Minnesota Medical Home Project: Evaluation Feasibility Study

1

Minnesota Medical Minnesota Medical Home Project: Home Project:

Evaluation Feasibility Evaluation Feasibility StudyStudy

Saturday, June 7, 2008 Saturday, June 7, 2008

SHRIG Meeting, Academy Health SHRIG Meeting, Academy Health

DRAFT2

What is a Medical Home Model of Care?

Healthy People 2010 Measures• Family/Professional Partnership• Comprehensive Health Care• Access to Health Insurance/Financing• Early/Continuous Screening• Access to Community Services• Transition to Adult Life

Minnesota Medical Home Project• Coordination of Care

DRAFT3

Who are Children with Special Health Care Needs (CSHCN)?

Era Terminology Scope

1930s-60s Crippled Children

Orthopedic impairments

1970s-80s Handicapped Children

Above plus developmental disabilities, other physical conditions

1990s

(Newacheck PW, 2007)

Children with Special Health Care Needs

Above plus emotional and behavioral conditions

DRAFT4

Children with Special Health Care Needs……..

”…have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally (DHHS, 2004).”

DRAFT5

What is the Minnesota Medical Home Project (MMHP)?

• Goal: provide comprehensive patient-centered care to children with special health care needs

• MNCSHN Section, MN Department of Health + partners

• Formed in 2004 with 11 primary care teams from practices around Minnesota

• Healthy People 2010 Objective 16-23

6

MN MN Medical Medical Home:Home:

20 Teams 20 Teams and and

GrowingGrowing……Slide credit: Carolyn Allshouse, MCSHCN/MDH

DRAFT7

MMHP Evaluation Components:

1) Family Perception Survey

2) Medical Home Index - MDH/MCSHN

3) Time Study - DHS/PMQI

4) 2001/2005 National CSHCN Survey

5) Evaluation Feasibility Study – DHS/PMQI

DRAFT8

What is an Evaluation Feasibility Study?

Determine whether the impact of the medical home model of care on the health service utilization and costs of care of Medicaid-enrolled children with special health care needs is feasible to assess.

Impact = More Appropriate Care

DRAFT9

Study Participants

Medical Home children (n = 513)

intervention group; identified by providers

9 clinics throughout Minnesota

Two comparison groups of CSHCN identified from

Minnesota Medicaid administrative data

“Internal”: same clinics, different MDs (n = 732)

“External”: no contact with Project (n = 15,042)

DRAFT10

Study Inclusion Criteria

0-18 years old

CSHCN status identified by a Project provider or by Minnesota Health Care Programs’ (MHCP) administrative claims data

enrolled for a minimum of one month per year in MHCP; all 3 years of the study

DRAFT11

Analysis Methods

Repeated measure mixed design multivariate regression analysis

Re-run analysis on random sample of the comparison groups

All statistical models controlled for differences in age, gender, race/ethnicity, metro/non-metro status, parental marital status, and health status across study groups.

DRAFT12

Preliminary Results

13DRAFT

Severity Weight Across Time by Study Group

0

0.2

0.4

0.6

0.8

1

1.2

Baseline (03/01/03-01/29/04) Year 1 (03/01/04-02/28/05) Year 2 (03/01/05-02/28/06)Study Period

Ave

rag

e A

CG

v6.

0-B

ased

Sev

erit

y W

eig

ht

External; n = 15042

Internal; n = 732

Medical Home; n = 513

14DRAFT

Severity Across Years for Most Healthy (Bottom 50%tile)

in Baseline Year

0

0.1

0.2

0.3

0.4

0.5

0.6

Baseline(03/01/03-01/29/04)

Year 1(03/01/04-02/28/05)

Year 2(03/01/05-02/28/06)

AC

G S

erv

eri

ty W

eig

ht

External; n = 7973 Internal; n = 333

Medical Home; n = 225

15DRAFT

Severity Across Years for Middle Percentile (GT 50 - LT 75)

in Baseline Year

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Baseline (03/01/03-01/29/04)

Year 1 (03/01/04-02/28/05)

