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Improving Quality and Reducing Disparities in Care through Enhancing Medicaid’s Involvement in P 2 Collaborative Nikki Highsmith, Senior Vice President Center for Health Care Strategies May 7, 2009

Improving Quality and Reducing Disparities in Care through Enhancing Medicaid’s Involvement in P 2 Collaborative Nikki Highsmith, Senior Vice President

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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

About Us…

4

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

How Medicaid Can Help P2 “Raise All

Boats”

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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 Innovations: Performance Data and

Reporting

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

Medicaid Innovations: Ambulatory Quality

Improvement

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

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Pennsylvania RDPS: Ability to Collect Performance Measures at the Practice Site

RDPS Step 2 – Outreach to Practices

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

an

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s t

o Q

I S

ys

tem

Ch

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ge

s t

o C

are

De

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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

How CHCS Can Help P2 Improve Quality and Equity

in Care

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

Questions?