Data to Enhance Public Health Outreach in Response to the Flint - - PowerPoint PPT Presentation

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The Role of Medical Claims Data to Enhance Public Health Outreach in Response to the Flint Water Crisis

Krutika Jariwala, PhD, MS Min Tao, PhD Elizabeth Wasilevich, PhD, MPH Blue Cross Blue Shield of Michigan

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Introduction

How it all started?

Picture credit: http://www.democracynow.org/2015/12/17/how_flint_michigan_saved_money_and. Retrieved on 6/6/2016

• In April 2014, Flint, MI changed its water

supply source from the treated Detroit Water and Sewage Department to the Flint River which has no corrosive inhibitor water

• treatment. This decision resulted in lead

leaking from pipes into the drinking water.

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Introduction

Why are we concerned? And who is affected the most?

Picture credit: http://www.democracynow.org/2015/12/17/how_flint_michigan_saved_money_and. Retrieved on 6/6/2016

• Consuming lead contaminated water can cause

significant lifelong health effects, especially for exposed young children and fetuses of pregnant women.

• Symptoms can range from constipation, vomiting

and anemia to some serious health effects such as irreversible cognitive defects and attention-related problems among children (Mayo Clinic website, 2016; National Toxicology Program report, 2012).

Mayo Clinic website: http://www.mayoclinic.org/diseases-conditions/lead-poisoning/basics/symptoms/con-20035487. Accessed on 6/6/2016 NTP report: https://ntp.niehs.nih.gov/ntp/ohat/lead/final/monographhealtheffectslowlevellead_newissn_508.pdf. Accessed on 6/6/2016

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• Expert estimates indicate ~6,000-12,000 children in Flint are potentially

at risk for lead exposure due to this contamination (United Way of Genesee County, MI).

• In Flint, MI, kids (≤5 years) with elevated blood lead level (≥5 µg/dL)

significantly increased from 2.4% (in 2013) to 4.9% (in 2015) with ~6.6% (4.0% to 10.6%) increase in selected neighborhoods (Hanna-Attisha et al., 2016).

• Another study in Flint, MI shows an initial declining elevated blood lead

trend from third-quarter (Q3)2010 (7.5%) to Q32013 (~3.6%; before the water system was changed) but an increase again in Q32014 (7%) and Q32015 (6%) among children (Laidlaw et al., 2016).

Introduction

Recent research in this area

Picture credit: http://www.mlive.com/news/index.ssf/page/flint_water_crisis.html Retrieved on 6/6/2016

Hanna-Attisha, Mona, et al. "Elevated blood lead levels in children associated with the Flint drinking water crisis: a spatial analysis of risk and public health response." American journal of public health 0 (2016): e1-e8. Laidlaw, Mark AS, et al. "Children’s blood lead seasonality in Flint, michigan (USA), and soil-Sourced lead hazard risks." International journal of environmental research and public health 13.4 (2016): 358. United Way of Genesee County, MI. http://www.wnem.com/story/30995770/united-way-estimates-cost-of-helping-children-100m. Accessed on 6/6/2016 3

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• Blue Cross Blue Shield of Michigan (BCBSM) and Blue

Care Network are reaching out to help the Flint community and our members who may be affected by lead exposure in drinking water.

• The primary short-term goal of the outreach program is

to ensure all young children (aged 0-6 years) and pregnant women in Flint are tested for lead exposure.

• The long term goal is to ensure children’s long term

health services needs are met.

Our Effort

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• To demonstrate how medical claims data can be used to assist with provider-driven and

health plan-implemented outreach programs by identifying potentially affected members who should be screened for high blood lead levels.

• To demonstrate how medical claims can be used as a surveillance tool.

Objectives

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Outreach Program

Identify Members

• Young children (0-6

years) and women of childbearing age (15-44 years)

BCBSM Outreach

• Letters to the

children’s (0-6 years) families

• Physician organizations
• BCBSM nurses direct
• utreach

Ongoing Surveillance

• Short term
• Tracking lead testing

and primary care utilization

• Case management if

lead level is high

• Long term
• Behavior health

services needs

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Methods

• Design: A longitudinal, descriptive study was

conducted using Blue Cross Blue Shield of Michigan commercial data.

