Health Care Costs and Spending in Nwe YorkS eatt · Services, health care spending by states and localities increased 10% in 2011, and consumed a larger share of revenues—about

Health Care Costs and Spending in New York State

FEBRUARY 2014

Prepared by:

Diana Rodin, M.P.H.

Jack Meyer, Ph.D.

Health Management Associates

Improving the state of New York’s health

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HEALTH CARE COSTS AND SPENDING IN NEW YORK STATE

Executive Summary 3Health Care Spending Growth in New York State 6The Growing Cost of Health Insurance Coverage 18Where Are We Spending Our Money? 25Getting More Bang for the Buck: The Quality Question 52 Conclusion 59

Contents

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Slowing the growth of health care spending continues to be a major challenge for the federal and state governments. In 2012, total U.S. health expenditures reached $2.8 trillion—17% of gross domestic product (GDP). Although health care spending growth has slowed in recent years, it is projected to grow faster than GDP over the next decade. While total U.S. health care spending grew slowly in 2012, rising about 4%, the story for state and local governments was different. According to the Centers for Medicare & Medicaid Services, health care spending by states and localities increased 10% in 2011, and consumed a larger share

of revenues—about 3 out of every 10 dollars—than has been the case for these expenses since at least 1987. As states emerge from the Great Recession, health care spending remains a source of financial stress.

New York’s health care spending overall and per capita are among the highest in the nation. Health spending has accelerated over time and is projected to increase to more than $300 billion by 2020. New York’s total health spending as a percent of gross state product is similar to the national average, but has grown over time.

Outpacing both inflation and overall economic growth, the rising cost of health care has far-ranging consequences for wages, employment, the price of goods and services, and the ability to fund other public services.

Increased health care costs are also reflected in the growing costs of health insurance. Insurance premiums in New York have risen dramatically and faster than household incomes. The high cost of coverage is felt by both employers and their workers and has adverse effects on New York’s economic growth.

New York’s health spending is evenly split between public and private payers. Private spending on health care has grown faster than public spending. New York’s Medicaid program covers millions of New Yorkers and is costly both overall and per capita. New York and U.S. spending on health services are generally similar. Spending on nursing

Executive Summary

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Executive Summary (continued)

homes, home health care, and personal care comprises the majority of the difference between New York and average U.S. spending. New Yorkers also are admitted to hospitals more frequently and have longer lengths of stay than U.S. averages.

Although New York fares well on key public health measures, such as obesity and smoking rates, it has high health care costs. Despite its high rate of spending, New York does not consistently demonstrate better quality of care. It ranks among the worst states on some measures of avoidable hospital costs and use. New York’s hospitals do exhibit relatively low mortality rates, and its health plans do achieve superior results on some measures of care. Generally, payment levels and quality of care bear little relationship to one another in New York.

The past four years witnessed a slowdown in the growth of national health expenditures. There is broad agreement that the recession and the associated increase in unemployment and decline in insurance coverage led individuals to cut back on their use of health care services. Yet there is also evidence that the slowdown in spending preceded the recent recession and seems to be continuing during the modest economic recovery. Underlying structural changes in the health system may also be playing a role in recent spending trends.

Ongoing pressure to control health care costs requires a serious, focused effort to fundamentally restructure the delivery of health care and associated spending. While different strategies exist, there is growing consensus that payment reform—as a move away from fee-for-service reimbursement—is required to drive meaningful change in health care costs. Fee-for-service methods of reimbursement encourage a volume-driven health care system rather than a value-driven system. Moreover, such payments can penalize providers for keeping people healthy, for managing chronic diseases, and for avoiding unnecessary and expensive care.

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Executive Summary (continued)

This chart book, “Health Care Costs and Spending in New York State,” pulls together a compendium of information on health care costs, spending, and payments based on existing State and national research. It synthesizes a wide range of data into an objective, easy-to-use resource that is intended to support and facilitate ongoing research and conversation on health care cost trends.

This product was prepared by Health Management Associates, with the support of New York State Health Foundation staff, including David Sandman, Amy Shefrin, and Emily Parker. Numerous individuals provided helpful comments and assistance, including David Cutler, Rose Duhan, Foster Gesten, Sherry Glied, and Karen Heller.

S E C T I O N

HEALTH CARE SPENDING GROWTH IN NEW YORK STATE

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Health Care Spending Growth in New York State

Health care expenditures in New York totaled $163 billion in 2009, the second highest in the country.

New York is ranked sixth highest in the nation for per capita health care expenditures as of 2009.

New York health care expenditures have grown rapidly in recent years.

Total health care spending in New York is projected to rise by more than $100 billion from 2013 to 2020, or about 53%.

$250,000

$200,000

$150,000

$100,000

$50,000

SOURCE: Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, 2011. NOTE: Data are for 2009.

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Health Care Expenditures by State of Residence (in Millions), 2009

New York Is Ranked Second Highest in the Nation for Total Health Care Expenditures

$3,833

$162,845

$230,090

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$10,000

SOURCE: Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, 2011.

NOTE: Personal health care expenditures include all spending on a wide range of services to treat individuals with specific medical conditions, but exclude other types of health care-related spending, such as health care-related research, government public health activity, and government administration and the net cost of health insurance. District of Columbia is not included.

