Sue Palsbo, PhD

AAHP Quality Conference: Health Plan Strategies with Clinical Impact

October 26, 2001

Acknowledgements

• Evaluation conducted by:

Susan Palsbo, PhD; Thilo Kroll, PhD;

Melissa McNeil, MSW, MS;

David Bauer, MPA. • RFP Shape:

Peter Fitzgerald, MSc (AAHP); Marian Parrott, MD, MPH (ADA).

• Funded by: The Commonwealth Fund

Presentation Outline

• Description of TOD

• History of the 3 Community Partnerships

• Evaluation Methodology

• Results

• Implications

Description of TOD

• Joint venture of ADA and AAHP

• 3 Components– Worksite interventions– National survey of diabetes programs– Community partnerships

• Accomplishments to date

Site DemographicsAlbuquerque1 Kansas

City2Westchester3

1. Demographics (2000)

a. Total population 713,000 838,886 923,000 % white 70.8% 76.7% 71.3% % Latino

420.3% 2.7% 9.7%

% African-American 2.8% 18.8% 14.2% % Asian – Pacific Islander 1.9% 1.3% 4.5% % Native American 4.2% 0.5% 0.3% b. Insurance composition

% Uninsured 26% 9% 16% % Medicaid 17% 13% 14% % Medicare 13% 13% 13% % Private 44% 65% 56% c. HMO penetration rates

Private 82% 55% 40% Medicaid 53% 43% 15% Medicare 29% 22% 18% Total market 49% 45% 27% d. Socioeconomic status

High school graduates, age 25+, 1990 82.1% 80.5% 81.0% Bachelor’s degree or higher, 1990 26.7% 20.0% 35.3% Homeownership rate, 2000 63.7% 64.6% 60.1% Median household income, 1997 $36,853 $46,602 (Clay)

$37,732(Jackson)

$55,040

Persons below poverty, 1997 14.6% 10.7% 9.3% % of Children below poverty, 1997 21.5% 16.2% 15.2% Foreign born population, 1990 5.3% 2.2% 18.1% % age 5+ who do not speak English “very

well”, 1990 8.3% 2.0% 9.6%

Persons age 65 and over, 2000 11.5% 12.1% 14.0% % population 16+ not in labor force, 1990 32.3% 31.3% 33.6% Persons per square mile, 2000 477 838 2133

2. Plan characteristics (MSA-wide)

a. Number of HMOs 4 18 14 b. Average plan age in years 16 11 16 c. Number based on group practice model 1 6 1

3. HMO Network reimbursement (MSA-wide) a. % Fee for service

PCP 58% 52% 84% Specialty 50% 80% 84%

b. % Capitation

PCP 9% 45% 10%

1 Bernallilo County

2 Clay and Jackson Counties. Total population for the MSA is 1,776,000.

3 Westchester County

4 Derived figure, by summing other racial categories and subtracting from 100%.

More Site Characteristics

b. % Capitation PCP 9% 45% 10% Specialty 5% 14% 10%

4. Physician characteristics a. Physicians/100,000

5311 251 668

b. Total active MDs, federal & non-federal,1998

2,216 2,108 6,165

c. Total active non-federal MDs, 1998 2,096 2,074 6,068 d. Total office-based MDs, non-federal, 1998 1,320 1,445 3,737 e. Total hospital-based MDs, non-federal,

1998482 404 1,427

f. Optometrists, 1990 68 95 114 g. Podiatrists, 1990 7 15 1405. Purchasers

a. Private nonfarm establishments with paidemployees, 1998

15,585 22,581 30,096

b. Class of worker

Private wage and salary 72.6% 80.8% 78.2% Government (state, local, federal) 19.8% 13.4% 14.5% Self-employed 7.2% 5.4% 7.0% Unpaid family 0.4% 0.3% 0.3% c. Presence and activity of purchaser

