1. 1 RIte Care’s Culture of Continuous Improvement Based on Research & Data Analysis Presentation to Academy Health- State Health Research and Policy Interest Group By Melinda Thomas Project Manager, RI Affordable Health Care Project RI Department of Human Services June 25, 2005

2. 2 Overview Understanding the Culture Applying Research and Data Analysis Lessons Learned

3. 3 Understanding the Culture

4. 4 Culture of Continuous Improvement Approach Set Goals Identify measurable indicators Establish a baseline Implement Program Intervention Monitor Trends Evaluate impact Make midcourse corrections

5. 5 Culture of Continuous Improvement Environment –Insist on data driven policymaking and program design –Focus on data-based decision making prevents decision making based on anecdotes and bias, which can be divisive and result in bad programs –Openness to participation in data analysis and discussion at all levels. “If you’re interested, you’re welcome” –Encouragement & support of any effort made to apply data analysis & research to program development –Openness to critique– “seen as an opportunity for improvement” –Respect for different standards and motivations of policy & program staff and academic researchers

6. 6 Cultural of Continuous Improvement Spanning Boundaries* Policymakers/Program Staff –Ease with generalization –Pragmatic –“Bias for Action” * Based on Steve Shortell presentation at 2002 Academy Health Policy Conference Researchers –Emphasis on scientific rigor –Stand- up to scrutiny –Long timeline

7. 7 Applying Research & Data Analysis

8. 8 RIte Care Created in 1994 under Medicaid R&D waiver with the following goals: 1.Reduce uninsurance for low-income children and families 2.Improve access, service quality and health status for the covered population 3.Control the rate of growth in Medicaid expenditures for the eligible population

9. 9 Goal 1 : Reduce uninsurance for low-income children and families

10. 10 RIte Care Enrollment Growth RIte Care Implemented Aug 94 Enrolled: -TANF Families - Children 0 to 60 yrs. Up to 250% FPL -Pregnant Women up to 350% FPL Enrollment Expansions Outreach May 97 Expanded to children 8 to 18 yrs. Up to 250% FPL April 99 – June 00 RIte Care Outreach Project July 99 Expanded to undocumented alien children and children up to 19 yrs. April 96 Expanded to children 6 to 8 yrs. Up to 250% FPL Nov 98 Expanded to parents up to 185% FPL Oct 98 Mail-in application information Oct 99 -Market Changes: -Rate Changes -HPHC Closes July 00 Health Care Reform RI 2000 signed into law Dec 00 Foster children transfer from fee- for-service to RIte Care May 01 RIte Share mandatory enrollment begins Begin 3% Premium share collection for 4,805 families and Direct Member Reimbursement for RIte Share Feb 01 RIte Share voluntary enrollment begins ChildAdult Dec-95Jun-96Dec-96Jun-97Dec-97Jun-98Dec-98Jun-99Dec-99Jun-00Dec-00Jun-01Dec-01Jun-02Dec-02Jun-03Oct-03 Total70,81971,36771,07672,99375,48475,21574,85386,61894,510104,041106,554111,624117,185117,024117,507119,257121,335 Child47,45448,66248,88450,32152.04252,20852,04656,62861,53367,63869,25472,81776,37976,08576,15176,95778,394 Adult23,36522,70522,19222,67223,44223,00722,80729,99032,97736,40337,30038,80740,80640,93941,35642,30042,941 Sept 03 Begin enrollment of Children with Special Needs Aug-02 Begin 5% Premium share collection Jun 02 RIte Share enrollment tops 2,000 Nov 03 RIte Share enrollment tops 5,000

11. 11 Percent Uninsured Rhode Islanders All Ages-1994-2003 Data Source: Medicaid Research and Evaluation Project, RI Access Project US Bureau of the Census, Current Population Surveys 1994-2003 (September estimates) 4th5th4th1st Tied 1 st National Ranking 8th6thTied 3 rd 2nd

12. 12 Percent Uninsured Rhode Island Children < 18 Years Old - 1994-2003 Data Source: Medicaid Research and Evaluation Project, RI Access Project US Bureau of the Census, Current Population Surveys 1994-2002 (September estimates) 2nd1st2nd3rd1st3rd National Ranking 8th25th2nd

13. 13 RI saw a Decrease in Employer Sponsored Coverage 2000-2003 Erosion in employer-based coverage has resulted in an increase in the state's uninsurance rate. In 2000, 77.7% of the population was covered by employer-based insurance and that percentage decreased to 68.4% in 2003.