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$6,000

$4,000

$2,000

$8,000

U.S., $6,815N.Y., $8,341

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Per Capita Personal Health Care Expenditures, 2009

$0

New York Is Ranked Sixth Highest in the Nation for per Capita Health Care Expenditures

SOURCE: Centers for Medicare & Medicaid Services (CMS), Health Expenditures by State of Residence, 2011. U.S. Bureau of Economic Analysis, http://www.bea.gov/regional/index.htm, 2013.

NOTE: GSP is the state-level equivalent of gross domestic product (GDP), and is the sum of the GDP originating in all of the industries in a state. State-level GSP data are available from 1997 through 2012. The time period over which state health expenditures are reported on the CMS website is 1991 through 2009. The U.S. amount is the weighted average among the 50 states. District of Columbia is not included.

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15%

10%

5%

20%

U.S., 15.1%

N.Y., 15.1%

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0%

New York’s Total Health Expenditures as a Percent of Gross State Product (GSP) Are in Line with the National Average

25% New York is ranked 29th in the nation

Total Health Expenditures as a Percent of GSP, 2009

* Even though New York’s health care share of GSP increased from 1997 to 2009, it did not increase as much as in other states. Therefore, its ranking was more favorable in 2009 (29th) than in 1997 (22nd).

SOURCE: Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, 2011. U.S. Bureau of Economic Analysis, http://www.bea.gov/regional/index.htm, 2013.

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10%200814.4%

30

200713.9%

31

199712.4%

22Health/GSPNY Rank*

200915.1%

29

200613.9%

30

200514.1%

28

200414.5%

21

200314.5%

21

200213.7%

26

200112.9%

27

200012.6%

24

199912.6%

22

199812.6%

22

New York’s Health Care Spending as a Percent of GSP

New York’s Health Care Expenditures as a Share of Gross State Product (GSP) Have Grown

16%

15%

14%

13%

12%

11%


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$0

$58

1991

$62

1992

$67

1993

$71

1994

$75

1995

$79

1996

$82

1997

$87

1998

$92

1999

$97

2000

$105

2001

$113

2002

$122

2003

$129

2004

$136

2005

$144

2006

$150

2007

$155

2008

$163

2009

New York Total Health Care Expenditures, Actual (in Billions), 1991–2009

Health Care Expenditures in New York Nearly Tripled Over 18 Years

$160

$20

$40

$60

$80

$100

$120

$140

SOURCE: The Kaiser Family Foundation State Health Facts.

NOTE: Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, 2011.

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New York Has Been Among the Highest-Spending States in Total Health Care Expenditures Since 1991

$0

$250,000

$50,000

$100,000

$150,000

$200,000

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

The average rate of growth of total health care spending in New York between 1991 and 2009 is relatively low among states at 5.9%, compared to the U.S. average of 6.5%.

However, over nearly two decades, the spending gap has widened among a set of states, in particular California, New York, Texas, and Florida. The four highest-spending states are shown here; all others have spending below $100 billion.

Health Care Expenditures by State of Residence (in Millions), 1991–2009

California New York Texas Florida


NOTE: Data are for 2009. The U.S. amount is the weighted average among the 50 states. District of Columbia is not included.

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Compound Annual Growth Rate of Total Health Care Expenditures per Capita, 2004–2009

New York’s Compounded Rate of Growth in per Capita Total Health Spending Has Been Modest in Recent Years

3%

2%

1%

6%

5%

4%

N.Y., 4.5%

U.S., 4.7%

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0%

8%

7%

$208.4

$318.8

SOURCE: The Lewin Group for the New York State Health Foundation, “Bending the Health Care Cost Curve in New York State: Options for Saving Money and Improving Care,” July 2010.

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Projected New York Spending (in Billions), 2013–2020

New York Health Care Spending Growth Is Projected to Continue

$0

$350

$150

$50

$200

$100

$250

$300

2013

$220.4

2014

$234.1

2015

$248.8

2016

$265.2

2017

$282.1

2018

$300.2

2019 2020

http://nyshealthfoundation.org/resources-and-reports/resource/bending-the-health-care-cost-curve-in-new-york-state-options-for-saving-mon

SOURCE: U.S. Government Accountability Office, State and Local Governments’ Fiscal Outlook, April 2012 update.

NOTE: Historical data are from the U.S. Bureau of Economic Analysis’s National Income and Product Accounts. Data in 2011 are GAO estimates aligned with published data where available. GAO simulations are from 2012 to 2060, using many Congressional Budget Office projections and assumptions, particularly for the next 10 years.

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Nationally, Health Spending Absorbs a Growing Share of State and Local Government Spending

0%

12%

4%

2%

6%

8%

10%

2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 2055 2060

10.4%, 2014

7.7%, 2060

7.2%, 2060

4.1%, 2014

Nationally, state and local spending on Medicaid and health benefits for state and local government employees and retirees is projected to grow faster than the GDP.

The U.S. Government Accountability Office (GAO) projects that nonhealth-related state and local government spending, such as on education, will decline as a percentage of the GDP.

Health and Nonhealth Expenditures of State and Local Governments as a Percentage of Gross Domestic Product (GDP)

Nonhealth care expenditures

Health care expenditures

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Health Spending Is Projected to Remain the Second-Largest Segment of New York State’s Budget

$02013 2014 2015 2016 2017

$120

$20

$40

$60

$80

$100

SOURCE: OpenBudget.NY.gov. Enacted State Operating Funds Budget for FY 2013 to FY 2017 by major functional category.

