Improving Quality and Reducing Disparities in Care through Enhancing Medicaid

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Improving Quality and Reducing Disparities in
Care through Enhancing Medicaids Involvement in
P2 Collaborative

• Nikki Highsmith, Senior Vice President
• Center for Health Care Strategies
• May 7, 2009

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Overview of Presentation

• About CHCS
• How Medicaid Can Help P2 Raise All Boats
• Medicaid Innovations
• How CHCS Can Help P2 Improve Quality and Equity
  in Care

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About Us
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CHCS Mission

• To improve health care quality for low-income
  children and adults, people with chronic
  illnesses and disabilities, frail elders, and
  racially and ethnically diverse populations
  experiencing disparities in care.
• CHCS Priorities
• Improving Quality and Reducing Racial and Ethnic
  Disparities
• Integrating Care for People with Complex and
  Special Needs
• Building Medicaid Leadership and Capacity

• National Reach
•   47 states (including all AF4Q communities)
• 160 health plans

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Aligning Forces for Quality (AF4Q) Initiative

• CHCS is one of eight entities supporting George
  Washington University (National Program Office)
• Working with AF4Q alliances, including P2
  Collaborative, to improve quality, reduce
  disparities in care, and raise all boats in 15
  regions/communities across the country

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CHCS Technical Assistance for AF4Q
Performance Measurement and Reporting
Ambulatory Quality Improvement
Consumer Engagement
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How Medicaid Can Help P2 Raise All Boats
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Why Medicaid?

• Health Insurance Coverage
• 30 million children
• 15 million adults in low-income families
• 14 million elderly and persons with disabilities
• 8.8 million aged and disabled dual eligibles
  (19 of Medicare beneficiaries )

MEDICAID 361 billion annual cost
Federal Spending 16 of national health
spending 44 of all federal funds to states
State Spending 25 of state budgets spent on
Medicaid
Numbers are not additive. Source Kaiser
Commission on Medicaid and the Uninsured, 2008
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Medicaid By the Numbers
67 million People in the U.S. who will receive Medicaid benefits in 2009
364 billion Estimated 2009 costs for Medicaid
1 million Additional Medicaid/SCHIP beneficiaries resulting from a 1 increase in unemployment
11-29 State residents covered by Medicaid
46 Adult Medicaid beneficiaries who have more than one chronic condition
50 Medicaid beneficiaries under age 65 who are racially and ethnically diverse
60 Medicaid recipients who are enrolled in managed care
Source Congressional Budget Office Source
Centers for Medicare and Medicaid Services
Source Kaiser Commission on Medicaid and the
Uninsured
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Medicaid Data Resources

• State Medicaid agencies are a good source of
• Data on beneficiary race and ethnicity, mostly
  collected at the point of eligibility
• Some data on language of beneficiary and
• Performance data, used for monitoring and
  ensuring quality care through public reporting at
  the plan level.
• State Medicaid agencies are increasingly able to
  aggregate and share performance information at
  the practice and/or provider level.

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Medicaid QI Infrastructure Opportunities for
Synergies

• Quality improvement resources
• State and health plan staff
• External quality review organizations (EQROs)
• Area Health Education Centers (AHECs)
• Other (e.g., contractors, universities, etc.)
• State requirements around QI (e.g., performance
  data collection and submission, public reporting,
  etc.)
• Increasing investment in primary care QI at the
  point of care

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What else does Medicaid bring to the table?

• Beyond data, leadership, and resources, Medicaid
  offers
• Access to and well-established relationships with
  safety net providers
• Leverage over health plans
• An entrée to other state resources state
  employee health coverage, policy makers,
  departments of health and insurance, etc.

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Medicaid Innovations Performance Data and
Reporting
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Medicaid Lead Regional Quality Improvement

• Rochester, New York
• Chart reviews and claims analysis for diabetes
  performance aggregated across Medicaid and
  commercial payers
• Arkansas
• Medicaid and commercial payers aggregating claims
  data at the county level on diabetes, prevention,
  and other measures

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Regional Quality Improvement (continued)

• North Carolina
• Data warehouse of claims, clinical and other data
  aggregated across payers (lead by Medicaid) for
  QI feedback loop for primary care practices
• Rhode Island
• Multi-payer patient centered medical home pilot
  with 5 primary care practices
• Aggregating performance data across payers at
  practice site and providing QI support

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Medicaid Innovations Ambulatory Quality
Improvement
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Practice Size Exploratory Project (PSEP)

• Participants from AR, MI, NY, and PA
• Goals
• To describe the distribution of practice settings
  (i.e., solo/small, medium, large, FQHCs) serving
  the Medicaid population, and
• To explore the relationship between practice size
  and performance for HEDIS measures.
• Findings
• Small practices play a critical role in caring
  for Medicaid beneficiaries
• Smaller practices are more challenged by chronic
  care, as opposed to access.
• Persistent racial/ethnic disparities exist across
  majority of measures

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Distribution of Medicaid Beneficiaries Across
Practice Size Results from PSEP
Percent of Beneficiaries Linked to Practice
Settings
Solo 2-3 PCPs 4-10 PCPs 10 PCPs FQHCs  
AR1 32 15 26 18 9  
MI1 24 29 25 8 14  
PA1 29 21 22 14 13  
 