14. 14  Rhode Island’s RIte Care strategy reduced uninsurance rates significantly through 2000 and helped contain the increase between 2000 and 2003  Since 2000 strategy is focused on stabilizing caseload and preventing erosion in employer sponsored health care  RIte Share – 6000 members, half the cost  Access to affordable health care for small employers and their employees RIte Care Strategy

15. 15 RIte Share Stabilizes Growth in RIte Care

16. Goal 2: Improve access, service quality and health status for the covered population

17. 17 Oversight and monitoring of Health Plan contracts site visits encounter data analysis Health Plan Performance incentives Trend access, quality and health outcome indicators for all enrollees Methods

18. 18 Performance Incentive Program Three types of performance goals: –Access –Clinical –Administrative Performance goals were selected to represent: –key areas of Health Plan performance - age and gender of the RIte Care population Use of HEDIS measures plus other measures specific to the population, such as lead screening

19. 19 Performance Category 199920002001200220032004 Administrative 60.1%71.5 %65.9 %83.7 %79.8 %74.8% Access 65.7 %61.8 %44.0 %73.2 %75.8 %81.5% Clinical 63.1 %57.8 %68.2 %68.6 %65.8 %59.5% Overall63.3 %62.0 %60.6 %73.2 %71.6 %69.2% Percent of Potential Incentive Payments Received by the Health Plans by Years Shows Significant Overall Improvement

20. 20 Percent of Potential Incentive Payments Received by Health Plans Over Six Years

21. 21 Six-year Trend of Performance Incentive Payments Shows Overall Improvement

22. 22 Monitoring Trends

23. 23 Percent of Women with Short Interval Births (<18 months) by Insurance Status 1993-2002 Data Source: Medicaid Research & Evaluation Project Vital Statistics Birth File 1993-2001 – (n=111,865)

24. 24 Percent of Women who Received Adequate/Adequate+ Prenatal Care by Insurance Status 1993-2002 Data Source: Medicaid Research & Evaluation Project Vital Statistics Birth File 1993-2001 – (n=111,865)

25. 25 RIte Care Lead Screening Rates Improve Percent of Two Year Olds with Timely Recommended Screening *** * GAO report + NHANES estimates ** Patrick Vivier, MD, Phd, 1997

26. 26 Comparison of Lead Screening and Lead Poisoning Rates for RIte Care and Commercially Insured Children Enrolled in the Same Managed Care Organization 2003 MeasureCommercialRIte Care Lead Screening Percent Ever Screened 87 %88 % Percent Never Screened 13 %12 % Lead Poisoning Percent ≥ 10 ug/dL 7 %17 % Percent < 10 ug.dL 93 %83 % Source: O’Hare, C. et. al. Lead Screening and Lead Poisoning in Medicaid and Commercially Insured Children Enrolled in the Same Managed Care Organization, American Public Health Association Poster Session, 2003.

27. 27 Immunization Rates for Children Enrolled in RIte Care Exceed the National Average Immunization Rates for 19- to 35-month-olds: US, RI and to RIte Care Overall*DtaP%Hib%Hepatitis B%MMR%Polio% National (CDC) 7681938491 Rhode Island (CDC) 818996879596 RIte Care818794889195 *Overall status includes all vaccines except hepatitis B Source: Vivier P.M. et. al. “An analysis of the immunization status of pre-school children enrolled in a statewide Medicaid Managed Care Program,” The Journal of Pediatrics, 139(5), November 2001, 624-629.

28. 28 Infant Mortality Rate Declines in Rhode Island Infant Mortality by Insurance Status 1990-1999 1990-1999 Data Source: Medicaid Research & Evaluation Project Center for Child & Family Health, Department of Human Services Linked Birth Death File 1990-99, Division of Family Health, Department of Health (n=905) Deaths per 1000 births to Infants 0-364 days – 3 year moving average

29. 29 Rhode Island’s Neonatal Mortality Rate Declines Neonatal Mortality by Insurance Status 1990-1999 1990-1999 Data Source: Medicaid Research & Evaluation Project Center for Child & Family Health, Department of Human Services Linked Birth Death File 1990-99, Division of Family Health, Department of Health (n=905) Deaths per 1000 births to Infants 0-364 days – 3 year moving average

30. 30 Rhode Island’s Postneonatal Mortality Rate Declines for Publicly Funded Births Rhode Island Postneonatal Mortality by Insurance Status 1990-1999 1990-1999 Data Source: Medicaid Research & Evaluation Project Center for Child & Family Health, Department of Human Services Linked Birth Death File 1990-99, Division of Family Health, Department of Health (n=905) Deaths per 1000 births to Infants 0-364 days – 3 year moving average

31. 31 Goal 3: Control the rate of growth in Medicaid expenditures for the eligible population

32. 32 RIte Care: Cost-Efficient RIte Care: Cost-Efficient “ A few states have revamped their organizational and management systems to ensure better access to medical care while keeping costs under control. Rhode Island stands out in this respect.” Governing Magazine, Feb 2004

33. 33 Lessons Learned

34. 34 “Lessons for other States” Building Quality into RIte Care: How RIte Care is Improving Health Care for Its Low-Income Populations by Sharon Silow-Carroll* Start Early to Establish a Baseline Use the Data in a Variety of Ways Integrate Research into the Medicaid Program Use Interdisciplinary Team Ensure Access to Data Acknowledge Trade-offs in Subsidizing Private Health Coverage Supplement Research and Evaluation with Outside Funding Monitor Long Term Goals *Field Report, The Commonwealth Fund, January 2003