NOTE: Disbursements include grants to local governments, State operations, and general State charges. Health spending summarized here includes not only Medicaid benefits and administration, but also public health spending, the Office for the Aging, and State funding for certain medical research. The mental hygiene category includes all mental and behavioral health, and developmental disabilities agency budgets.

Substantial federal funding for the Affordable Care Act’s Medicaid expansion will reduce pressure on the State budget even as Medicaid enrollment grows.

Education

Health

Higher Education

Mental Hygiene

Transportation

Social Welfare

Public Protection/Criminal Justice

Elected Officials

General Government

Economic Development and Government Oversight

Local Government Assistance

Parks and the Environment

All Other Categories

Spending by Function of State Operating Funds (in Millions)

THE GROWING COST OF HEALTH INSURANCE COVERAGE

S E C T I O N

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The Growing Cost of Health Insurance Coverage

New York’s large employers contribute higher shares of premium costs than employers in any other state.

Over the last decade, the cost of employer-sponsored family health insurance premiums in New York rose by an average of 92%.

Rising premiums translate to lower wages, reduced benefits, more restrictive health coverage eligibility, and less affordability for employees to take up insurance.

In New York over the last decade, employees’ required premium contributions as a percentage of their income roughly doubled.

N.Y., $16,924

SOURCE: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey data.

NOTE: Average total family premium (in dollars) per enrolled employee at private-sector establishments that offer health insurance by firm size and selected characteristics. Data not available for 2007. These data show the total cost of the premium, rather than the total employee contributions, which are shown on page 23.

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New York State Health Insurance Premiums Have Grown Steadily

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012$0

$8,000

$6,000

$4,000

$2,000

$10,000

$12,000

$14,000

$16,000

$18,000

U.S., $4,954

U.S., $15,473

N.Y., $5,315

New York State premiums for employer-based family coverage have grown an average of 9% annually between 1996 and 2012, similar to the national average of 8.9%, with total premiums more than tripling over that period in New York.

Average Family Premiums For Employer-Based Coverage, United States and New York State, 1996–2012

United States

New York State

11%

SOURCE: Cumulative Increases in Health Insurance Premiums, Workers’ Contributions to Premiums, Inflation, and Workers’ Earnings, United States, 1999-2012. Kaiser Family Foundation/Health Research & Educational Employer Health Benefits Survey, 1999-2012. U.S. Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1999-2012; U.S. Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999-2012 (April to April).

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Nationally, Workers’ Health Insurance Costs Have Grown Faster than Earnings and Inflation

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

200%

0%

80%

60%

40%

20%

100%

120%

140%

160%

180%

8%

29%

172%

38%24%

109%

180%

47%

113%

38%

38%

Workers’ contributions to premiums have grown four times as much as their earnings.

Premium growth has squeezed out pay increases.

Health Insurance Premium Growth, 1999–2012

Health Insurance Premiums

Workers’ Contribution to Premiums

Overall Inflation

Workers’ Earnings

Average family premiums in New York were 33% of median household income in 2011 compared to 16% in 1999.

While employers pay most of the premiums, ultimately their cost is passed through to employees in the form of lower wages and income.

SOURCE: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey data.

NOTE: Average total family premium (in dollars) per enrolled employee at private-sector establishments that offer health insurance by firm size and selected characteristics. Data not available for 2007. These data show the total cost of the premium, rather than the total employee contributions, which are shown on page 23. Data for median income from U.S. Census Bureau, State Median Income. Median Household Income is in 2011 inflation-adjusted dollars.

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Family Health Insurance Premiums Are Growing Faster than Household Income in New York

1999 2000 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011

$60,000

$0

$10,000

$20,000

$30,000

$40,000

$50,000

35%

25%

15%

5%

30%

20%

10%

0%

16%

33%

New York Average Family Premiums and Median Income, 1999–2011

New York Average Family Premiums

New York Median Household Income

Premium as % of Income

7.6%

4.7%

5.4%

SOURCE: Chart data are from the Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey data.

NOTE: The employee contribution includes the portion of the total health insurance premium paid by the enrolled employee, but does not include other employee cost sharing. Data not available for 2007. Median household income is in 2011 inflation-adjusted dollars.

SIDEBAR SOURCE: Families USA, “Costly Coverage: Premiums Outpace Paychecks in New York,” September 2009.

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$0

Employee Contributions to Health Insurance Premiums Have Roughly Doubled in New York

$4,500

$2,000

$1,500

$1,000

$500

$2,500

$3,000

$3,500

$4,000

$3,824

$1,175

From 2000 to 2009, New York family contributions to health insurance premiums grew 6.4 times faster than median income. Family contributions rose by an average of 92.3%, while median income rose by only 14.4%.

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011

3.3%3.4% 3.6% 3.5%

3.6% 3.7%

4.5% 4.2%

5.5%

6.7%6.0%

7.3%

Average New York Employee Contribution for Family Plan

Average Employee Contribution as Percentage of Median Income

Employee Contribution to Health Insurance Plan Compared to Median Income, 1996–2011

25%

22%20%

15% 14%

5% 5% 4%

SOURCE: J. Gabel, H. Whitmore, and J. Pickreign, “A Decade of Decline: A Survey of Employer Health Insurance Coverage in New York State,” New York State Health Foundation, November 2010.

NOTE: Totals are not additive.

