New York State Vision for Women and Children’s Health Care Hudson Valley Regional Perinatal Forum October 25, 2007 Foster Gesten, MD Medical Director Office of Health Insurance Programs

Vision Medical home –Coverage and access Medical home improvement –Evidence based care –Decision supports –Patient/family engagement Improved health outcomes –Reduced/eliminated disparities Value

New York’s Medicaid Program Accounts for Nearly One-Third of All Health Care Expenditures in the State Commercial Insurance/Self Pay $79.0B (49%) Medicaid $48.7B (31%) Medicare $27.0B (17%) Public Health $5.5B (3%) Source: 2007 Health Care expenditures projected by DOB using actual 2004 data from the CMS, Office of the Actuary, National Health Statistics Group; 2007 NYS Economy projected by DOB based on NYS Personal Income data.

Medicaid Covers Over 4 million New Yorkers Over 85% of Medicaid enrollees are from working families Over 1.8 million children (CHPlus covers another 390,000 children) Medicaid covers one-half of all births

Medicaid Reform: Guiding Principles To operate Medicaid with the vision and discipline required of a health insurer that covers 4.5 million New Yorkers and does so with public resources exceeding $48 billion. –To ensure continuity of coverage. –To purchase value (high quality / fair cost). –To prevent waste and fraud. To leverage Medicaid’s role in the health care market place in order to advance universal coverage and reform New York’s health care delivery system.

Universal Coverage Starts with Medicaid, FHPlus & CHPlus

One Half of the Uninsured are Eligible for Medicaid, FHPlus or CHPlus 36% 27% 15% 22%Less than 100% FPL % FPL %FPL Over 300% FPL 2.5 Million Uninsured

Reforming the Eligibility Process and Eligibility Standards Began in Last Year’s Budget Elimination of documentation at renewal 12-month continuous for adults Expansion of CHPlus eligibility to 400% of the Federal Poverty Level FHPlus buy-in for employers

Reforming the Medicaid Eligibility and Renewal Process will Continue in This Year’s Budget As will Reform of Payment and Quality Standards

Medicaid is Becoming a Smart Purchaser The right care The right standards The right setting The right price

NY’s Health Care and Medicaid Expenditures are Among the Highest in the Nation New York’s health care spending per capita is among the highest in the nation. New York’s per enrollee MA spending is the highest in the nation, and almost triple that of California. Notes: (1) Computed using data from Health Affairs 26, no. 6 (2007) (2) Computed using data from CMS and the Kaiser Foundation Total Per Capita Health Care Spending By State of Residence (2004) 1 Total Per Enrollee MA Spending (2004) 2

Relationship between costs and quality?

The Quality of Ambulatory Care Delivered to Children in the US Mangione-Smith, et al, in NEJM, October 11, 2007 On average, children received about 46% of indicated care Varied from 92% to 34%, depending on clinical area evaluated Deficits in care are similar (although somewhat lower) than those found for adults

New York State’s Health System Ranks 22 nd Nationwide, Lags Even Further in Quality

New York State Rankings 28 th in Nation in percent low birth weight 17 th in Nation in percent preterm births –Annie E. Casey Foundation/Kids Count 26 th in Nation in percent of children vaccinated 37 th in Nation in percent of children with emotional/behavioral/developmental problems receiving mental health care 32 nd in Nation in hospital admissions for pediatric asthma 13 th in Nation in infant mortality –Commonwealth Fund State Scorecard

Improving Value Means Expanding Affordable Coverage Investing in Primary and Preventive Care Coordinating and Managing Care Improving Clinical Outcomes and Patient Safety Improving Transparency and Accountability Strengthening Program Integrity

Coordinating Care Improves Quality Based on Study Conducted in 2000

Children’s Preventive Care (2005) * Well care data for Medicaid and Dental Visit data from 2006.

Perinatal Health Prenatal Care Birth outcomes NICU Disparities PCAP

Women’s Prenatal Care (2006) *Not collected for Commercial.

