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Improving Quality and Reducing Disparities in Care through Enhancing Medicaid’s Involvement in P 2 Collaborative . Nikki Highsmith, Senior Vice President Center for Health Care Strategies May 7, 2009. Overview of Presentation. About CHCS How Medicaid Can Help P 2 “Raise All Boats”

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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

overview of presentation
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
chcs mission
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
aligning forces for quality af4q initiative
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
chcs technical assistance for af4q
CHCS Technical Assistance for AF4Q

Performance Measurement and Reporting

Ambulatory Quality Improvement

Consumer Engagement

why medicaid
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 )


$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

medicaid by the numbers
Medicaid By the Numbers

*Source: Congressional Budget Office

**Source: Centers for Medicare and Medicaid Services

*** Source: Kaiser Commission on Medicaid and the Uninsured

medicaid data resources
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.


medicaid qi infrastructure opportunities for synergies
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
what else does medicaid bring to the table
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.

medicaid lead regional quality improvement
Medicaid Lead: Regional Quality Improvement

Rochester, New York

Chart reviews and claims analysis for diabetes performance aggregated across Medicaid and commercial payers


Medicaid and commercial payers aggregating claims data at the county level on diabetes, prevention, and other measures

regional quality improvement continued
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

practice size exploratory project psep
Practice Size Exploratory Project (PSEP)

Participants from AR, MI, NY, and PA


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.


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

distribution of medicaid beneficiaries across practice size results from psep
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


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

Reducing Disparities at the Practice Site


Small Practices

Chronic Care Improvement in Medicaid



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

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




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

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
performance measurement and public reporting
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

how is chcs supporting p 2
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

ambulatory quality improvement
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

supporting the primary care wave
Supporting the Primary Care Wave


Pipeline of primary care professionals (internists, family practice, pediatricians, nurse practitioners)


Medical home and practice support demonstrations

ARRA HIE/HIT investments

Payment reform

National health care reform

how is chcs supporting af4q alliances
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

equity in care
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

how is chcs supporting p 21
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

af4q team key chcs staff
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


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