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Rising Premiums Adversely Affect Employer Decisions About Hiring, Wages, and Benefits

0%

30%

10%

5%

15%

20%

25%

Reduced or froze wages

Avoided hiring more workers

Relied on more part-time workers

Reduced eligibility for benefits

Dropped dependent coverage

Reduced benefits

Eliminated positions

Increased waiting periods for eligibility

Even though the percentage of New York employers offering coverage remains high, employers have increased restrictions on employee eligibility for coverage; costs are going up for both the employer and employee; and fewer employees are choosing to take up coverage when available.

The percentage of workers in New York insured by their employer’s coverage has decreased from 69% in 2001 to 58% in 2009.

Enrollment in preferred provider organizations and high-deductible plans has grown, while use of health maintenance organizations and point-of-service plans has declined.

New York Employer Responses to Increasing Premium Costs

http://nyshealthfoundation.org/resources-and-reports/resource/decade-of-decline-survey-of-employer-health-insurance-coverage-in-new-york

WHERE ARE WE SPENDING OUR MONEY?

S E C T I O N

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In New York, health spending by private payers has grown faster than health spending by public payers, such as Medicaid and Medicare.

Medicaid spending on aged and disabled enrollees is second highest in the nation, and is driving New York’s high Medicaid spending per enrollee.

New York has higher hospital admission rates, longer lengths of stay, more hospital outpatient visits, and slightly higher emergency department use compared to the national average.

While the high levels of hospital utilization help explain New York’s overall high costs, they are not necessarily driving rapid year-to-year cost growth.

New York has a high number of physicians and specialists per capita.

Prices are a likely driver of continuing cost growth.

Where Are We Spending Our Money?


NOTE: Data are for 2009.

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Total Health Care Expenditures by Payer in New York (in Millions), 2009

New York Health Spending Is Evenly Split Between Public and Private Payers

Private/Other

$81,207

Medicare

$34,081

Medicaid

$47,557

50%

29%

21%


NOTE: Data are for 2009; Payer shares may not sum to 100% because of rounding.

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Public Payers Account for a Larger Share of Spending in New York than Nationwide

0%2009

United States New York

2009

100%

30%

20%

10%

40%

50%

60%

70%

80%

90%

61%

17%

23%

50%

29%

21%

Private/Other

Medicaid

Medicare

—29—


Private Health Spending Has Grown Faster than Public Spending, Growing 250% Between 1991 and 2009

$0

$90,000

$60,000

$70,000

$80,000

$50,000

$10,000

$20,000

$30,000

$40,000

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009


Private health spending was 2.5 times higher in 2009 than in 1991, and the gap in growth between private and public spending is growing.

Medicare

Medicaid

Private/Other

Total Personal Health Expenditures by Payer in New York, 1991–2009 (in Millions)

3,394,448 3,454,2663,696,720

3,955,6404,119,436

4,461,327

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Medicaid Enrollment Has Continued to Grow in New York

2007 2008 2009 2010 2011 2012

5,000,000

0

4,000,000

3,000,000

2,000,000

4,500,000

3,500,000

2,500,000

1,000,000

1,500,000

500,000

SOURCE: New York State Department of Health, Medicaid Quarterly Reports of Beneficiaries, Expenditures, and Units of Service by Category of Service by Aid Category by Region, accessed May 2013. John Holahan, Matthew Buettgens, Caitlin Carroll, and Stan Dorn, “The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State-by-State Analysis,” The Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, November 2012.

NOTE: Figures are averages of monthly total enrollment for calendar years except 2012 data, which are for the fourth quarter. They are therefore lower than the annual enrollment totals shown on page 31, since many individuals move in and out of coverage over the course of a year, increasing annual total enrollment compared to estimates derived from monthly snapshots.

Enro

llees

By 2022, New York’s Medicaid program is projected to grow by 1.03 million enrollees, with the Affordable Care Act (ACA) Medicaid eligibility expansion adding an estimated 320,000, or 31.2%, of the total increase.

Average Monthly Total Medicaid Enrollment, New York, 2007–2012

New York has the largest Medicaid budget in the United States—slightly more than $52 billion in FY 2010—and 27% of the population is enrolled, which is the fourth highest proportion among states.

Total Population 19,541,453 307,006,550

Total Medicaid Enrollment 5,208,135 62,692,693

Percent of Population Enrolled in Medicaid 27% 20%

Total Medicaid Spending (State and Federal)* $52,122,037,794 $389,084,333,952

Per Enrollee Medicaid Spending $8,960 $5,527

Per Capita Medicaid Spending $2,388 $1,129

* Total spending is for FY 2010.

SOURCE: The Kaiser Family Foundation State Health Facts and The Kaiser Family Foundation, “Why Does Medicaid Spending Vary Across States: A Chart Book of Factors Driving State Spending,” November 2012. Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2009 Medicaid Statistical Information System; 2009 population estimates for states from the U.S. Census Bureau.

NOTE: Medicaid enrollment is based on data for FY 2009. Population data estimates are for July 1, 2009.

—31—


New York’s Overall and per Capita Spending on Medicaid Is High

New York United States

—32—


Total Annual Medicaid Spending per Enrollee, FY 2009

New York Has the Third-Highest Medicaid Spending per Enrollee Among States

$6,000

$12,000

$10,000

$4,000

$2,000

$8,000 U.S., $5,527

N.Y., $8,960

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NOTE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2009 Medicaid Statistical Information System and Centers for Medicare & Medicaid Services CMS-64 reports, 2012. Spending includes both state and federal payments to Medicaid. These figures represent the average (mean) level of payments across all Medicaid enrollees. Spending per enrollee does not include disproportionate share hospital payments.

