Exploring Access and Quality in Medicaid Pediatric and

www.chcs.org

Improving the quality and cost-effectiveness of publicly financed health care

January 27, 2014

12:00-1:30 pm (ET)

DIAL-IN #: (888) 282-4044PASSCODE: 307055

Made possible by Aetna, Inc., the Aetna Foundation, and the Annie E. Casey Foundation

Exploring Access and Quality in Medicaid Pediatric and Obstetric Care: A Three-State Analysis

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Today’s Speakers

• Stacey Chazin, Senior Program Officer, Center for Health Care Strategies (CHCS)

• Roopa Mahadevan, Program Officer, CHCS

• Jason Kessler, MD, Medicaid Medical Director, Iowa Medicaid Enterprise

• Robert Anderson, MD, Pediatrician, Genesis Health Group, Bettendorf Pediatrics, Iowa

• William Golden, MD, Medical Director, Arkansas Medicaid

• David Kelley, MD, Chief Medical Officer, Pennsylvania Department of Public Welfare

• Ron Yee, MD, MBA, Chief Medical Officer, National Association of Community Health Centers

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A non-profit health policy resource center dedicated to improving services for Americans receiving publicly financed care

► Priorities: (1) enhancing access to coverage and services; (2) advancing quality and delivery system reform; (3) integrating care for people with complex needs; and (4) building Medicaid leadership and capacity.

► Provides: technical assistance for stakeholders of publicly financed care, including states, health plans, providers, and consumer groups; and informs federal and state policymakers regarding payment and delivery system improvement.

► Funding: philanthropy and the U.S. Department of Health and Human Services.

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Agenda

I. Study Overview

II. Key Findings

III. State Perspectives

IV. Electronic Q&A

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Why Study Medicaid?

• Medicaid is nation’s largest health care payer

► Serves 67 million individuals – likely to reach nearly 80 million by 2019 under the ACA

► Single-largest payer of reproductive-related services, financing 48% of all births in the US

► Covers one-third of all children in the US

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Research Questions

• Quantitative Phase (AR, IA, and PA)

► Where are pediatric and obstetric patients getting care?

► What is the quality of that care?

• Survey Phase (IA and PA)

► How are practices delivering care?

► What are practices doing to advance access and quality?

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Delivery System Overview

• Eligible beneficiaries

• Beneficiary demographics

• Serving providers

• Site of provider practice

• Practice site size

• Racial composition, group affiliation, and multi-specialty nature of practice

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Pediatric Measures Reported by All States

• Well-child visits in the first 15 months of life

• Well-child visits in 3rd-6th years of life

• Child and adolescent access to PCPs

• BMI assessment for children/adolescents

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Pediatric Measures Reported by a Subset of States

• Preventive care measures► Adolescent well-care visits (PA)

► Lead screening in children (PA)

• Chronic illness care measures► Annual A1c testing for patients with diabetes (AR, PA)

► Annual number of asthma patients (2 through 20 yrs old) with ≥1 asthma-related ER visits (IA, PA)

► Use of appropriate medication for people with asthma (PA)

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Pediatric Measures Reported by a Subset of States (cont’d)

• Behavioral health care measures► Developmental screening in first three years of life (IA, PA)

► Follow-up after hospitalization for mental illness (AR, IA)

► Follow-up care for children prescribed ADHD (AR, PA)

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Obstetric Measures Reported

• Prenatal care measures (IA, PA)

► Frequency of ongoing prenatal care:

> 80 percent of expected visits

► Timeliness of prenatal care

• Birth outcomes

► Percent of live births weighing less than 2,500 grams

► Cesarean rate for nulliparous singleton vertex (first live singleton birth) at 37 weeks of gestation or later

► Estimated gestational age of delivered infants ≥ 37 weeks (IA only)

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Agenda

I. Study Overview

II. Key Findings


IV. Electronic Q&A

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QUANTITATIVE FINDINGS

Assessing Care Access and Quality

Beneficiary and Provider Distributions May Be Useful for Targeting QI Interventions

• Solo providers are the largest percentage of pediatric practices in each state

• The majority of obstetric practices in AR and IA have three or fewer providers

• Certain practice sizes/types may serve a disproportionate share of beneficiaries

• Racial/ethnic patterns in practice size/type

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Patterns in PCP Access and Well Visits

• States are stronger in access to PCPs than well-child visits

• High rates of access to PCPs among adolescents do not correspond to rates of adolescent well-care visits

• Caucasian children score better than non-Caucasians on most preventive care measures across the states

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Rates of Behavioral Health Care Delivery Are Low, With Some Exceptions

• Relatively low in AR and PA, mixed in IA

• In PA, smaller practices perform better on all measures

• In AR and IA, solo practices lag in key measures

• Hispanic beneficiaries have lowest rates of developmental screening in IA and PA, but the highest in AR

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Greatest Need for Improvement in Chronic Illness Care is for Racial/Ethnic Minorities

• Caucasians have rates better than or similar to non-Caucasians on every measure of chronic illness care reported by each state

• Large areas for improvement in asthma patients with ER visits for African-Americans in IA and PA, and Hispanics in PA

• Very low scores for appropriate medication for asthma among Hispanics in PA

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Racial/Ethnic Minorities Lower in Prenatal Care, But Not Always in Birth Outcomes

