Improving Quality and Reducing Disparities in Care through Enhancing Medicaid’s Involvement in P 2 Collaborative

1. Improving Quality and Reducing Disparities in Care through Enhancing Medicaid’s Involvement in P2 Collaborative Nikki Highsmith, Senior Vice President Center for Health Care Strategies May 7, 2009

2. Overview of Presentation • About CHCS • How Medicaid Can Help P2 “Raise All Boats” • Medicaid Innovations • How CHCS Can Help P2 Improve Quality and Equity in Care

3. 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

5. Aligning Forces for Quality (AF4Q) Initiative • CHCS is one of eight entities supporting George Washington University (National Program Office) • Working with AF4Q alliances, including P2 Collaborative, to improve quality, reduce disparities in care, and “raise all boats” in 15 regions/communities across the country

6. CHCS Technical Assistance for AF4Q Performance Measurement and Reporting Ambulatory Quality Improvement Consumer Engagement

7. How Medicaid Can Help P2 “Raise All Boats”

8. Why Medicaid? • 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 ) MEDICAID $361 billion annual cost Federal Spending 16% of national health spending 44% of all federal funds to states State Spending 25% of state budgets spent on Medicaid *Numbers are not additive. Source: Kaiser Commission on Medicaid and the Uninsured, 2008

9. Medicaid By the Numbers *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. 10

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

12. 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.

13. Medicaid Innovations: Performance Data and Reporting

14. 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

15. 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

16. Medicaid Innovations: Ambulatory Quality Improvement

17. 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

18. Distribution of Medicaid Beneficiaries Across Practice Size: Results from PSEP Percent of Beneficiaries Linked to Practice Settings 1 Practice identification based on site address 2 Practice identification based on TIN

19. Reducing Disparities at the Practice Site (RDPS) • 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

20. Reducing Disparities at the Practice Site Disparities Small Practices Chronic Care Improvement in Medicaid 20

21. 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 22

23. RDPS Step 2 – Outreach to Practices

24. RDPS Step 3 – QI Support Package Practice Changes State/Plan Supports Quality Improvement Support at the Practice Site Leadership commitment to business not as usual Provide timely and aggregated diabetes performance data to practices Registry or other electronic tracking system Track and document diabetic patients and outcomes using electronic data management tool Changes to QI System Select and support implementation of evidence-based guidelines (EBG) for diabetes Tools for evidence-based diabetes care Adopt and incorporate EBG for diabetes Incorporate QI feedback loops into ongoing practice operations Shared Practice Site Improvement Coach Provide funding/financial incentives directly linked to QI and diabetes care supports and changes Shared Nurse Care Manager (or other clinical or social service professional ) Incorporate team-based care into ongoing diabetes care delivery Provide support for culturally and linguistically competent patient self-management Tools/training for culturally and linguistically competent self-management Changes to Care Delivery Encourage culturally and linguistically competent patient self-management Assess Outcomes Using HEDIS/AQA Diabetes Measures 24 24

25. RDPS Step 4 – “Boots on the Ground” • 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

26. 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

27. How CHCS Can Help P2 Improve Quality and Equity in Care

28. Performance Measurement and Public Reporting Supporting efforts to bring Medicaid fee-for-service data and race/ethnicity/language data to P2’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

29. How is CHCS Supporting P2? 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

30. 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

31. 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

32. 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

33. 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

34. How is CHCS Supporting P2? 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 35

36. VisitCHCS.org to… Download practical resources to improve the quality and efficiency of Medicaid services. Subscribe to CHCS eMail 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. www.chcs.org

37. Questions?