—33—


Medicaid Spending Per Capita, FY 2009

New York Has the Second-Highest Medicaid Spending per Capita Among States

$1,500

$3,000

$2,500

$1,000

$500

$2,000

U.S., $1,129

N.Y., $2,388

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SOURCE: The Kaiser Family Foundation, “Why Does Medicaid Spending Vary Across States: A Chart Book of Factors Driving State Spending,” November 2012.

NOTE: Medicaid spending and enrollment figures from Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2009 Medicaid Statistical Information System (MSIS) and Centers for Medicare & Medicaid Services CMS-64 reports, 2012. 2008 MSIS was used for Pennsylvania, Utah, and Wisconsin, because 2009 data was unavailable. State Population - Table 1. Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico: April 1, 2000 to July 1, 2009 (NST-EST2009-01), U.S. Census Bureau, Population Division, released December 2009.

—34—


New York’s Medicaid Spending on Aged and Disabled Enrollees Is Among Highest in the Nation, and

Is Driving New York’s High Spending per Enrollee

$10,000

$5,000

$15,000

$20,000

$25,000

$30,000

$35,000

$29,881

$22,494

$15,840

$13,149

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NOTE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2009 Medicaid Statistical Information System and Centers for Medicare & Medicaid Services CMS-64 reports, 2012. The chart shows a sampling of states from all four quarters, representing a range of spending levels. Spending includes both state and federal payments to Medicaid. These figures represent the average (mean) level of payments across all Medicaid enrollees. Spending per enrollee does not include disproportionate share hospital payments.

Total per Capita Annual Medicaid Spending on Aged and Disabled Enrollees, FY 2009

Aged

Disabled

SOURCE: Center for Medicare & Medicaid Services, Health Expenditures by State of Residence, 2011.

NOTE: Hospital services include all services billed for by hospitals, including room and board, ancillary charges, services of resident physicians, inpatient pharmacy, and hospital-based nursing home and home health care. Physician services include all services provided by physicians and laboratories. Drugs and other medical nondurable equipment include prescription and nonprescription drugs and medical sundries. Nursing home, home health, and other personal care services include spending for Medicaid home- and community-based waivers; care provided in residential care facilities; ambulance services; school health; and work site health care. Dental and other professional services include care provided by private-duty nurses; chiropractors; podiatrists; optometrists; and physical, occupational, and speech therapists. Durable medical equipment includes retail sales of items such as contact lenses, eyeglasses, and other ophthalmic products; surgical and orthopedic products; hearing aids; and wheelchairs. For full definitions, see http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/quickref.pdf.

Nursing Home, Home Health, and Personal Care Are Contributing to the Differences

Between New York and U.S. Health Care Spending

New York per Capita Spending by Service, 2009 United States per Capita Spending by Service, 2009

Hospital Care

Physician and Clinical Services

Drugs and Other Medical Nondurables

Nursing Home, Home Health, and Other Personal Care

Dental and Other Professional Services

Durable Medical Equipment

2%1%

36%

14%

16%23%

7%

20%

36%

13%

8%

24%

—35—


*Dual-eligible for Medicare-Medicaid.

SOURCE: United Hospital Fund, “Medicaid Long-Term Care in New York: Variation by Region and County,” 2010.

NOTE: Almost all Medicaid enrollees age 65 and older are also enrolled in Medicare, and thus are considered dually eligible for these programs.

—36—


$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

Medicaid Long-Term Care Spending per Elderly Dual Recipient*, 2005

Medicaid Spending per Recipient of Long-Term Care Services Is Higher in Downstate Regions of New York

New York City Long Island Westchester/ Rockland

Upstate Urban Upstate Rural

Any Long-Term Care

Nursing Facility

Home Health

Personal Care

*Dual-eligible for Medicare-Medicaid.

SOURCE: United Hospital Fund, “Medicaid Long-Term Care in New York: Variation by Region and County,” 2010.

—37—


Percentage of Medicaid Elderly Dual Beneficiaries* Using Long-Term Care, by Region and Service, 2005

In New York City, Use of Nursing Facilities Is Less Common and Home Health Care Is More Common

0%

10%

20%

30%

40%

50%

60%

New York City Long Island Westchester/ Rockland

Upstate Urban Upstate Rural

Any Long-Term Care

Nursing Facility

Home Health

Personal Care

SOURCE: United Hospital Fund, “New York’s Nursing Homes: Shifting Roles and New Challenges,” 2013.

—38—


Percent of Elderly in Nursing Facilities (Age 85+)

Nursing Facility Use Has Declined for Oldest New Yorkers

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

2000 2005 2010

New York City

Rest of State

SOURCE: Physicians per capita data from Dartmouth Atlas. Evidence for relationship between more physicians and higher spending from Fisher, E.S., et. al., “The Implications of Regional Variations in Medicare Spending. Part 1: The Content, Quality, and Accessibility of Care,” Annals of Internal Medicine, Feb. 18, 2003.

NOTE: Physician counts are estimated from rates and population and are not exact. District of Columbia is excluded.

—39—


New York Is Among States with the Most Physicians and Specialists per Capita

200

150

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300States with more physicians and a higher proportion of specialists tend to have higher spending on health care.