Year 2 (03/01/05-02/28/06)

AC

G S

ever

ity W

eigh

t

External; n = 2315 Internal; n = 138 Medical Home; n = 55

16DRAFT

Severity Across Years for

Most Severe/Chronic (Top 25%tile) in Baseline Year

0

0.5

1

1.5

2

2.5

Baseline (03/01/03-01/29/04)

Year 1 (03/01/04-02/28/05)

Year 2 (03/01/05-02/28/06)

AC

G S

ever

ity W

eigh

t

External; n = 4754 Internal; n = 261 Medical Home; n = 233

17DRAFT

Health Condition Over Time

Association with Intervention StatusOdds Ratio (95% CI)

Measure:Health Condition Worsening Between Baseline Year and Year 2

Results: Total Population

Comparison Group 0.4 (0.3 to 0.5)

Medical Home Group Reference (Odds Ratio = 1)

Results: Only the “Healthy” Children in the Baseline Year

Comparison Group 0.3 (0.2 to 0.4)

Medical Home Group Reference (Odds Ratio = 1)

DRAFT18

Medical Home Children: PMPM Inpatient Admissions

Hypothesized effect of the intervention

Observed direction Year 2 – Baseline -28.55 admissions per

1000 member months

Significant? yes, p = <.0001

19DRAFT

Inpatient Admissions by Study Group (PMPM Adjusted Rate)

0

0.01

0.02

0.03

0.04

0.05

0.06

Baseline (03/1/03-02/29/04)

Year 1 (03/01/04-02/28/05)

Year 2 (03/01/05-02/28/06)

Study Period

PM

PM

Ad

just

ed R

ate

External Sample n=513

Internal Sample n=513

Medical Home Sample n=513

DRAFT20

Medical Home Children: PMPM Emergency Department Visits

Hypothesized effect of the intervention

Observed direction Year 2 – Baseline -8.0 visits per

1000 member months

Significant? no, p = .418

21DRAFT

Emergency Department Visits by Study Group (PMPM Adjusted Rate)

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

Baseline (03/1/03-02/29/04) Year 1 (03/01/04-02/28/05) Year 2 (03/01/05-02/28/06)Study Period

PM

PM

Ad

just

ed R

ate

External Sample n=513

Internal Sample n=513

Medical Home Sample n=513

DRAFT22

Medical Home Children:PMPM Well Child Visits

Hypothesized effect of the intervention

Observed direction Year 2 – Baseline -68.5 visits per

1000 member months

Significant? yes, p = <.0001

23DRAFT

0

0.05

0.1

0.15

0.2

0.25

Baseline (03/1/03-02/29/04) Year 1 (03/01/04-02/28/05) Year 2 (03/01/05-02/28/06)

Study Population

PM

PM

Ad

just

ed R

ate

External Sample n=513

Internal Sample n=513

Medical Home Sample n=513

Well Child Visits by Study Group (PMPM Adjusted Rate)

DRAFT24

Medical Home Children:PMPM Dental Visits

Hypothesized effect of the intervention

Observed direction Year 2 – Baseline +23.7 visits per

1000 member months

Significant? no, p = .813

25DRAFT

Dental Visits by Study Group (PMPM Adjusted Rate)

0

0.02

0.04

0.06

0.08

0.1

0.12

Baseline (03/1/03-02/29/04) Year 1 (03/01/04-02/28/05) Year 2 (03/01/05-02/28/06)

Study Population

PMPM

Adj

uste

d R

ate

External Sample n=513

Internal Sample n=513

Medical Home Sample n=513

26DRAFT

Any Well Child Year 2 Visit:

PredictorsOdds Ratio (95% CI)

Intervention Status

External Controls 0.9 (0.8 to 1.10)

Internal Controls 1.0 (0.8 to 1.3)

Medical Home Reference (Odds Ratio = 1)

Baseline PMPM Rate 8.5 (6.7 to 11.0)

Interaction Terms

Study Group X Age Group Wald Chi-Sq p=.004

Study Group X Baseline PMPM Wald Chi-Sq p=.05

27DRAFT

Any Well Child Year 2 Visit:

Intervention Effect by AgeOdds Ratio (95% CI)

Intervention effect for ages 0 – 24 months

External Controls 0.5 (0.4 to 0.9)

Internal Controls 0.6 (0.3 to 1.02)

Medical Home Reference (Odds Ratio = 1)

Intervention effect for ages 2 – 6 years

External Controls 0.7 (0.5 to 0.998)

Internal Controls 1.06 (0.7 to 1.7)

Medical Home Reference (Odds Ratio = 1)

28DRAFT

Any Dental Year 2 Visit:

PredictorsOdds Ratio (95% CI)

Intervention Status

External Controls 0.8 (0.6 to 0.9)

Internal Controls 0.8 (0.6 to 1.06)

Medical Home Reference (Odds Ratio = 1)

Baseline PMPM Rate 25.5 (19.2 to 40.0)

Race/Ethnicity

All other 0.7 (0.7 to 0.8)

White, Non-Hispanic Reference (Odds Ratio = 1)

29DRAFT

Inpatient Admissions by Enrollee Care Plan Status

PMPM rate over time; medical home participants only; overall PMPM rate is not adjusted

0

0.02

0.04

0.06

0.08

0.1

0.12

Baseline (03/1/03-01/29/04) Year 1 (03/01/04-02/28/05) Year 2 (03/01/05-02/28/06)

Study Period

PM

PM

Adju

ste

d R

ate

No Care Plan n = 294

Care Plan Developed n = 219

Overall Rate n = 513

30DRAFT

Emergency Department Visits by Enrollee Care Plan Status

PMPM rate over time; medical home participants only; overall PMPM rate is not adjusted

0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

Baseline (03/1/03-01/29/04) Year 1 (03/01/04-02/28/05) Year 2 (03/01/05-02/28/06)

Study Period

PM

PM

Ad

juste

d R

ate

No Care Plan; n = 294

Care Plan Developed; n = 219

Overall Rate; n = 513

31DRAFT

Professional Services

77%

Long-Term Care - 0%

Dental - 1%

Med Supplies 1%Inpatient - 10%

Pharmacy - 9%

Outpatient 2%

Fee-For-Service PMPM Costs: All Study Groups

Percent by Category of ServiceMarch 1, 2003 - February 28, 2006

*Only children with 4+ months FFS enrollment in each study year

32DRAFT

0

500

1000

1500

2000

2500

3000

3500

BL YR1 YR2 BL YR1 YR2 BL YR1 YR2

External Internal Medical Home

Study Groups Across Evaluation Periods

PM

PM

Re

imb

urs

em

en

ts

Professional Services

InPatient

Pharmacy

OutPatient

Medical Supplies

Dental

Fee-For-Service PMPM Costs by Category of Service and Study Group

March 1, 2003 - February 28, 2006

*Only children with 4+ months FFS enrollment in each study year.

33DRAFT

Fee-For-Service PMPM Costs: All Study Groups By Age of Child at Baseline

*All Categories of Service except long-term care

*Only children with 4+ months FFS enrollment in each study year.

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Mar 1, 2003 - Feb 29, 2004 Mar 1, 2004 - Feb 28, 2005 Mar 1, 2005 - Feb 28, 2006

Study Periods

Un

ad

jus

ted

PM

PM

Re

imb

urs

em

en

ts

0-2 year old2-6 year olds7-12 year olds13-18 years old

34DRAFT

Fee-For-Service PMPM Costs: All Study Groups By Severity of Condition at Baseline*All Categories of Service except long-term care

*Only children with 4+ months FFS enrollment in each study year.

