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

Overview of Presentation About CHCS How Medicaid Can Help P 2 “Raise All Boats” Medicaid Innovations How CHCS Can Help P 2 Improve Quality and Equity in Care

About Us…

4 CHCS Mission To 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 P 2 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 P 2 “Raise All Boats”

8 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 spending 44% of all federal funds to states Federal Spending 16% of national health spending 44% 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

9 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

10 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.

11 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 Solo2-3 PCPs 4-10 PCPs 10+ PCPsFQHCs AR 1 32%15%26%18%9% MI 1 24%29%25%8%14% PA 1 29%21%22%14%13% Solo2-5 PCPs 6-20 PCPs21-70 PCPs70+ PCPs FQHCs Bronx, NY 2 16%7%6%2%25%44% Erie Co, NY 2 13%22%14%35%11%5% 1 Practice identification based on site address 2 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)

20 Reducing Disparities at the Practice Site DisparitiesSmall 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

22 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 Changes State/Plan Supports 24 Track and document diabetic patients and outcomes using electronic data management tool Adopt and incorporate EBG for diabetes Incorporate QI feedback loops into ongoing practice operations 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 24 Provide timely and aggregated diabetes performance data to practices Registry or other electronic tracking system Tools for evidence-based diabetes care Leadership commitment to business not as usual Encourage culturally and linguistically competent patient self-management Provide support for culturally and linguistically competent patient self- management Assess Outcomes Using HEDIS/AQA Diabetes Measures Tools/training for culturally and linguistically competent self-management Tools/training for culturally and linguistically competent self-management Changes to QI System Changes to Care Delivery Shared Practice Site Improvement Coach 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 P 2 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 P 2 ’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 P 2 ? 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 P 2 ? 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

35 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 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.

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