Specialists as a Share of all Physicians by State, 2006 (Physicians per 100,000)

Specialists Nonspecialists

SOURCE: The Kaiser Family Foundation State Health Facts. AHA Annual Survey Copyright 2012 by Health Forum LLC, an affiliate of the American Hospital Association, special data request, April 2012. Population data from Annual Population Estimates by State, U.S. Census Bureau, available at http://www.census.gov/popest/. NOTE: Data include staffed beds for community hospitals, which represent 85% of all hospitals. Federal hospitals, long-term care hospitals, psychiatric hospitals, institutions for the intellectually disabled, and alcoholism and other chemical dependency hospitals are not included.

Mississippi

—40—


New York Is Above Average in Total Hospital Admissions

100

250

200

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150U.S., 114N.Y., 129

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New York is ranked 13th in hospital admissions per 1,000 people and 13% above the national average.

Hospital Admissions per 1,000 Population, 2010

SOURCE: Apprise Health Insights, Community Hospital Units by State (2011), with data from the American Hospital Association 2011 Survey of Hospitals.

—41—


New York Has the Third-Highest Length of Stay for Inpatient Admissions

2

3

4

5

8

7

1

6 U.S., 4.97N.Y., 6.06

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New York’s average length of stay, the third highest nationally, is 22% above the national average.

Average Length of Stay (Days)

SOURCE: Dartmouth Atlas of Health Care, Hospital Care Intensity Index and Inpatient Days in the Last Two Years of Life, 2010.

NOTE: The Hospital Care Intensity Index is computed by comparing each hospital’s utilization rate, which is based on the number of days patients spend in the hospital and their total physician visits, with the national average and adjusting for age, sex, race, and severity of illness.

—42—


New York Medicare Beneficiaries Have Second-Highest Use of Inpatient Hospital Care in Last Two Years of Life

0.4

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1

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0

National Average

New York hospital inpatient days for Medicare enrollees in the last two years of life totaled 23.9 on average in 2010, the most of any state, compared to the national average of 16.7 days and exceeding the 90th percentile of 18.6 days.

Hospital Care Intensity Index for Beneficiaries in the Last Two Years of Life, by State, 2010

Despite high admission rates, longer lengths of stay, more outpatient visits, and higher emergency department use in New York’s hospitals, mortality rates are relatively low compared with the national average.

—43—


New York Hospitals Exhibit Comparatively Low Mortality Rates

Heart Attack 59%

Heart Failure 60%

Pneumonia 52%

ConditionPercent of New York Hospitals with

Medicare Risk-Adjusted 30-Day Mortality Rates Better than the U.S. Median

SOURCE: Centers for Medicare & Medicaid Services, Hospital Compare Database, https://data.medicare.gov/data/hospital-compare, July 2013.

SOURCE: The Kaiser Family Foundation State Health Facts. AHA Annual Survey Copyright 2012 by Health Forum LLC, an affiliate of the American Hospital Association, special data request, April 2012. Population data from Annual Population Estimates by State, U.S. Census Bureau, available at http://www.census.gov/popest/.

NOTE: Data include staffed beds for community hospitals, which represent 85% of all hospitals. Federal hospitals, long-term care hospitals, psychiatric hospitals, institutions for the intellectually disabled, and alcoholism and other chemical dependency hospitals are not included.

—44—


New York’s Rates of Hospital Admissions and Bed Counts Have Declined, but Remain Above the National Average

100 0

135 4

1152

110

1.5

105

1

0.5

1202.5

1253

130 3.5

1999

Hos

pita

l Bed

s

Hos

pita

l Adm

issi

ons

2000 2001 2002 2003 2004 2005 2006 20102007 2008 2009

The number of inpatient hospital beds declined in New York from 1999 to 2010, mirroring national trends, while New York’s hospital admission rates decreased less than national rates.

N.Y. Hospital Admissions Per 1,000 Population

U.S. Hospital Admissions Per 1,000 Population

N.Y. Hospital Beds Per 1,000 Population

U.S. Hospital Beds Per 1,000 Population

Hospital Admissions and Beds, per 1,000 Population, 1999–2010

N.Y. Hospital Outpatient Visits per 1,000 Population

N.Y. Hospital Inpatient Days per 1,000 Population


NOTE: Data include staffed beds for community hospitals, which represent 85% of all hospitals. Federal hospitals, long-term care hospitals, psychiatric hospitals, institutions for the intellectually disabled, and alcoholism and other chemical dependency hospitals are not included.

—45—


Hospital Outpatient Visits and Inpatient Days, per 1,000 population, 1999–2010

Outpatient Visits Have Increased and Inpatient Days Have Fallen in New York

2,100 800

2,900 1,100

2,500

1,000

2,400

950

2,300

2,200

900

850

2,600

2,700

2,8001,050

1999

New

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its

2000 2001 2002 2003 2004 2005 2006 20102007 2008 2009


—46—


New York Hospitals Provide a Substantial Amount of Outpatient Care

0New York United States

3,000

1,500

1,000

500

2,000

2,500

2,7672,106

31% Higher than U.S. AverageWhile the State is slightly above average in its number of inpatient visits, it is more significantly above average in outpatient hospital use.

New York has reduced inpatient admissions, and outpatient hospital visits continue to grow.

Hospital Outpatient Visits per 1,000 Population, 2010


NOTE: Data are for 2009. Readmissions data from Deborah Chollet, Allison Barrett, and Timothy Lake, “Reducing Hospital Readmissions in New York State: A Simulation Analysis of Alternative Payment Incentives,” Mathematica Policy Research, September 2011. District of Columbia is not included.