coalitionsNone. None. Some

6. Integration of delivery systems High Low Somewhathigh

7. Legislative and regulatory environment Moderate Active Very active State laws require insurers to provide

coverage for diabetic supplies, equipment,and/or out-patient management training

Yes All policiesand plansmust offer

Yes

8. Significant health organizations/opinionleaders

a. Number of integrated delivery systems 4 (+1 military) 7 (+1 military) 4 (+1 military) b. Number of hospitals 19 48 103 c. Number of medical schools 1 1 d. Hospital beds / 1000 2.7 4.4 4.4 e. HMO inpatient days/1000 (private) 211.4 180.4 252.7 f. HMO inpatient days/1000 (Medicare) 1228.4 1135.7 1945.9 g. CDC Diabetes Control Programs, 2000 Core Core Comprehen-

sive9. Statewide Diabetes deaths/100,000 (#rank),

199815 (#14) 14 (#19) 11 (#44)

Albuquerque1 KansasCity2

Westchester3

1 Bernallilo County

2 Clay and Jackson Counties. Total population for the MSA is 1,776,000.

3 Westchester County

Site CharacteristicsHMO/PPOpenetration

W K A

< 20% 20-49% 50%+

Medicare/Medicaidreimbursement

W K A

Mostly Fee-for-Service

Mixed Mostly capitated

IDNs W A, K

Rare Mixed Common

Physicianorganization

W K A

Fragmented Mixed Consolidated

Payer competition K A, WMild (few products,many actors)

Moderate Strong (manyproducts, few actors)

Employer coalition A W K

None Few members Many members

Albuquerque, NM

• Location

• Origin

• Interventions

• Accomplishments

Westchester County, NY

• Location

• Origin

• Interventions

• Accomplishments

Kansas City, MO

• Location

• Origin

• Interventions

• Accomplishments

Evaluation Methodology

• Formative

• Group and organizational theory

• Fuzzy set scoring

• 50 measures

Causal Complexity

Need

Composition

Governance

CoordinationIntegration Differentiation

Alignment

Market Characteristics

Index of Governance/Accountabilitya. Impetus to form partnershipb. Impetus to maintain the partnershipc. Involvement of AAHP 1. Initial 2. Continuousd. Involvement of ADA 1. Initial 2. Continuouse. Financial accountabilityf. Contributions by Partnersg. Continuous funding availableh. Funding for subprojectsi. Meeting coordinatorj. Clear decision making strategyk. Tracking progress towards objectives 1. Developed 2. Conducted.l. Outcome-oriented evaluation tools.m. Professionals used for evaluation.

Nature of the Problem Being Addresseda. Common mission or vision established.b. High motivation for competing organizations to: 1. Join partnership. 2. Participate in partnership.c. Agreement on problem definition.d. Development of clear goal setting strategies.

Partnership Compositiona. Participation of key players.b. Membership composition involves active public sector participation.c. A local champion or impetus occurred.d. Collaborative environment present at start-up.e. PRO is essential player.(Role of PRO).f. Core group present.

Index of Differentiationa. Homogeneous group at start up.b. Homogenous group on-going.e. Only selected players involved.f. Key player NOT involved.

Scored Characteristics

Coordination and Integrationa. Active meeting coordinator present.b. Local site coordinator present.c. Equal involvement of all participating members.d. Copes with difficulties/unsuccessful initiatives.e. Mutual sense of ownership or buy-in f. Partnership relies on formal contracts established.g. Partnership relies on informal agreements.

Index of Centrality -- (Importance)a. Internally there is a sense of accomplishment and contribution.b. Work of organization affected.c. Media/news coverage has occurred.d. Backing of the partnership from elected officials.e. Members have request for participation in at least one other partnership.f. Presence of dual agency representation.

Index of Alignmenta. Match between problems addressed and partnership composition.b. Match between partnership composition and community need/priorities.c. Match between partnership coordination of task/activities and structure of the partnership.

Index of Market StructureM1 HMO/PPO penetration of commercial marketM2 Number of HMOs in coreM3 % PCPs contracting with HMOs/PPOsM4 Legislative and regulatory environmentM5 Presence and activity of purchaser coalitionsM6 Collaborative environment present at start-up (from row 37, above).M7 % of plans with AAHP MembershipM8 Stability of HMO/PPO marketM9 Physician integration

Scored Characteristic

# values 0.0 = fully out

0.5 = neither out nor in 1.0 =fully in Hypothesis Comment.