Solo 2-5 PCPs 6-20 PCPs 21-70 PCPs 70 PCPs FQHCs
Bronx, NY2 16 7 6 2 25 44
Erie Co, NY2 13 22 14 35 11 5
1 Practice identification based on site address 2
Practice identification based on TIN
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Reducing Disparities at the Practice Site (RDPS)

• Goal To reduce disparities in diabetes care in
  high volume, high opportunity primary care
  practices
• Four state Medicaid teams NC (Fayetteville
  area), MI (Detroit), OK (statewide), and PA
  (Philadelphia)
• 3-year initiative (with 9-month planning phase)
• Testing new models of practice site improvement
  in small, low resource primary care practices

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Reducing Disparities at the Practice Site
Disparities
Small Practices
Chronic Care Improvement in Medicaid
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RDPS Step 1 Identification of High Volume, High
Opportunity Practices

• States able to aggregate data across plans and
  identify practices based on the following general
  criteria
• 5 or fewer providers
• gt 500 Medicaid patients
• gt 60 racially/ethnically diverse patients
• gt 50 diabetics
• Gaps in performance based on HEDIS scores

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Pennsylvania RDPS Ability to Collect Performance
Measures at the Practice Site
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RDPS Step 2 Outreach to Practices
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RDPS Step 3 QI Support Package
Practice Changes
State/Plan Supports
Quality Improvement Support at the Practice Site
Leadership commitment to business not as usual
Provide timely and aggregated diabetes
performance data to practices
Registry or other electronic tracking system
Track and document diabetic patients and outcomes
using electronic data management tool
Changes to QI System
Select and support implementation of
evidence-based guidelines (EBG) for diabetes
Tools for evidence-based diabetes care
Adopt and incorporate EBG for diabetes
Incorporate QI feedback loops into ongoing
practice operations
Shared Practice Site Improvement Coach
Provide funding/financial incentives directly
linked to QI and diabetes care supports and
changes
Shared Nurse Care Manager (or other clinical or
social service professional )
Incorporate team-based care into ongoing diabetes
care delivery
Provide support for culturally and linguistically
competent patient self-management
Tools/training for culturally and linguistically
competent self-management
Changes to Care Delivery
Encourage culturally and linguistically competent
patient self-management
Assess Outcomes Using HEDIS/AQA Diabetes Measures
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RDPS Step 4 Boots on the Ground

• Quality improvement coaches entering practices
  and conducting practice assessments
• Implementing and populating registries
• Analyzing and sharing performance with practices
• Nurse care managers providing support to complex,
  high need, high risk patients
• Convening learning collaboratives with practices

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Insights from Initial Implementation

• Practice support
• Most feared (but most needed) registry/EMR
• Most wanted nurse care management
• Most unknown practice facilitator
• Most likely to be needed payment
  incentives/payment reform

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How CHCS Can Help P2 Improve Quality and Equity
in Care
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Performance Measurement and Public Reporting

• Supporting efforts to bring Medicaid
  fee-for-service data and race/ethnicity/language
  data to P2s performance measurement and
  reporting efforts
• Increasing completeness of physicians panel
  performance
• Increasing ability to stratify performance by
  R/E/L
• Increasing ability to identify practices that
  could benefit from QI support

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How is CHCS Supporting P2?

• Meeting with NY State Medicaid staff for access
  to fee-for-service and R/E/L data
• Offering TA as needed around measurement and
  reporting
• Providing small seed grants to help support P2
  efforts

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Ambulatory Quality Improvement

• Exploring opportunities for state Medicaid agency
  and health plan collaboration around ambulatory
  QI activities
• Using performance data to identify and outreach
  to high-opportunity primary care practices
• Leveraging state Medicaid and health plan
  resources and align activities

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Supporting the Primary Care Wave

• Concerns
• Pipeline of primary care professionals
  (internists, family practice, pediatricians,
  nurse practitioners)
• Opportunities
• Medical home and practice support demonstrations
• ARRA HIE/HIT investments
• Payment reform
• National health care reform

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How is CHCS Supporting AF4Q Alliances?

• Seeking ambulatory QI synergies across regional
  health plans
• Supporting design and development of practice
  site improvement project for AF4Q
• Offering TA as needed
• Providing small seed grants and financial
  incentives to physicians

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Equity in Care

• Understanding how commercial health plans are
  collecting and using race, ethnicity and language
  information
• Enhance collection of information
• Enhance use of information for quality purposes

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How is CHCS Supporting P2?

• Assisting Alliances in assessing capacity of
  commercial plans to collect race, ethnicity, and
  language information in health plans with
  majority market share
• Offering TA as needed to improve collection of
  such data
• Providing small seed grants and financial
  incentives

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AF4Q Team Key CHCS Staff

• Nikki Highsmith, Co-Director
• Steve Somers, Co-Director
• Dianne Hasselman, Deputy Director
• Lindsay Palmer, Project Manager
• JeanHee Moon, R/E/L Manager
• Richard Baron, MD, Clinical Advisor
• Stacey Chazin, Communications
• Vincent Finlay, Project Scheduling and
  Administration

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to improve the quality and efficiency of Medicaid
services. Subscribe to CHCS eMail Updates to
find out about new CHCS programs and resources.
Learn about cutting-edge state/health plan
efforts to improve care for Medicaids
highest-risk, highest-cost members.
www.chcs.org
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Questions?