—47—


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U.S., $2,475N.Y., $2,949

$4,500

$4,000

$3,500

$3,000

$2,500

$1,500

$500

$2,000

$1,000

New York Has the 13th-Highest Hospital Spending per Capita

New York’s per capita hospital spending is 19% above the national average.

All readmissions in New York—nearly 274,000 hospital stays for all patients in 2008—cost $3.7 billion. Readmissions for avoidable costs occurred in 3.9% of initial hospital stays and cost $1.3 billion out of the total of $3.7 billion.

Hospital Spending per Capita, 2009

The Bronx has the highest regional rates for 30-day medical and surgical readmissions in the nation, at 18.1% and 18.3%. Part of this variation likely reflects the different medical needs of residents of these areas.

Surgical readmission rates show wider variation than medical readmissions.

—48—


Hospital Readmission Rates Vary Across New York State; the Bronx Has Highest Rates in Nation

National Average 15.9% 12.4%

Bronx 18.1% 18.3%

Manhattan 17.3% 16.0%

East Long Island 16.7% 16.3%

Rochester 16.6% 12.5%

White Plains 16.1% 17.4%

Binghamton 16.0% 10.8%

Albany 16.0% 15.2%

30-Day Medical Readmissions

30-Day Surgical Readmissions

SOURCE: Robert Wood Johnson Foundation, “The Revolving Door: A Report on U.S. Hospital Readmissions,” February 2013.

NOTE: The authors note that “efforts to draw firm conclusions about the causes of specific differences in readmission rates among hospitals or regions—or of changes over time—are challenged by the multiple factors that can influence inpatient severity of illness, the settings to which patients are discharged, and the effectiveness of post-discharge care coordination. It is also important to recognize that readmission rates and early follow-up visits are only indirect measures of the effectiveness of care coordination. Better measures, such as patient reports of their care experiences or health outcomes, are not yet widely available.”

New

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Nev

ada

Mis

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Okl

ahom

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Col

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Geo

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Wis

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New

Jer

sey

New

Mex

ico

Mic

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Flo

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Ala

bam

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Was

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Ohi

o

Mas

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uset

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Min

nes

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Lou

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Ore

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Nor

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Idah

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Cal

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Pen

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10.50%

8.9%$14,640

SOURCE: Jeff Lemieux and Teresa Mulligan, “Trends in Inpatient Hospital Prices, 2008 to 2010,” American Journal of Managed Care, published online March 6, 2013.

NOTE: Data from MarketScan for the commercially insured population under the age of 65; calculations by the authors. Average prices were defined as the average of insurer-paid reimbursements plus patient cost-sharing obligations. Not all states are included because MarketScan restricts the publication of information to states or localities where the data include a sufficient number of respondents to maintain the confidentiality of the employers and health insurance plans that contribute data.

—49—


Rapid Growth of Hospital Prices in New York May also Help Explain Cost Trends

$0 -2%

$25,000

$15,000

$20,000

$10,000

$5,000

12%

10%

6%

4%

2%

0%

8%

Aver

age

Ann

ual G

row

th

Aver

age

Pric

e pe

r H

ospi

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dmis

sion

New York had the highest absolute growth in average prices per hospital admission from 2008 to 2010, at 10.5%, and the third highest after adjusting for intensity of services (i.e., the use of more procedures or more complex procedures per admission), at 8.9%. These prices are the amount agreed to between insurers and providers.

Nationally, prices for inpatient hospital care grew from 2008 to 2010, even after adjusting for intensity. However, prices and their growth varied widely among states and locally.

Average Price per Admission, 2010 Average Annual Growth, 2008–2010 Intensity Adjusted Price Growth

New York is one of 29 states receiving an F grade on health care price transparency laws from Catalyst for Payment Reform in 2013.

SOURCE: Catalyst for Payment Reform and the Health Care Incentives Improvement Institute, “Report Card on State Price Transparency Laws,” March 2013.

—50—


New York Ranks Poorly on Health Care Price Transparency

G R A D E

A B C D F

—51—


Price-Standardized Medicare Spending per Beneficiary—a Measure of Service Utilization—Is Below the U.S. Average in All Regions of New York

Rochester ($174) 0%

Bronx ($166) 1%

Buffalo ($166) 1%

Syracuse ($131) 6%

Binghamton ($121) 8%

Elmira ($117) 8%

Albany ($97) 14%

New York City (Manhattan, Brooklyn, Staten Island) ($51) 31%

White Plains (northern suburbs) ($17) 46%

East Long Island (Long Island and Queens) ($15) 47%

New York Hospital Referral Regions (HRRs)*

Monthly Spending Below the U.S. Average

Percentile Rank Among 306 HRRs

* Hospital referral regions (HRRs)—Created by Dartmouth to represent regional health care markets for tertiary (complex) medical care. Dartmouth Atlas Project defined 306 HRRs by assigning hospital service areas to regions where the greatest proportion of major cardiovascular procedures were performed, “with minor modifications to achieve geographic contiguity, a minimum total population size of 120,000, and a high localization index.”

SOURCE: Committee on Geographic Variation in Health Care Spending and Promotion of High-Value Care, Institute of Medicine, “Variation in Health Care Spending: Target Decision Making, not Geography,” July 2013.

NOTE: Price standardization removes payments associated with local wage differentials, graduate medical education, and disproportionately poor patients, thereby distilling differences due to utilization.

