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Impact of a Managed Care Environment on the Quality of Health Care

Impact of a Managed Care Environment on the Quality of Health Care. Iffath Abbasi Hoskins, M.D. Senior Vice President, Chairman & Residency Director Dept. of OB/GYN Lutheran Medical Center Brooklyn, NY GA Perinatal Association Sept 15, 2005. Impact on: General Medicine Mental Health

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Impact of a Managed Care Environment on the Quality of Health Care

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  1. Impact of a Managed Care Environment on the Quality of Health Care Iffath Abbasi Hoskins, M.D. Senior Vice President, Chairman & Residency Director Dept. of OB/GYN Lutheran Medical Center Brooklyn, NY GA Perinatal Association Sept 15, 2005

  2. Impact on: General Medicine Mental Health Maternal & Child Health

  3. Feb 18, 2005 House Bill: Senator Bingaman (D- N.M) and Senator Smith (R-Ore) 5338 Bipartisan Commission on Medicaid. 23 members (State & Federal legislators, policy experts, providers & beneficiaries. 14 months (conduct hearings, commission research, make recommendations) How to best address rising Medicaid expenditures Nation’s largest health care program

  4. Medicaid reductions may undermine efforts to ensure that our healthcare safety net is reliable, secure, and provides quality care to our nation’s poor & elderly. Therefore, Congress should reject any proposal that will put our most vulnerable citizens in jeopardy. Feb. 15th Letter to Congress. 21 provider groups

  5. Intentions of Medicaid Managed Care • chronic disease management • pharmacy cost management • quality improvement programs • fraud prevention • manage racial/ethnic disparities

  6. Managed Care: Strengthening the Consumer Voice in Managed Care: VI. The GA Peer Specialist Program Managed Care Programs, when adequately funded and wisely managed, can, should, and sometimes promote 3 objections: consumers and their families should have a prominent place in the health system as advocates participants in overseeing policy providers of service Sabin JE, Daniels N. Psychiatric Serv 54:497-98 April 2003

  7. Feb. 2, 2005 HHS Secretary, Mr. Michael Leavitt “With sweeping reforms in Medicaid, we can realize savings of $60 billion over 10 years.”

  8. Total projected savings (based on new contracted rates) $60 million • for FY ending June 06 & $20 million for FY ending June 07

  9. Medicaid Managed Care: • Salvation or Disaster? • Governor Purdue’s directive. Medicaid (and PeachCare) • will be controlled by private managed care companies • called Care Management Organizations (CMOs) • Current expenses $5 billion/year • Cons: • Cuts of hundreds of millions of dollars will have devastating • consequences especially for rural hospitals (called “financial • pressure cooker.”) • Crawford T. Dec 2004

  10. July 19, 2005 DCH awarded contracts for Georgia Healthy Families (Managed Care delivery system covering 1 Million Medicaid & Peach Care members). Contract is for one year, option of six renewal periods Implementation: Atlanta, Central* Jan. 06 N&E* Jul. 06 SW & SE* Dec. 06 Annual Value $1 Billion * Based on population & patterns of care

  11. Current System: • fee for service • low income pts. receive medical care • doctors & hospitals bill Georgia • funds are mix of state & federal $ • creates $200-300 million deficit due to inflation of costs (10-15%/yr.) • and increasing eligible recipients • fastest growing part of state budget • projected deficit $700 million in 2006 • Crawford T. 2004

  12. Each patient selects PCP • All benefits currently covered by Medicaid will be included • (immunizations, prenatal care, chronic ds. e.g. htn, DM, • asthma) • Contractors will provide full coverage & receive per member, • per month premium (PMPM) • DCH will continue to receive $1.53 Federal match for every • $1.00 State funds

  13. Inclusions: • low income families • pregnant women • new mothers & their babies/children • PeachCare • Breast & Cervical Cancer, Medicaid eligible, • women • Exclusions: • Aged, blind & disabled (will continue in current fee for service • model) • home & community based waiver programs • children in foster care

  14. How Medicaid HMOs Will Work: HMO files application forms with DMA DMA approves application forms MEC contacts Medicaid recipients Recipients educated about managed care and selection of HMOs Recipients choose to join an HMO or not MEC enrolls Recipients in HMO and forwards infor- mation to HMO HMO begins service

