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Associations Betw een Practice- Reported Medical Homeness and Health Care Utilization Among Publicly Insured Children Presentation at the AcademyHealth Annual Research Meeting Minneapolis, MN June 16, 2015 Anna L. Christensen, PhD Joseph

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Associations Betw een Practice- Reported Medical Homeness and Health Care Utilization Among Publicly Insured Children

Presentation at the AcademyHealth Annual Research Meeting Minneapolis, MN

Anna L. Christensen, PhD • Joseph S. Zickafoose, MD, MS • Brenda Natzke, MPP • Stacey McMorrow, PhD • Henry T. Ireys, PhD

June 16, 2015

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Citation

  • Publis hed in May 2015 volume of Academic

Pediatrics :

– Chris tens en AL, Zickafoos e J S , Natzke B , McMorrow S , Ireys

  • HT. As s ociations between practice-reported medical

homenes s and health care utilization among publicly ins ured

  • children. Academic Pediatrics . 2015; 15: 267–274.
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Background

  • C hildren’s Health Ins urance Program R eauthorization

Act (C HIPR A) Quality Demons tration Grant Program

– $100 million to improve health care for children – 10 awardees (18 s tates ), 5-year grants s tarting in 2010 – 52 total projects – National evaluation overs een by the Agency for Healthcare R es earch and Quality (AHR Q)

  • 12 s tates with patient-centered medical home (PC MH)

projects

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Background & Research Question

  • R elations hip between “medical homenes s ” and

children’s health care utilization

– R es ults vary by s tudy, outcome (preventive care, E D vis its , hos pitalizations ), and population (general population vs children with chronic conditions ) – Mos t s tudies as s es s parent-reported medical homenes s – Two s tudies of practice-reported medical homenes s s how mixed res ults (Cooley 2009, Paus tian 2013)

  • Is the “medical homenes s ” of primary care practices

as s ociated with health care utilization by publicly ins ured children?

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Methods

  • C ros s -s ectional bas eline analys is

– 3 s tates : IL, NC, S C – 64 practices (IL = 32, NC = 18, S C = 14)

  • C hildren (birth – 18 y) in Medicaid

– Fee-for-s ervice or primary care cas e-management – E xclus ions : >1-month gap in coverage, partial benefits , waiver program, other ins urance, ins titutionalization

  • Attribution of children to practices

– Majority of well-child vis its – If no majority of well-child vis its , majority of other vis its

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Methods: Measures

  • Practice-reported “medical homenes s ”

– National Committee for Quality As s urance (NCQA) 2011 medical home s elf-as s es s ment: IL – Medical Home Index (MHI): NC – Medical Home Index- R evis ed S hort Form (MHI-R S F): S C – Tertiles : low, medium, high

  • Utilization (prior 12 mo.)

– WCV: ≥75% of recommended # of well-child vis its – E DV: any non-urgent, potentially avoidable emergency department vis it (NYU algorithm; B en-Is aac 2010)

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Methods: Analysis

  • Multi-level logis tic regres s ion

– S eparate models for IL and NC/S C

  • C ovariates

– Child-level: age, race/ethnicity, chronic condition/dis ability

  • Pediatric Medical Complexity Algorithm (Simon, et.al. 2014)
  • Medicaid eligibility based on disability

– Practice-level (NC/S C only): urban/rural, # of providers

  • S ens itivity tes ts

– R e-es timated models with medical homenes s as :

  • Continuous variable
  • Categorical variable with cut points at 25th and 75th percentile

– Inferences did not change

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Child Characteristics

IL (n = 33,895) NC/SC (n = 57,553) Age group, % 0 to 5 years 53 57 6 to 12 years 31 30 13 to 18 years 16 14 Race/ethnicity, % black 45 33 white 31 45

  • ther

24 22 Chronic condition or disability, % 31 34

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Results: Medical Homeness & Well-Child Visits

10 20 30 40 50 60 70 80 90 100 IL (NCQA) NC/SC (MHI-RSF) Regression Adjusted Percent

Low MH Medium MH High MH

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Results: Medical Homeness & Well-Child Visits

76 74 77 10 20 30 40 50 60 70 80 90 100 IL (NCQA) NC/SC (MHI-RSF) Regression Adjusted Percent

Low MH Medium MH High MH

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Results: Medical Homeness & Well-Child Visits

76 69 74 69 77 63 10 20 30 40 50 60 70 80 90 100 IL (NCQA) NC/SC (MHI-RSF) Regression Adjusted Percent

Low MH Medium MH High MH

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Medical Homeness & Non-Urgent ED Visits

29 26 23 10 20 30 40 50 60 70 80 90 100 IL (NCQA) NC/SC (MHI-RSF) Regression Adjusted Percent

Low MH Medium MH High MH

* OR = 0.65 (95% CI 0.47-0.92)

*

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Medical Homeness & Non-Urgent ED Visits

29 29 26 29 23 27 10 20 30 40 50 60 70 80 90 100 IL (NCQA) NC/SC (MHI-RSF) Regression Adjusted Percent

Low MH Medium MH High MH

*

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Conclusions

  • Medical homenes s was not as s ociated with well-child

vis its

  • Higher medical homenes s was as s ociated with fewer

non-urgent E D vis its , but only in IL where NC QA medical home s elf-as s es s ment meas ure was us ed

  • Limitations

– Cros s -s ectional – May not be repres entative of Medicaid managed care – Could only attribute children with s ome s ervice us e – Different meas ures vs . different s tates

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Implications

  • Meas uring medical homenes s

– No s ingle bes t meas ure – Different meas ures capture different proces s es – Differences in definitions and meas ures of medical homenes s may contribute to mixed findings in current literature – Cons ider us ing more than one meas ure

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For More Information

  • National E valuation of the C HIPR A Quality

Demons tration Grant Program

http://www.ahrq.gov/policymakers /chipra/demoeval/index.html

  • Anna C hris tens en

achris tens en@ mathematica-mpr.com

  • Henry Ireys , Project Director

hireys @ mathematica-mpr.com

  • Acknowledgements : C indy B rach & Linda B ergofs ky (AHR Q),

C arl C ooley (C rotched Mountain), J eanne McAllister (Indiana), S arah S cholle (NC QA), Genevieve K enney (Urban Ins titute), C atherine McLaughlin (Mathematica)

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Extra Slides

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  • Use CMS ’ core pediatric quality measures (Category A)
  • Promote Health Information Technology/E lectronic

Health R ecords (Category B)

  • Implement provider-based models (Category C)
  • Apply model pediatric E HR format (Category D)
  • Other innovative approaches (Category E )

CHIPRA Quality Demonstration Program Focus: Five Broad Strate gies to Improve Quality

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Demonstration Grantees* and Partnering States, by Grant Category

States A B C D E Oregon* x x x Alaska x x x West Virginia x x x Maryland* x x Georgia x x Wyoming x x x Utah* x x x Idaho x x x Florida* x x x x Illinois x x x x Maine* x x x Vermont x x x Colorado* x x New Mexico x x Massachusetts* x x x South Carolina* x x x Pennsylvania* x x x North Carolina* x x x

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Results: Medical Homeness & Well-Child Visits

74 64 78 66 75 64 10 20 30 40 50 60 70 80 90 100 IL (NCQA) NC/SC (MHI-RSF) Unadjusted Percent

Low MH Medium MH High MH

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Medical Homeness & Non-Urgent ED Visits

31 29 27 31 30 25 10 20 30 40 50 60 70 80 90 100 IL (NCQA) NC/SC (MHI-RSF) Unadjusted Percent

Low MH Medium MH High MH