GETTING MORE BANG FOR THE BUCK: THE QUALITY QUESTION

S E C T I O N

—52—


—53—


Getting More Bang for the Buck: The Quality Question

Despite high spending, hospital quality in New York is similar to U.S. averages.

New York ranks poorly on several measures of avoidable hospital use and costs.

In New York, an individual hospital’s costs show no consistent relationship to quality.

97.1% 97.7% 97.0%98.0%

96.0% 95.8% 95.8% 95.9%97.1% 97.5%

SOURCE: WhyNottheBest.org, “Quality - Overall Recommended Care,” data for Q3 2011-Q2 2012. Data are from the Centers for Medicare & Medicaid Services (CMS).

NOTE: Medical record, all patients 18 years old and older, all-payer. These totals reflect a combined 31 measures that capture how often hospitals delivered recommended care processes in the following four areas: heart attack, heart failure, pneumonia, and surgical care improvement. This includes 13 legacy measures, which CMS has retired and for which hospitals are no longer required to report data.

—54—


Overall Recommended Hospital Care Score

Despite High Spending, New York Is Similar to the United States on Overall Hospital Quality

70%

75%

80%

85%

90%

95%

100%

Overall Recommended Care Overall Heart Failure Care Overall Surgical CareOverall Heart Attack Care Overall Pneumonia Care

New York National Average

SOURCE: Commonwealth Fund, Health System Data Center. Data from D. McCarthy, S. K. H. How, C. Schoen, J. C. Cantor, D. Belloff, “Aiming Higher: Results from a State Scorecard on Health System Performance, 2009,” The Commonwealth Fund, October 2009.

Hospital admissions for pediatric asthma per 100,000 children 35 253.5 2005

Percent of adult asthmatics with an emergency room or urgent care visit in the past year 31 21.2 2001–2004

Medicare hospital admissions for ambulatory care sensitive conditions per 100,000 beneficiaries 40 7,269 2006–2007

Medicare 30-day hospital readmissions as a percent of admissions 29 18.3 2006–2007

Percent of long-stay nursing home residents with a hospital admission 34 20.6 2006

Percent of short-stay nursing home residents with a hospital readmission within 30 days 35 22.5 2006

Percent of home health patients with a hospital admission 49 39.3 2007

Hospital Care Intensity Index, based on inpatient days and inpatient visits among chronically ill Medicare beneficiaries in last two years of life 50 1.322 2005

Total single premium per enrolled employee at private-sector establishments that offer health insurance

38 $4,638 2008

Total Medicare (Parts A and B) reimbursements per enrollee (higher-spending states get higher numerical rankings) 51 $9,564 2006

Potentially Avoidable Hospital Use and Cost of Care—New York Overall Rank: 50th N.Y. Rank State Rate Year

New York Fares Poorly on Several Measures of Avoidable Hospital Use and Costs

—55—


Centers for Medicare & Medicaid Services (CMS) Hospital

Compare Summary Quality Scores, Overall

Total Medicare Reimbursements per Decedent, as a Ratio to

the National Average

SOURCE: Dartmouth Atlas, Total Medicare Reimbursements per Decedent in the Last Two Years of Life, 2010 (extracted from CMS data), and CMS Hospital Compare Quality Summary Score by New York Hospital, 2007.

NOTE: Each bar represents a hospital in New York State. Only hospitals for which both quality scores and total Medicare reimbursements are available are included.

—56—


Individual Hospital Medicare Payments Show No Consistent Relationship to Quality Scores

75% 0

100%

90%

95%

85%

80%

2

1.8

1.4

1.2

1

0.8

0.6

0.4

0.2

1.6

Qua

lity

Scor

es

Med

icar

e R

eim

burs

emen

ts

Hospital Medicare Reimbursement as Compared to Quality Scores

SOURCE: National Committee for Quality Assurance, The State of Health Care Quality: Focus on Obesity and Medicare Plan Improvement, October 2012.

—57—


Comprehensive Diabetes Care: Good Glycemic Control (HbA1c<7% for a selected population), 2011

New York Health Plans Exhibit High-Quality Diabetes Care

0%

10%

5%

15%

20%

25%

30%

35%

40%

45%

50%

Commercial HMO MedicaidCommercial PPO

United States

New York

SOURCE: National Committee for Quality Assurance, The State of Health Care Quality: Focus on Obesity and Medicare Plan Improvement, October 2012.

—58—


Follow-Up After Hospitalization for Mental Illness: Within Seven Days Post-Discharge, 2011

New York Health Plans Exhibit High-Quality Mental Health Follow-Up Services

0%

20%

10%

30%

40%

50%

60%

70%

80%

Commercial HMO Medicare PPOCommercial PPO Medicaid HMO Medicare HMO

United States average

New York average

CONCLUSION

S E C T I O N


—59—

—60—


Conclusion

Health care costs in New York State are high and growing.

Health care costs are reflected in high health insurance premium expenses for businesses and their workers, which adversely affect wages, employment, and economic growth.

Despite high levels of spending, New York does not consistently demonstrate better quality of care.

There are gaps in publicly available data on health care costs in New York.

Improved data access and price transparency could enable purchasers and consumers to make better-informed decisions about the cost and quality of providers and services, and stimulate payment innovations.

Further payment reforms can drive better outcomes and lower spending.

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Improving the state of New York’s health

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Health Care Costs and Spending in Nwe YorkS eatt · Services, health care spending by states and localities increased 10% in 2011, and consumed a larger share of revenues—about