  15. Cons: • Was tried 10 years ago – unsuccessful • $250 Million (10% of available pot) will go to CMOs for administrative • costs & profits. • Additional loss of $100 million in Upper Payment Limit from Federal • Government • Crawford T. 2004

  16. Trends in Quality of Care & Racial Disparities in MEDICARE • Managed Care • analyzed 1.8 million individual level observations from 183 • health plans • 1997-2003 • clinical performance improved on all • measures for white & black enrollees (P<0.001) • gap b/w whites & blacks narrowed for 7 measures (P<0.01) • measured quality of care for elderly pts. in managed care • plans improved • Trivedi AN, Zaslavsky AM, Schneider EC, et al • N Engl J Med Aug. 2005

  17. Trends in Racial Disparities (cont’d.) • Racial disparities did not decrease • glucose control in diabetics (rose to 7% from 4%; p<0.001) • cholesterol control in CV and disease pts. (rose to 17% from • 14%, p=0.72) • Trivedi AN et al N Engl J Med Aug. 2005

  18. Rural-urban Differences in Health Risks, Resource Use & Expenditures within 3 State Medicaid Programs: Implications for Medicaid Managed Care • Medicaid claim data for income eligible enrollees (CA, GA, MS) • compared expenses, resource usages, health risks b/w pts. in rural & urban areas • resource use measured by RBRVUs (prof. service, hosp. days, out-pt. visits, • private insurance reimbursement rates) • health risks measured using dx. based Adjusted Clinical Group system • Resource use is compared on a risk adjusted basis with use of urban Medicaid • enrollees as a benchmark Bronstein JM, Adams EK. J Rural Health 2002. Winter; 18(1):38-48

  19. Rural-urban Differences (cont’d) • actual expenses for rural care users are lower than for urban care users • because proportion of Medicaid enrollees who use care is higher in rural • than in urban areas in all 3 states studied, expenses per rural enrollee are not • consistently lower • case mix is more resource intensive for rural vs. urban pts. in all 3 states • although resource usage is not systematically lower overall for rural enrollees, • on a risk-adjusted basis they tend to use less hospital resources vs. urban pts. Bronstein JM 2002

  20. Rural-urban Differences (cont’d) • capitation rates based on historical per enrollee expenses do not appear • to under-reimburse managed care organizations for the care of rural vs. • urban residents in the study states Bronstein JM, et al 2002

  21. Risk factors include: Rural Medicaid

  22. Effect of Medicaid Managed Care on Rural Public Health Departments • Medicaid managed care programs operate in more than 50% of all rural • counties in the U.S. (2001) • Site visits. 4 rural public health depts. 5 states. Total 20 case studies. • Each site visit = in person interviews of county public health dept. directors. • In recent years, most health depts. had decreased /discontinued well/child • visits resulting in lost Medicaid $. • None were in danger of closing, but lost income security. Slifkin RT, Silberman P, Reifs. J Rural Health 2001 Summer; 17(3): 187-96

  23. Effect of Medicaid Managed Care on Rural Public Health Departments (cont’d) • Medicaid Managed Care has increased no. of children with medical homes in • private sector but adequacy & continuity of care remain issues. • Privatizing Medicaid Managed Care has not decreased fragmentation of care • (tracking & screening are important parts of comprehensive care for poor, • rural pts.) Slifkin RT et al 2001

  24. Improving Prenatal Care in Medicaid Managed Care January 12, 2005

  25. Goals for Today • Review the current status of Prenatal Care provided to Medicaid Managed Care members: what do we know? • Identify barriers/gaps that prevent women from accessing early prenatal care and timely postpartum care • Identify barriers/gaps that prevent women from receiving comprehensive prenatal and postpartum care • Develop high priority recommendations that can improve care

  26. Data Sources • QARR Measures • IPRO Chart Reviews: Prenatal Study (1999 (N=1672) and 2002 (N= 2740) ) • Prenatal Member Survey (2001 (N=2188)) • Access and Availability Surveys

