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Creating a Cost-map From Claims Data to Guide Improvement Actions for Children With Asthma

Abstract

Purpose

It is difficult to reduce cost and improve quality without knowledge pertaining to the distribution of expenses in the population in question. We describe the process of creating a “costmap” using claims data to both confirm the selection of and define the key drivers to reduce cost and improve care in pediatric patients with asthma.

Methods & Materials

The Johns Hopkins Adjusted Clinical Groups (ACG®) System was used to evaluate 12 months of medical and pharmaceutical claims data for children (4-18 years) in a commercial value-based plan between1/1/2022 and 12/31/2022. Data was categorized by Resource Utilization Band (RUB): 0 non-user, 1healthy user, 2 low-morbidity, 3 moderate morbidity, 4 high morbidity, & 5 very high morbidity. We selected the top 3 chronic conditions with the highest prevalence in RUBs 4 and 5 as potential target areas for cost reduction. Medical and pharmaceutical were then evaluated to define potential key drivers of cost reduction.

Results

3,285 members were categorized into RUBs 4 (n=2,756) and5 (n=529) out of a total 40,022 members. Asthma was one of the top three chronic conditions with the highest prevalence in RUBs 4 & 5 (RUB 4: 21%, n=571; RUB 5: 24%, n=127) and was therefore selected as an area for improvement. Evaluation of expenditures was performed on the 698 asthma patients in RUB 4 & 5. These patients had a total expenditure of $9.3M [average per member per year (PMPY) expense of $13,361 ± $44,254]. 27 of those patients with extremely high-cost comorbidities (malignancy, cystic fibrosis, tracheostomy, cerebral palsy) accounted for 37% of total expenditures ($3,449,571; Average PMPY $127,762 ± $182,934). After excluding those 27members, the average PMPY for the final asthma cohort was $8,757 ± $13,786 (n=671). Outpatient expenditures ($4,429,346) accounted for 75% of total costs, followed by inpatient ($966,491; 16%)and pharmacy ($480,075; 8%). Top outpatient expense categories included clinic visits($1,193,530; $1,779 PMPY), Emergency Department (ED) visits ($538,828 total, $803 PMPY),outpatient procedures ($835,695 total, $1,245 PMPY), and outpatient behavioral health ($718,484total, $1,071). Outpatient procedures were determined not to be specific to asthma. The most influenceable target for action for this cohort of asthma patients was determined to be reduction of ED visits.

Conclusions

Cost mapping of claims data was a useful tool in both selection of asthma as an area for potential cost reduction as well as guiding actions to focus cost-reduction and improvement efforts