Infertility Prevention Project Region I Advisory Board Meeting Lessons Learned In Michigan

1. Infertility Prevention Project Region I Advisory Board MeetingLessons Learned In Michigan Amy Peterson, MPHMichigan Department of Community HealthJune 1, 2009

2. Presentation Topics • Michigan Background • Quick and Dirty Cost Savings Analysis • Use of Cost Saving Information • Michigan IPP Program Management • Targeted Expansion • Gonorrhea/Chlamydia Reduction Plan • Program Expansion and Contraction

3. Michigan Background

4. Gonorrhea and Chlamydia Burden in Michigan 46,555 reported cases of chlamydia 77% age ≤ 24 17,905 reported cases of gonorrhea 66% age ≤ 24 * All numbers reflect CY 2008 4

7. Michigan IPP Tie-Dye • Quarterly Alliance Meetings • STD • FP • Bureau of Labs • Adolescent Health • Oakland County • Juvenile Detention

8. IPP Screening Activity Calendar Year 2008 ~ 105,000 (104,621) screened for chlamydia Over 10.3% (10,789) found positive 75% of positives are 15-24 yrs/age (63% of tests) ~ 90,000 (91,835) screened for gonorrhea 4.2% (3,840) found positive 61% of all positives are 15-24 yrs/age (58% of tests) Diagnose ~23% of the State’s morbidity 8

9. Quick and Dirty Cost Savings Analysis

11. Funding for IPP Activity • STD • Federal IPP (tests/administration) • State General Fund/Michigan Health Initiative (tests/administration) • Local Public Health Operating funds (staff) • Local health jurisdiction funding (staff) • Family Planning • Tests and Plan First!/Medicaid • Adolescent and School Health Program • Tests/coordinating consultant

12. Cost Savings Analysis • Began as a way to avoid cuts during 2007 budget crisis • Good PR tool for all stakeholders • Local Health Jurisdiction – IPP analysis • Medicaid cost analysis

13. Steps in Michigan’s Unscientific Formula • Identify number of FEMALES diagnosed with CT and/or GC in population of choice (IPP, total morbidity, persons on Medicaid, etc) • Apply CDC statement – undiagnosed 30-40% may progress to PID • Multiply # positives times .40, times cost of treating a case of PID (multiple reference articles available). • Add disclaimers and footnotes • Use terms like “estimated” and “expected” frequently

14. Medicaid Cost Savings Analysis • Two calculations: • Estimated amount saved based on avoided PID at current screening level • Cost to treat cases of PID which could have been avoided with 100% screening of eligible patients

15. Medicaid Analysis Data Sources • Requested data from Michigan Medical Services Administration, Data Analysis and Quality Assurance Section (MSA) • Number screened was gathered from the Medicare Managed Care Annual Report • Received number diagnosed with PID by race from MSA – based on diagnosis code • MSA system does not collect number of positives, only number of tests. Received aggregate count by age and race; # of positives were estimated based on Michigan case rates. • See handout for details

16. Missed Screening Opportunities Cost Michigan Money • Amount spent by Medicaid to screen female members age 16-25 in 2006 – • ~ $2.2 million • Cost to screen and treat 100% of eligible Medicaid female members age 16-25 in 2006 - • ~ $4 million • Cost to treat chlamydia related PID in 2006 – • ~ $5.5 million

17. Screening for CT is a good investment Projected cost/savings in 2012(shown in millions)

18. Cost Savings Analysis as Advocacy Tool • Garnering good will with screening partners and their upper level administrators • Build case for additional funding from State; proven cost savings for Medicaid • Advocate to keep resources based on “Evidence Based”, “Cost-Effective Public Health Strategy” • $ adds power to sound bites

19. Michigan’s IPP Program Management

20. Program Management • Pre-Paid Forms • CT-only Testing Algorithm • Constant Monitoring of Usage

21. Pre-Paid Forms • See handout

22. CT-only Testing Algorithm: Targeted Use of Resources • See Handout

23. Constant Monitoring of Utilization • Monitored semi-annually • Robin Hood approach to test re-allocation

24. Targeted Expansion

25. Juvenile Detention/Adolescent Health Expansion • 2002 – RVIPP Mini-grant to target juvenile detention • Children’s Village/ Lynda Byer • JD sites in high morbidity counties approached • School based health centers – Oakland • Statewide expansion with Carrie Tarry

26. Wayne County Juvenile Detention • Over two years of trying, asking, begging • Multiple staff and attempts • New Medical Director – Dr. Carla Scott • Full implementation July 2006 • 01/08 – 12/08 (paid for ½ of tests themselves) • 3,771 tested 770 F; 3001 M • 424 + CT (22% F, 9% M) • 87 + GC (6% F, 1.3% M)

27. Expansion and Contraction

28. Dream Big… • Focus on mission of program • Acknowledge uncomfortable decisions that come with limited resources • Challenge politics as usual • Target non-traditional partners • Target services to address health disparities (not just racial) • Look for yield from every test supported

29. Gonorrhea/Chlamydia Reduction Plan

30. Status Quo: gonorrhea and chlamydia in Michigan 144 new infections per day 52,673* cases per year removing 144 infections per day * Average 2002-2007

31. Goal of Initiative To decrease overall prevalence of gonorrhea and chlamydia by identifying and treating infected individuals at a faster rate than new infections occur. How…

32. Evidence Based Components of the Plan • Increase school-based screening • Implement universal screening of males in STD sites • Increase private sector screening • Support alternative site high-risk screening

33. Evidence Based Components of the Plan • Implement CDC re-testing guideline • Utilize electronic medium to notify partners • Encourage field-delivered therapy for identified cases • Improve partner management in public and private sector

34. Targeted Expansion – 2009 Pilot Projects in High Morbidity Areas • School Blitz (8.3/11.9) • Teen Health Centers (19 CT, 5.2 GC) • Wayne County Jail (10 CT, 3 GC) • Pregnancy Test Only (10.2 vs. 7.5) • University Dorms (15 CT, 3.3 GC) • Federally Qualified Health Center – STD Overflow (11 CT, 4 GC) • Expanded Screening Initiative (ESI) Grants • Retesting • Universal male screening in STD Clinics

35. Likely Targeted Contraction - 2010 • Maintaining screening criteria age limit at 24 years old • State support of health center screening at Oakland University – likely discontinued (6 / 9 CT) • ESI Grants – support for testing only • Discontinue universal male screening in STD clinics

36. Targeted Contraction - 2010 • Reviewing Adolescent Health and Family Planning sites • cutting low prevalence sites to minimum • encouraging billing Medicaid and “Plan First!” when possible (50% estimated) • drill down analysis to ID who is testing positive and providing guidance • Shifting resources to high prevalence sites

37. Calling on Our Partners in 2010 • Adolescent health picking-up larger portion of costs • Targeted expansion to two new screening sites in high prevalence sites • Family Planning willing to make hard calls with low positivity sites • Increase attention to private sector (Nancy). Using LPH partners to increase knowledge and action among local providers

38. No/ low cost program improvements • School blitz guidance • Messages to private sector through managed care organizations to increase attention to HEDIS measure • Re-test in current sites • Field delivered therapy guidance • Work with IPP providers to increase partner management capacity and intentions

39. Questions…Contact Amy Peterson IPP Coordinator Michigan Department of Community Health STD Program 313/456-4425 petersonam@michigan.gov 39