  27. Low Birth Weight Rates

  28. Commercial Maternal age (30+ 1.2) NYC (1.4) Black (2.7) Hispanic (1.8) Zero parity (1.9) Previous lbw (3.9) Smoking (1.9) Prenatal care index no care (3.5) intense (.67) Medicaid Education (</= HS/1.4) Maternal age (30+ 1.5) NYC (1.4) Black (2.7) Hispanic (1.8) Zero parity (1.4) Previous lbw (3.5) Drug use (1.7) Smoking (1.7) Prenatal care index no care (2.8) Risk factors for LBW (VS)

  29. Prenatal Care in the First Trimester

  30. ‘Timeliness of Prenatal Care’(QARR) • Percentage of women who gave birth in last year who had a prenatal visit in their first trimester OR within 42 days of enrollment in their health plan • Commercial 2001/2002: 87%/88% • Medicaid 2001/2002: 76%/78%

  31. Characteristics of women not seeking early/any prenatal care • VS data • Commercial • younger age • less education • Black • tobacco/alcohol use • unmarried • Medicaid • younger age • Black • tobacco/alcohol use • unmarried

  32. Women receiving care after the 1st trimester were…. Survey Results 2001 • Less likely to be screened for feelings towards pregnancy • Just as likely to have Medicaid coverage at time of pregnancy • Report more difficulty obtaining routine visits • Were less likely to receive assistance in accessing specialty care • Were less likely to have discussed family planning with provider

  33. Reasons for not seeking PNC early 2001 Survey • 88% stated they received PNC as early as they desired • Barriers/issues cited by 12% who did not: • Unaware of pregnancy (36%) • Problems getting on Medicaid (25%) • Unsure about keeping the baby (16%) • Difficulty getting an appt with a prenatal provider (14%) • Did not want anyone to know (11%) • Difficulty getting transportation to the clinic or doctor's office (8%) • Inconvenient office hours (5%)

  34. Prenatal Care Provider Access and Availability • Data Source - 2002/2003 NYSDOH Provider Access and Availability Survey • Study Purpose - Assess compliance of network providers with NYSDOH appointment timeliness standards • Sampling – Random sampling of providers from MCO HPN submissions by plan/by DOH region • Methodology -“Secret shopper” survey – using standardized scenarios to request the earliest available appointment

  35. Prenatal Access and Availability Standards • Initial prenatal visit –1st trimester – w/in three weeks (not surveyed) • Initial prenatal visit - 2nd trimester – w/in two weeks • Initial prenatal visit – 3rd trimester – w/in one week • Plan issued Statement of Deficiency if appointments in a provider category <75% • Note - prenatal calls are subset of OB/GYN calls

  36. Access and Availability Study Findings • Timeliness of total appointments 2nd and 3rd trimester • NYC – 73% (N =267) • Rest of state – 69% (N =339) • No significant regional differences • Timeliness of appointments for 2nd v. 3rd trimester • NYC - No significant difference • Rest of state - Timely 2nd trimester appointments more likely than timely 3rd trimester appointments (74% v. 61%)

  37. Access and Availability Study Results 2002/03 PNC Scenarios • Statewide total PNC appointments made within the time frames during the 2nd and 3rd trimester = 72% • Plan Rates – ranged from 33% to 100% • 15 Medicaid MCO’s (56%) had total PNC appointment rates < 75%

  38. Study Indicators: Chart Reviews 1999 and 2002 • Based on accepted standards of care • Indicators Dropped 2002 • H/H 1st trimester (high performance) • Patient education (survey) • Indicators Added 2002 • Group B Strep (guideline change) • Domestic violence • Secondhand smoke

  39. Study Objectives • Evaluate Provision of Prenatal Care related to: • Access to Care • Risk Assessments • Prenatal Laboratory Testing • Postpartum Care • Identify any trends in performance • Opportunities for improvement

  40. Study- Risk Assessments

  41. Study -Laboratory Testing

  42. Effects of Age, Region and Race/Ethnicity and Aid Category • Hispanics more likely to receive some of the tests/assessments (nutrition, domestic violence, psychosocial, substance use, chlamydia, urinalysis/urine culture) with Whites tending to have the lowest rates • Blacks had lowest prenatal/postpartum visit rates

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