Index of Governance/Accountability

a. Impetus to form partnership 7 None. Weak StrongNeed strong reason to establish partnership. Impetus was internal or external.

b. Impetus to maintain the partnership 7 None. Weak StrongNeed strong reason to maintain partnership. Evidence of sustainability.

c. Involvement of AAHP

1. Initial 7 Not present Weak Strong presenceSince involves healthplans, need AAHP at start.

2. Continuous 7 Not present Weak Always present

Since involves healthplans, need AAHP at every meeting.

d. Involvement of ADA

1. Initial 7 Not present Weak Strong presenceSince it is diabetes, need ADA to establish.

2. Continuous 7 Not presentPresent 1/2 the time Always present

Since it is diabetes, need ADA to maintain.

e. Financial accountability 7 Not presentAd-hoc tracking of expenses.

Complete financial statements. Need to "mind the store".

G2 Contributions by Partners 7 No publicSmall percentage

More than 25(?)%.

Need financial buy-in of public sector and private funds for public-private sector partnership. "Public" means external to participating health plans.

g. Continuous funding available 7 Not present Hinted at. Assured

Need assurance that partnership is a "going concern".

h. Funding for subprojects 7 Never Sometimes Always

Partnership needs to have the financial resources to continue operationalizing interventions. Distinguish between external Rx ??

i. Meeting coordinator 7 Not presentPresent 1/2 the time Always

Need coordinator to make the meetings happen and do follow-up.

j. Clear decision making strategy 7 None. Unclear Very clear

Need to have a clear decision making process so things are done. Consensus may be the strategy, or Robert's Rules of Order.

k. Tracking progress towards objectives

1. Developed 7 No system.Informal system. Comprehensive

Need process to show something is being accomplished.

2. Conducted. 7 No. Incomplete. Complete.

Need to monitor progress to measure success and/or take corrective actions.

l. Outcome-oriented evaluation tools. 7 None.Under discussion. Established.

Need to show that partnership has a reason to exist.

m. Professionals used for evaluation. 7 No. Yes.Only professionals can do an evaluation. Check article: why is this hypothesized?

Data coding dictionary to calibrate scores.Fuzzy set -- permits membership in the interval between 0 and 1 (p.6) Continuous values p.156.Characteristics of

Partnerships

Results- Degree of MembershipNeed

Common missionCommon motivation

all

K A W

CompositionAAHP or ADAKey players

AKW

K W A

Coordination & IntegrationActive meeting coord.Local site coordinatorMutual ownership

AWK

K A Wall

0fully out

0.5neither in nor out

1.0fully in

Results - Degree of MembershipAlignment

Match between problems addressed and partnership

compositionK AW

0fully out

0.5neither in nor out

1.0fully in

Market CharacteristicsStage of insurance mkt Collaborative environ% hlth plans AAHP

KW A

WK AA WK

OUTCOMEEstablishedSustained

AWKAWK

Conclusions• Requirements to establish:

1. Active coordinator

2. Contributions by each participant (in-kind or financial)

3. Neutral, outside party to convene the Partnership that is acceptable to all

4. Strong local champion

5. Agreement that there is a clear need for community-wide intervention

6. Willingness by participants to work on mutual objective

7. Relatively stable healthcare market

8. All key participants comprise small, core group

Conclusions

• Requirements to sustain:1. Accomplish a visible, clearly beneficial, low-

cost intervention within 12 months.

2. Local site coordinator.

3. Link up with external body that has, as its mission, working with physicians on quality.

Implications• TOD Community Partnerships are a good

model for industry-wide initiatives on chronic conditions and for developing interventions with community physicians.

• “Leveling the playing field” through collaboration, instead of risk adjustment, is good approach to encouraging investment in tackling chronic, disabling conditions.

Importance of Market Structure

• Market structure has a less important role in the creation of health community partnerships than has been found in prior research.

• Market structure is more important in determining the success of the quality intervention, particularly at the level of individual community physician.