 1,000 admissions with appendicitis was 232. The States that contributed to the achievable benchmark were Connecticut, Hawaii, Massachusetts, and New Jersey.
  • No group had reached the benchmark by 2013.

Slide 21

Men age 40+ who had a screening prostate-specific antigen test in the past year as part of routine exam, by age, race, and education, 2014

Race / Education	40-54	55-74	75+
Total	11.4	30.0	28.0
White	11.3	31.8	29.0
Black	15.5	25.4	24.7
Asian	5.5	17.4	23.3
AI/AN	7.6	18.4	16.7
<High School	6.7	18.5	18.0
High School Grad	10.4	27.0	26.7
Any College	13.4	34.7	32.8

Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance Survey, 2014.
Denominator: Men age 40 and over.

Notes: For this measure, lower rates are better. The 2014 data are not comparable with previous data, because screening is defined as a routine exam in the past year.  Data in last year’s chart were based on broader definition of screening.

• Importance: Finding more harm than benefit, in 2008, the U.S. Preventive Services Task Force recommended against screening men age 75 and over with prostate-specific antigen (PSA) tests. In 2012, this recommendation was extended to all men.
• Overall Rate: In 2014, 21.1% of men age 40 and over reported a PSA test in the past year (data not shown).
• Groups With Disparities:
  • In 2014, men ages 40-54 were less likely to receive a PSA test in the past year compared with those ages 55-74 and 75 and over.
  • Among men ages 40-54, Asians were less likely than Whites to receive PSA testing and Blacks were more likely to receive the test.
  • Among men ages 55-74, Blacks, Asians, and American Indians and Alaska Natives (AI/ANs) were less likely than Whites to receive PSA testing.
  • Among men age 75 and over, AI/ANs were less likely than Whites to receive PSA testing.
  • Across all age groups, men with less than a high school education and those with a high school education were less likely than men with any college to receive PSA testing.

Slide 22

Supplemental Measures of Care Affordability

• Supplemental measures:
  • May provide contextual information related to health care quality.
  • Are not part of the measure set tracked in the QDR because they are difficult to interpret.
• Supplemental measure of Care Affordability:
  • Per capita national health expenditures.

Slide 23

Per capita national health expenditures in 2009 $, by largest components, 2003-2014

Component	2003	2004	2005	2006	2007	2008	2009	2010	2011	2012	2013	2014
Hospital	2,263	2,295	2,363	2,399	2,440	2,465	2,543	2,570	2,608	2,667	2,683	2,739
Physician and Clinical	1,421	1,474	1,523	1,572	1,575	1,628	1,636	1,634	1,677	1,709	1,739	1,799
Prescription Drug	725	758	774	808	829	821	826	785	765	745	741	798
Nursing Care Facilities	432	432	440	441	451	447	447	447	452	446	445	453
Net Cost of Health Insurance	420	434	428	450	450	467	451	460	442	450	479	497
Other	2,010	2,065	2,118	2,141	2,226	2,264	2,256	2,288	2,307	2,328	2,336	2,367

Source: Centers for Medicare & Medicaid Services, National Health Expenditure Data, 2003-2014.
Denominator: U.S. population.

Notes: Net cost of health insurance consists of insurers’ costs of paying bills, advertising, sales commissions, and other administrative costs; net additions to reserves; rate credits and dividends; premium taxes; and profits or losses. Other includes other professional services; dental services; other health, residential, and personal care; home health; government administration; other nondurable medical products; durable medical equipment; government public health activities; research; structures; and equipment.

• Importance: Increases in national expenditures on health care can affect costs for consumers.
• Trends:
  • Total per capita national health expenditures in 2009 dollars rose from $7,271 in 2003 to $8,653 in 2014.
  • Expenditures on hospitals and physicians rose an average of 2% per year while expenditures on prescription drugs changed little.
  • The five largest components of national health expenditures were hospital, physician and clinical, prescription drug, and nursing care facilities, along with net cost of health insurance (revenues minus expenses).