1. Translating Research for Health Policy Development Presentation to University of Medical Sciences of Bhutan Faculty of Nursing and Public Health March 13, 2015

2. Overview Translating research into policy: factors to consider Examples of how data have been used in Connecticut to inform state health policy development Strategies for effectively communicating research to policy makers

3. Stakeholders and Constituencies National and local government officials (elected and appointed) Government as payer for health care Health care institutions Individual health care consumers Advocates for special interest groups Health care providers

4. Values that Influence Policy Making Equity in access to care and outcomes Quality of care and accountability Personal responsibility Professional ethics Consumer sovereignty Privacy, confidentiality Informed consent Social welfare and cost to society Rationing

5. Process Challenges Research is intellectual, rational, time- intensive, and strives for objectivity. Policy making occurs in a political context, is reactive and relies on readily available information that is responsive to a particular question, viewpoint. Policy making is a process that involves negotiation and compromise

6. Political Challenges Research is only one factor that influences the political process and policy making. Policy making is incremental adjustments to competing pressures rather than a rational, goal-driven process. Threshold for government intervention into individual or family affairs may be high, even in the face of compelling evidence, and public investment may be low

7. Communication Challenges Researchers use complex methodology and statistics, present the findings in lengthy reports in discipline-specific language, and do not include specific recommendations or actionable conclusions. Even if researchers and policy makers share fundamental values, they may have very different goals, information needs, constituencies, time constraints, and tolerance for probability v. certainty

8. Using Data for Policy Development in Connecticut’s Health Insurance Program for Low Income Families

9. Connecticut’s HUSKY Program Publicly-funded health insurance for 450,000 children, parents, and pregnant women in low income families State-federal partnership (financing, administration) No cost-sharing for most families Coverage for all medically necessary care for children

10. Independent HUSKY Program Performance Monitoring Connecticut Voices for Children is a non- profit, non-partisan organization that conducts research and policy analysis on issues related to children and families in Connecticut Since 1995, state-funded performance monitoring in Connecticut’s HUSKY Program (health insurance for low income children, families, pregnant women

11. HUSKY Program Data Enrollment: Unique beneficiary number, name, date of birth, Social Security Number, address, gender, self-reported race/ethnicity, HUSKY Program coverage group – Records by month for all current enrollees – Longitudinal database for everyone ever enrolled Claims: Beneficiary number, date of service, procedure code, diagnosis code, provider identifiers

12. Claims are for asthma services for 1 person

13. Claims for services provided on one day

14. Current Procedural Terminology (CPT) codes for office-based services

15. Diagnosis codes for claims for asthma- related services

16. The National Drug Codes (NDC) for asthma medications

17. On another date of service, hospital emergency department visit for asthma care

18. Measures and Results Study enrollment and health services for continuously enrolled beneficiaries Report results in plain English, based on unadjusted rates and relative risk – If results show OR=2.95 (95% CI: 2.49-3.52)… – …we report “After taking into account age and gender, children with X were three times more likely to have Y.” Emphasize results that are meaningful in program and policy terms v. all statistically significant results

19. Data-Driven Policy Development: Examples from Connecticut Health insurance coverage: Informing efforts to increase enrollment of eligible children and improve retention Preventive care: Informing efforts to improve access to preventive care and reduce emergency visits Maternal health and birth outcomes: Informing efforts to improve care for mothers and babies

20. Quantifying Problems with Health Insurance Coverage …Not Enrolled the Following Month Comparison Age Groups Among babies enrolled in birthday month… After 1 st birthday After 5 th birthday After 10 th birthday 42% newborn coverage group 2% 6% all other coverage groups 20Connecticut Voices for Children

21. Four in Ten Babies in Newborn Group Lost Coverage When They Turned One 21Connecticut Voices for Children Source: CT Voices analysis of 2008-09 enrollment data from CT Department of Social Services.

22. More Evidence of Administrative Barriers …Not Enrolled the Following Month Comparison Age Groups Among adolescents enrolled in birthday month… After 18 th birthday After 10 th birthday After 15 th birthday 16% 2% 22Connecticut Voices for Children

23. An 18 year old discovered that he was no longer covered when he went for a check-up over Spring Break. Mother was told he lost coverage because he is in college. He is eligible until 19. 23Connecticut Voices for Children Source: CT Voices summary of calls to HUSKY Infoline Illustrating the findings with stories …

24. A mother called to ask for help paying for prescriptions for her HIV-positive daughter who lost coverage when she turned 18. She is eligible until age 19. 24Connecticut Voices for Children Source: CT Voices summary of calls to HUSKY Infoline Making the data about real children …

25. Source: Connecticut Voices for Children analysis of enrollment data from the Connecticut Department of Social Services.

