1. Lisa Raiz, William Hayes, Keith Kilty, Tom Gregoire, Christopher Holloman Ohio Employer and Ohio Family Health Research Conference July 29, 2011

2. Agenda  Project Aims  Defining Primary Care  Expanded Focus  Aim 1  Aim 2  Policy Considerations  Next Steps

3. Project Aims 1. To estimate the proportion of Ohioans who have, or do not have, primary care 2. To examine the association between having, or not having, primary care and unmet health needs, health status and health outcomes 3. To develop an operational definition of Enhanced Primary care Home specific to Ohio policy, rules and laws

4. Defining Primary Care 1. Usual source of care a. yes/no 2. Place care is received a. Clinic or health center b. Doctor’s office or HMO c. Hospital emergency room d. Other 3. Levels of care use a. Enhanced use b. Limited use c. No use

5. Three Levels of Primary Care Use 1. Enhanced use Received a routine check-up during previous year 2. Limited use No routine check-up; visited a doctor during previous year 3. No use No routine check up; did not visit a doctor during previous year

6. Sociodemographic Variables Chronic Conditions Not chronic Chronic mental health Other chronic Insurance Medicare Medicaid Dual eligibles Private ESI Other private Uninsured Region Appalachia Rural, non-Appalachia Suburban Metropolitan Race/Ethnicity Asian Black Hispanic White Age 18-24 25-34 35-44 45-54 55-64 Sex Female Male SES <100%FPL 101-138%FPL 139-150%FPL 151-200%FPL 201-250%FPL >300%FPL

7. Logic Model

8. Expanded Focus INDIVIDUALS WITH CHRONIC CONDITIONS

9. Patient Protection and Affordable Care Act  Title II: Role of Public Programs Subtitle I: Improving the Quality of Medicaid for Patients and Providers ○ Section 2703: State Option to Provide Health Homes for Enrollees with Chronic Conditions ○ Eligible individuals: Eligible for State assistance Has at least: -2 chronic conditions -1 chronic condition and is at risk of having a second chronic condition; or -1 serious and persistent metal health condition

10. Chronic Conditions  Populations with chronic conditions Not chronic Chronic mental health Other chronic Risk Factors: ○ Currently smokes cigarettes ○ Positive response to any episodes of binge drinking

11. Chronic Groups Group VariableTotal0-100%FPL101-138%FPL Chronic Groups 2008 Not chronic Chronic mental health Other chronic 2010 Not chronic Chronic mental health Other chronic 71.3% 6.4% 22.3% 71.4% 8.2% 20.4% 62.0% 14.0% 24.0% 63.1% 14.2% 22.7% 67.4% 9.3% 23.3% 67.3% 12.0% 20.7%

12. Aim 1  What is the proportion of Ohioans who have primary care?  What is the proportion of Ohioans who have primary care, based on sociodemographic variables?  What variables are associated with an increased likelihood of having primary care?

13. Usual Source of Care: Chronic Conditions % with a usual source of care

14. Usual Source of Care: Insurance Type % with a usual source of care

15. Usual Source of Care: Region of Residence % with a usual source of care

16. Usual Source of Care: Age % with a usual source of care

17. Usual Source of Care: Race and Ethnicity % with a usual source of care

18. Usual Source of Care: Socioeconomic Status % with a usual source of care

19. Place Care is Received  11 response categories (if usual source of care) Clinic or health center Doctor’s office or HMO Hospital emergency room Hospital outpatient department Military hospitals Does not go to one place most often Books/internet/hotline Hospital Urgent care Family member or friend Some other place

20. Place Care is Received - 2008 Doctor’s Office or HMO: 73.6% all Ohioans >73.6% Medicare Private ESI Not chronic Rural – Non App Suburban35-4445-5455-64WhiteFemale201-250%FPL251-300%FPL>300%FPL60%-73.5% Other private Other chronic AppalachiaMetro25-34AsianMale101-138%FPL139-150%FPL151-200%FPL50-59.9%Medicaid Dual eligible Chronic mental health health18-24<100%FPL40-49.9%UninsuredBlackHispanic

21. Place Care is Received - 2010 Doctor’s Office or HMO: 72.5% all Ohioans >72.5% Medicare Private ESI Other private Not chronic Rural – Non App Suburban45-5455-64WhiteFemale201-250%FPL251-300%FPL>300%FPL60%-72.4% Other chronic AppalachiaMetro25-3435-44Male101-138%FPL139-150%FPL151-200%FPL50-59.9%Medicaid Dual eligible Chronic mental health health18-24AsianHispanic<100%FPL40-49.9%UninsuredBlack Increased by >4% Decreased by >4%

22. Place Care is Received - 2008 Clinic: 13.1% all Ohioans >20% >20%Medicaid Dual eligible Uninsured Chronic mental health healthBlackAsian Hispanic (>30%) <100%FPL13.2-19.9% Other private Other chronic AppalachiaMetro18-2425-34Male101-138%FPL139-150%FPL151-200%FPL201-250%FPL <13.1% Medicare Private ESI Not chronic Rural non-App Suburban35-4445-5455-64WhiteFemale251-300%FPL>300%FPL