0

500

1000

1500

2000

2500

3000

3500

Mar 1, 2003 - Feb 29, 2004 Mar 1, 2004 - Feb 28, 2005 Mar 1, 2005 - Feb 28, 2006

Study Period

Un

ad

jus

ted

PM

PM

Av

era

ge

Re

imb

urs

em

en

t

3_Most Severe

2_Moderate Chro

1_Minor Chronic

4_Healthy/Acute

35DRAFT

Any Year 2 Health Services: Association with Medical Home Clinics

Any InpatientAdmissions

Any Emergency Department Visits

Medical Home Site

Care Coordinator Hours

Odds Ratio (95% CI)

Odds Ratio (95% CI)

Clinic A 0 4.72 (1.35 to 16.58) 0.60 (0.15 to 2.36)

Clinic B 4 3.65 (1.75 to 7.61) 1.19 (0.66 to 2.13)

Clinic C 5 2.62 (0.97 to 7.03) 0.42 (0.16 to 1.09)

Clinic D 16 1.85 (1.13 to 3.03) 1.33 (0.98 to 1.81)

Clinic E no CC 1.52 (0.33 to 7.11) 0.94 (0.32 to 2.73)

Clinic F no CC 1.16 (0.14 to 9.56) 0.48 (0.11 to 2.17)

Clinic G 24 0.95 (0.32 to 2.78) 1.70 (0.89 to 3.27)

Clinic H 0 0.78 (0.36 to 1.65) 1.74 (1.23 to 2.45)

Clinic I no CC ----- ----- ----- 0.90 (0.28 to 2.87)

All Non-MMHP Sites Reference Reference

36DRAFT

Inpatient Admissions by Medical Home Status of Clinics

*overall PMPM rates are not adjusted

-0.02

0

0.02

0.04

0.06

0.08

0.1

0.12

BL YR1 YR2

Study Period

PM

PM

Adj

uste

d R

ate

n = 54

n = 15n = 17

n = 13

n = 39n = 33

n = 13n = 185

n = 144

overall non-MH; n = 15774overall MH; n = 513

37DRAFT

Emergency Department PMPM Visits by Medical Home Status of Clinics

*overall PMPM rates are not adjusted

0

0.02

0.04

0.06

0.08

0.1

0.12

Baseline (03/1/03-01/29/04) Year 1 (03/01/04-02/28/05) Year 2 (03/01/05-02/28/06)

Study Period

PM

PM

Ad

jus

ted

Ra

te

n = 54

n = 15

n = 17

n = 13

n = 39

n = 33

n = 13

n = 185

n = 144

overall non-MH; n = 15774

overall MH; n = 513

38

Preliminary Results: Potential Impact

Rates decreased over time IP Admissions Medical supply claims (steepest for MH)

Increased likelihood of any Year 2

dental visits

well-child visits for 0-6 year olds

Care plans associated with decreased IP admissions

39

Preliminary Results: Learnings

“Appropriate care” measures multiple categories of servicedo not look at utilization/cost in isolation

CSHCN ascertainment methodology initial comparison group analysis

More standardization and/or data needed from the medical home teams

40

Preliminary Analysis: Limitations

Selection Bias

Outcomes defined as cost and/or utilization offsets rather than quality of life, other externalities

Exposure Misclassification and Measurement Error

Administrative Data

41

Preliminary Results: Feasibility?

Can the medical home program

be evaluated using

administrative data?

Answer:

Only provides a partial picture…..

42

Future Research Directions

Revise control group ascertainment method

Relative weight analysis to better evaluate the overall impact of the MMHP

Develop CSHCN-specific performance measures

Standardize and measure medical home “exposure”

Evaluate the sensitivity/specificity of administrative data for CSHCN

43

Acknowledgements

Funding Source/Grant Number

MNDHS and MCSHCN/MDH staff (Jon Huus, Jeff Tenney, Greg Gifford)

Medical home teams and participants

Tonga Nfor, MD

44

Authors: Muree Larson-Bright, PhDAuthors: Muree Larson-Bright, PhD Susan CastellanoSusan Castellano Tonga Nfor, MDTonga Nfor, MD

Minnesota Department of Human ServicesMinnesota Department of Human ServicesPerformance Measurement and Quality Performance Measurement and Quality

ImprovementImprovementMaternal and Child Health AssuranceMaternal and Child Health Assurance

651.431.2635651.431.2635muree.larson-bright@state.mn.usmuree.larson-bright@state.mn.us