26. Informing Efforts to Improve Preventive Care for Adolescents Connecticut Voices for Children

27. Understanding How Families Use Emergency Care Emergency Visits for Ambulatory Care-Sensitive Conditions

28. Seeking Solutions to Access Problems: Dental Care for Children Hartford children All other children Hartford children All other children Connecticut Voices for Children

29. Describing Racial/Ethnic Differences in Dental Care Utilization

30. 2010 Birth Data Match ALL in-state BIRTHS 36,784 births HUSKY A & B ENROLLMENT DATA 460,014 ever enrolled MEDICAID FFS 3,300 records Match mother’s Social Security Number and Verify mother’s enrollment on baby’s date of birth 11,846 HUSKY A & B records matched 1,051 Medicaid FFS records matche d … and for records not linked on SSN … Match mother’s exact name and date of birth and Verify mother’s enrollment on baby’s date of birth 367 HUSKY A & B records matched 1,205 Medicaid FFS records matched ALL CT BIRTHS 37,711 births Connecticut Voices for Children

31. Understanding the HUSKY Program’s Impact on Maternal and Infant Health: 2010 Births by Payer Type Percent of all 2010 births to Connecticut residents (37,711)

32. Maternal Age by Payer Type, 2010 Connecticut Voices for Children

33. Impact of the HUSKY Program on Maternal and Infant Health in Connecticut’s Cities, 2010 33 Connecticut Voices for Children

34. Trends: Early Prenatal Care by Payer Source Connecticut Voices for Children

35. Trends: Low Birthweight by Payer Source Connecticut Voices for Children

36. Trends: Cesarean Delivery Rates by Payer Source Connecticut Voices for Children

37. Trends: Maternal Smoking Rates by Payer Source Connecticut Voices for Children

38. Describing Dental Care Utilization by Pregnant Women and New Mothers New mothers who were continuously enrolled 6 months during pregnancy and 12 months postpartum. Source: Analysis of linked birth-HUSKY A (Medicaid) enrollment and claims data by Connecticut Voices for Children

39. Evaluating Impact of Outreach on Dental Care for New Mothers New mothers who were continuously enrolled for 12 months after giving birth. Source: Analysis of linked birth-HUSKY A (Medicaid) enrollment and claims data by Connecticut Voices for Children

40. New mothers who were continuously enrolled for 12 months after giving birth. Source: Analysis of linked birth-HUSKY A (Medicaid) enrollment and claims data by Connecticut Voices for Children Identifying Areas for Dental Program Improvement

41. Strategies for Working with Policy Makers

42. Influencing Public Policy Development Policy analysts and advocates seek to: – Raise public awareness – Mobilize other advocates and communities – Recommend sound policies aimed at improving health Effectively communicating with policy makers: – Define and describe the problem and a policy solution – Develop the message – Respectfully communicate the message in written materials, testimony and meetings with legislators, and strategic use of the media

43. Design Policy-Relevant Research Know current issues and incorporate policy relevance into the research agenda. Applied research findings are more likely to be translated into policy, especially if timely, responsive to issues under consideration. Embed research into conceptual framework that facilitates translation into policy development.

44. Build Relationships with Policy Makers Be sensitive to political timing and context for identifying relevant questions and solutions that are politically viable. Be respectful of policy makers’ specialized knowledge and experience. Identify legislative or ministry champions. Establish liaisons who can maintain relationships with policy makers.

45. Communicating with Policy Makers Powerful words: “research shows….” Anecdotes are compelling. Avoid using jargon or complex explanations of methodology, statistics. Make recommendations based on findings. Communicate in a variety of ways simultaneously, including fact sheets, written briefs, in-person meetings and briefings, testimony.

46. Conclusions The best health policy is data-driven. Research can be relevant to current conditions and policy questions, timely, and responsive to policy makers’ information needs. Effective communication of results is important for ensuring that policy development is informed by data.

47. For more information: Mary Alice Lee, Ph.D. Lecturer Yale School of Public Health 60 College Street New Haven, Connecticut 06520 203-785-2854 203-785-5267 fax maryalice.lee@yale.edu