23. Place Care is Received - 2010 Clinic: 14% all Ohioans >20% >20%MedicaidUninsured Chronic mental health healthBlack Hispanic (>30%) <100%FPL14.1-19.9% Dual eligible Other private Other chronic AppalachiaMetro18-2425-3445-54AsianMale101-138%FPL139-150%FPL151-200%FPL <14% Medicare Private ESI Not chronic Rural non-App Suburban35-4455-64WhiteFemale201-250%FPL251-300%FPL>300%FPL Increased by >4% Decreased by >4%

24. Place Care is Received - 2008 Emergency Room: 5.8% all Ohioans <5.8%Medicare Private ESI Other private Not chronic Rural – Non App Suburban45-5455-64WhiteAsianFemale201-250%FPL251-300%FPL>300%FPL5.8-9.9% Other chronic AppalachiaMetro25-3435-44HispanicMale139-150%FPL151-200%FPL10-14.9% Dual eligible Chronic mental health health18-24Black101-138%FPL >15% MedicaidUninsured<100%FPL

25. Place Care is Received - 2010 Emergency Room: 5.2% all Ohioans <5.2%Medicare Private ESI Other private Not chronic Appalachia Rural – Non App Suburban45-5455-64WhiteFemale151-200%FPL201-250%FPL251-300%FPL>300%FPL5.2-9.9% Other chronic Chronic mental health healthMetro18-2425-3435-44HispanicMale101-138%FPL10-14.9%Medicaid Dual eligible Black<100%FPL139-150%FPL >15% Uninsured Increased by >4% Decreased by >4%

26. Place Care is Received: Chronic Conditions - 2008 % with % with place for care

27. Place Care is Received: Insurance Type - 2008 % with place for care

28. Place Care is Received: Insurance Type - 2010 % with place for care

29. Place Care is Received: Region of Residence - 2008 % with place for care

30. Place Care is Received: Region of Residence - 2010 % with place for care

31. Place Care is Received: Race and Ethnicity - 2008 % with place for care

32. Place Care is Received: Race and Ethnicity - 2010 % with place for care

33. Place Care is Received: Socioeconomic Status - 2008 % with place for care

34. Place Care is Received: Socioeconomic Status - 2010 % with place for care

35. Logic Model

38. Aim 2  What is the relationship between having primary care and ER use?  What is the relationship between having primary care and access to care from a specialist?  What is the relationship between having primary care and health status?  What is the relationship between having primary care and health outcomes?

39. Aim 2  ER use: number of ER visits  Access to a specialist: degree of difficulty seeing a specialist  Health status: general health  Health outcomes: number of hospitalizations; BMI; smoking status, Diabetes control  Unmet needs: not filled a prescription due to cost; not get other health care needed, frequency of getting needed help coordinating care  Rating of health care

40. Having a Usual Source of Care is associated with:  More ER visits * Hospital admissions * Control of diabetes * Satisfaction with health care *  Less Difficulty seeing a specialist *+ Worse general health* Likely to smoke + Likely to report not getting other needed care

41. Outcomes by Place Care is Received Clinic v. ERClinic v. DoctorER v. Doctor ER Visits 2008 more 2010 morensmore Hospital admissions 2008 morensmore Difficulty seeing a specialist 2008 more 2010 morensmore

42. Unmet Needs by Place Care is Received Clinic v. ERClinic v. DoctorER v. Doctor Not filled a prescription due to cost 2008 morensmore 2010 morensmore Not get other health care needed 2008 morensmore 2010 ns more

43. Select Variables by Place Care is Received Clinic v. ERClinic v. DoctorER v. Doctor General Health 2008 nsbetter 2010 ns better Health care rating 2008 better 2010 ns better Smoking status 2008 morensmore 2010 morensmore

44. Policy Considerations  Additional questions/revision of current questions would promote better population level data on primary care and its association with outcomes

45. Policy Considerations  Although the Hispanic population continues to lag behind other racial and ethnic groups in having a usual source of care, they experienced a 6% increase between 2008 and 2010. Factors associated with this increase should be investigated.

46. Reduction in use of ER as a usual source of care must address the primary factors associated with high ER utilization among Ohioans: Uninsured (>15% in 2008 and 2010) <100%FPL Medicaid Dual eligible African American  Chronic mental health  18-24  101-138%FPL  139-150%FPL Policy Considerations

47.  As income increases, a larger percentage of Ohioans have a doctor as their usual source of care while smaller percentages have either a clinic or the ER

48. Policy Considerations  For select unmet needs (not filling a prescription due to cost; not getting other needed health care), having a usual source of care was critical in both 2008 and 2010. However, whether that usual source of care was a clinic or a doctor did not matter.

49. Next Steps  Development of multivariate models to predict the likelihood of having primary care  Continued examination of the relationship between primary care and health outcomes and unmet needs  Comparison of findings to MEPS data

50. Appendix

51. Usual Source of Care: Gender % with a usual source of care

52. Place Care is Received: Age - 2008 % with place for care

53. Place Care is Received: Age - 2010 % with place for care

54. Place Care is Received: Gender - 2008 % with place for care

55. Place Care is Received: Gender - 2010 % with place for care

56. Level of Care Use: Insurance Type - 2008 % level of care use

57. Level of Care Use: Region of Residence % with a usual source of care