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Improving Quality and Reducing Disparities in Care
through Enhancing Medicaid’s Involvement in
P2 Collaborative
Nikki Highsmith, Senior Vice PresidentCenter for Health Care Strategies
May 7, 2009
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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CHCS MissionTo 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
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
CHCS Technical Assistance for AF4Q
Performance Measurement and
Reporting
Consumer Engagement
Ambulatory Quality Improvement
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Why Medicaid?
State Spending
25% of state budgets spent on Medicaid
State Spending
25% of state budgets spent on Medicaid
MEDICAID$361 billion annual cost
MEDICAID$361 billion annual cost
Federal Spending
16% of national health spending44% of all federal funds to states
Federal Spending
16% of national health spending44% of all federal funds to states
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 )
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 )
*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
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.
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
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
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
Distribution of Medicaid Beneficiaries Across Practice Size: Results from PSEP
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 address2 Practice identification based on TIN
Percent of Beneficiaries Linked to Practice Settings
• 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
Reducing Disparities at the Practice Site (RDPS)
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Reducing Disparities at the Practice Site
Disparities Small Practices
Chronic Care Improvement in
Medicaid
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– > 500 Medicaid patients– > 60% racially/ethnically diverse patients– > 50 diabetics– Gaps in performance based on HEDIS scores
Quality Improvement Support at the Practice Site
Practice ChangesPractice ChangesState/Plan SupportsState/Plan Supports
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Track and document diabetic patients and outcomes using electronic data management tool
Track and document diabetic patients and outcomes using electronic data management tool
Adopt and incorporate EBG for diabetes Adopt and incorporate EBG for diabetes
Incorporate QI feedback loops into ongoing practice operations
Incorporate QI feedback loops into ongoing practice operations
Provide funding/financial incentives directly linked to QI and diabetes care supports and changes
Provide funding/financial incentives directly linked to QI and diabetes care supports and changes
Select and support implementation of evidence-based guidelines (EBG) for diabetes
Select and support implementation of evidence-based guidelines (EBG) for diabetes
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Provide timely and aggregated diabetes performance data to practices
Provide timely and aggregated diabetes performance data to practices Registry or other electronic tracking systemRegistry or other electronic tracking system
Tools for evidence-based diabetes careTools for evidence-based diabetes care
Leadership commitment to business not as usualLeadership commitment to business not as usual
Encourage culturally and linguistically competent patient self-management
Encourage culturally and linguistically competent patient self-management
Provide support for culturally and linguistically competent patient self-management
Provide support for culturally and linguistically competent patient self-management
Assess Outcomes Using HEDIS/AQA Diabetes MeasuresAssess Outcomes Using HEDIS/AQA Diabetes Measures
Tools/training for culturally and linguistically competent self-management
Tools/training for culturally and linguistically competent self-management
Ch
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Shared Practice Site Improvement Coach Shared Practice Site Improvement Coach
Incorporate team-based care into ongoing diabetes care delivery
Incorporate team-based care into ongoing diabetes care delivery
Shared Nurse Care Manager (or other clinical or social service professional )Shared Nurse Care Manager (or other clinical or social service professional )
RDPS Step 3 – QI Support Package
• 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
RDPS Step 4 – “Boots on the Ground”
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
Performance Measurement and Public Reporting
• Supporting efforts to bring Medicaid fee-for-service data and race/ethnicity/language data to P2’s performance measurement and reporting efforts– Increasing completeness of physician’s panel
performance– Increasing ability to stratify performance by R/E/L – Increasing ability to identify practices that could
benefit from QI support
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
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
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
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
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
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
Visit CHCS.org to…
Download practical resources 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 Medicaid’s highest-risk, highest-cost members.
www.chcs.org