Women’s Perinatal Health (2005) *A low rate is desirable.

Women’s Prenatal Care Commercial Medicaid

Low Birth Weight Adjusting for demographic, clinical and social risk factors: –In Medicaid Managed Care, Black women are 2.5 times more likely to have a LBW delivery, compared to White women. –In commercial managed care, Black women are 2.3 times more likely to have a LBW delivery, compared to White women.

2005 Upstate NYS Women with a current preterm or low birthweight (LBW) delivery There were 18,012 cases of preterm (<37 weeks) or LBW (<2500g) delivery, or 14.5% of all payers. –5.6% of these 18,012 cases had a previous preterm delivery – as indicated on the birth certificate. There were 6,680 cases of preterm or LBW delivery, or 15.4% for Medicaid (FFS/MMC). –7.2% of these 6,680 cases had a previous preterm delivery – as indicated on the birth certificate.

2005 Upstate NYS Medicaid (FFS/MMC) Women with a previous preterm delivery 27% had a current low birthweight delivery (<2500g) as compared to 23% for total payer. 32% had a current preterm delivery (<37 weeks) which was the same for total payer (32%). 7% had a current very preterm delivery (<32 weeks) as compared to 6% for total payer. 65% received prenatal care in the first trimester as compared to 77% for total payer. A women is 3X (OR 3.1) more likely to have a LBW infant if there is a previous preterm birth

What is Promising? Aggressive, systematic identification of high risk with associated care coordination and management of medical and psychosocial factors –Healthy Babies (Philadelphia) –Healthy Beginnings (Monroe Plan) –Others: Alpha Maxx (Tennessee)

Healthy Beginnings Identification –Mandatory prenatal registration form with payment incentive Stratification –Coordination between perinatal health and behavioral health Outreach –Use of internal and external/community outreach Intervention –Targeted psychosocial intervention to high risk teens –Care management software to coordinate/support activities Results –Nearly 50% reduction in NICU admissions –ROI of ~2.5

Creating a Statewide Approach Medicaid has an important leadership role/opportunity We can do better Identification and Coordination are key –Within health plans –For women in FFS Pilot project –Draft registration form –Internal and external stakeholders –Budget and infrastructure

Percent Admission to the NICU – All NYS Births by Payor Multiples removed

NICU Mortality Vermont Oxford Network CMS Improvement Initiative NICU Module of SPDS VS/SPARCS Matched File –Adjusting for relevant clinical variables, how much variation in mortality do we see? –How might this relate to health disparities? –How do we best support improvement?

Medicaid NICU Costs (2005 SPARCS) ~11.6% of deliveries result in NICU admits Account for ~50% of delivery costs Average DRG for NICU $17,622 vs $2427 for non-NICU stay

Note: White, Black, Asian and Hispanic categories are mutually exclusive. Source: NYS Department of Health, Bureau of Biostatistics

Notes: 1)White, Black, Asian and Hispanic categories are mutually exclusive. 2)Unknowns are excluded. Source: NYS Department of Health, Bureau of Biostatistics

Note: White, Black, Asian and Hispanic categories are mutually exclusive. Source: NYS Department of Health, Bureau of Biostatistics.

Note: White, Black, Asian and Hispanic categories are mutually exclusive. Source: New York State Department of Health, Bureau of Biometrics

Role of PCAP Managed care enrollment –But over 60% of pregnant women spend some part of their pregnancy in FFS –How do plans and providers best coordinate care for high risk women? Frozen rates for over 10 years –Budget initiatives to improve funding for primary, preventive care Challenges –Obesity –Services not in rate (17P) –Mental health –Preconception care

Focus Investment in primary, preventive care Coordination –Benefits –Providers –Programs Home visiting programs Intensive case management of high risk

Vision Medical home –Coverage and access Medical home improvement –Evidence based care –Decision supports –Patient/family engagement Improved health outcomes –Reduced/eliminated disparities Value