• Racial/ethnic disparities in frequency and timeliness in IA, and timeliness in PA

• African-Americans have greater % of live births less than 2,500 grams in AR and IA, and higher rates of C-section in IA

• Hispanics score best in % of live births less than 2,500 grams in all states, despite low rates of prenatal care relative to others

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Quality Differences Appear by Practice Size/Type

• Solo practices better than others in majority of obstetric measures in IA and PA

• FQHCs poor in:

► All reported preventive measures in AR, and majority in PA

► Majority of behavioral health measures in each state

• RHCs in PA and IA below-average in child and adolescent access to PCPs; but RHCs in AR and PA excelled in BMI assessment and asthma management compared to others

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SURVEY FINDINGS

Practice Efforts to Advance Care Access and Quality

Overview of Surveys

• 42-question survey completed by identified practices

► IA: 14 pediatric; 11 obstetric

► PA: 16 pediatric; 8 obstetric

• Surveys explored:

► Care- and access-advancing behaviors in eight domains

► Areas for—and barriers to—improvement

► Types and sources of support needed

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Access, Care Coordination, and Cultural Competency

• Majority of pediatric and obstetric practices use:

► Same-day appointments for sick patients

► Telephone access when office is closed

► Engagement of families/caregivers in referrals and treatment choices

► Collection of race, ethnicity, or language data

• Fewer practices consistently implement:

► Internet scheduling

► Cultural competency training for providers

► Health literacy assessments of patients

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Behavioral Health, Chronic Care, and IT

• Barriers to behavioral health care quality for pediatric providers

► Few providers for referrals and/or para-professional staff on-site

► Poor communication with behavioral health providers after referred visit

► Billing obstacles

• Most pediatric practices (>obstetric) have a chronic disease registry and use a range of other chronic care strategies

• Most pediatric and obstetric practices use both electronic and paper records to track clinical and administrative information

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Quality Measurement and Improvement

• More pediatric practices than obstetric practices collect quality measures, share performance data with physicians, and pursue formal quality improvement methodologies

• Self-reported areas for improvement include:

► Better/faster implementation of electronic health records (EHRs) to improve office efficiency, enhance care coordination, and engage patients in their own care

► More effective communication with patients and families

► Enhanced workforce availability

► Addressing transportation barriers that lead to patient no-shows

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Practice Support Received and Requested

• Most desired are technological and financial, then educational

• Very few receive government/philanthropic funding, or participate in QI collaboratives (pediatric > obstetric)

• All practices look foremost to state Medicaid agencies for support; obstetric practices also look to parent organizations

• The most common Medicaid incentive program in which practices participate is EHR Meaningful Use

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Study Implications

• Populations, health services, and care settings that could benefit most from Medicaid agency support

• Future research with larger sample sizes, looking into underlying causes

• Changes in data collection and reporting that could benefit state measurement efforts

• Areas of support for pediatric and obstetric practices

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Questions?


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Agenda

I. Study Overview

II. Key Findings


IV. Electronic Q&A

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State Perspective: Iowa

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Implications of Findings for Quality Improvement Work

Comparing results from state-to-state is difficult

Comparing different practice settings is difficult

Some reasons for results are suggested by the data we have and some are not


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Insights into Obstetric Risk Factor Findings

There are many ways to look at data

Prenatal care does not correlate to improved outcomes in the presence of other overriding risks

It would be interesting to develop a longitudinal data set,linked by mothers to understand behavior change


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Recommendations for Other States Looking to Assess Pediatric and Obstetric Care Quality and Access

Know your state’s demographics

Know the practice patterns

Look for reasons for unexpected results

Provider Perspective

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Robert Anderson, MD, PediatricianGenesis Health Group, Bettendorf Pediatrics, Iowa

State Perspective: Arkansas

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Valid metrics help set priorities for QI initiatives

► Cornerstones for PCMH, episodes of care, P4P

EMRs still cannot provide practice level data


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Insights into Pediatric Data

BMI collected elsewhere in system

Well child visits built into PCMH and shared savings

FQHCs now collecting, using data


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Cost efficient data reporting essential

JCAHO, NQF hospital metrics can drive care

Reform payment to reward outcomes (incentives)

State Perspective: Pennsylvania

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Use race and ethnicity drill down to drive quality improvement strategies

Focus on improving coordination between physical and behavioral health

Engage practices in quality improvement training


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Insights into Pediatric and Obstetric Care Quality at FQHCs

Nuances in assessing claims-based quality measures

FQHCs assessed primarily in rural areas

FQHCs key partners in access to high quality care


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Rely on claims plus chart review or EHR extraction

Assess rural versus urban regional variation in quality measures

Measure and publicly report comparative rates for each managed care organization or by PCCM/FFS program

National Perspective

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Ron Yee, MD, MBA, Chief Medical OfficerNational Association of Community Health Centers

Agenda

I. Study Overview

II. Key Findings


IV. Electronic Q&A

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Questions?


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Questions?

Full report forthcoming.

Contact

Stacey Chazin, Senior Program Officer

[email protected]

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• Learn about cutting-edge efforts to improve care for Medicaid’s highest-need, highest-cost beneficiaries

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Documents

Exploring Access and Quality in Medicaid Pediatric and