• Identification of potentially affected children (0-

6 years) and women of childbearing age (15-44 years).

• Time period:

April 2014 through December 2015

• Zip codes: seven Flint zip codes
• Current and relocated members since

April 2014 were included

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• Key information for outreach using medical claims data
• Demographic (age as of 12/31/2015 and sex)
• Contact information (address, phone number, etc.)
• Member’s Primary Care Physician (PCP) attribution and practitioner information
• Member’s group and subscriber information

Methods

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• Ongoing surveillance for lead assay test
• Surveillance data for lead assay test (after 04/2014) was obtained from three different

sources:

• Medical claims (identified using the codes below for children and women)
• CPT: 83655
• LOINC_CD: '10368-9', '10912-4', '14807-2', '17052-2', '25459-9', '27129-6',

'32325-3', '5671-3', '5674-7', '77307-7'

• Reports from Wellness Care Management (WCM) using Michigan Care

Improvement Registry (MCIR) data for children

• Reports from Physician Organization (PO) for children and women

Methods

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• Ongoing surveillance for primary care physician utilization
• PCP visit after first lead test and April 2014 by using medical claims data for children
• Any visit with professional rendering physician as PCP
• No CPT code/s restrictions
• Any preventive E&M Service visit with professional rendering physician as PCP
• CPT: 99381-99387, 99391-99397, 99401-99429

Methods

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Results – Demographic Distribution

Initial Results

* Both current and relocated members after 04/2014 were included.

Total Flint BCBSM Members Pediatric members (0-6 years) Female members of childbearing age (15-44 years) Members 16,463 946 (6%) 3,455 (21%) Male 8,049 (49%) 462 (49%)

• Female

8,414 (51%) 484 (51%) 3,455 (100%) Location* Moved to Flint 1,115 (7%) 84 (9%) 294 (9%) Moved out of Flint 1,729 (11%) 132 (14%) 418 (12%) Always in Flint 13,619 (83%) 730 (77%) 2743 (79%)

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Results – Lead Testing

Pediatric members (0-6 years) 2016 data

*Members who are not exposed to Flint water crisis are excluded from the denominator and numerator over time. **So far six members had lead levels ≥5 µg/dL since 04/2014. Four of these members were re-tested for lead and had lead levels <5µg/dL.

PO = Physician Organization; WCM = Wellness Care Management; MCIR = Michigan Care Improvement Registry

Jan_16 Feb_16 Mar_16* April_16* May_16* Jun_16* Total number (percent) with ≥1 lead assay test since 4/1/2014 verified by claims, MCIR

• r physician organization

336 (36%) 353 (37%) 459 (55%) 489 (70%) 495 (75%) 504 (77%) # identified by claims 222 257 286 329 329 394 # identified by PO

• 187

257 264 289 # identified by WCM/MCIR 314 314 431 451 452 461 Lead level documented (5 µg/dL or higher) since 4/1/2014 # with high level (≥5 µg/dL ) at least once 4 5 6 6 6 6** # with high level (≥5 µg/dL ) based on the most recent test performed 4 3 3 2 2 2**

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Results – Primary Care Utilization

Pediatric members (0-6 years) 2016 data

*Members who are not exposed to Flint water are excluded from the denominator and numerator over time.

3/28/2016* 4/25/2016** 05/16/2016* 06/10/2016* Total number (%) of members who had a PCP visit after 4/1/2014 and after their first lead test 249 (54%) (Out of 459) 261 (54%) (out of 489) 294 (59%) (out of 495) 311 (62%) (out of 504) Total number (%) of members who had a PCP visit for preventive service after 4/1/2014 and after their first lead test 177 (39%) (Out of 459) 179 (37%) (out of 489) 205 (41%) (out of 495) 219 (44%) (out of 504)

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Results

First lead assay test performed (after April 2014) for pediatric members (0-6 years)

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14 12 12 19 21 13 12 8 6 14 6 11 19 10 12 8 10 18 29 22 24 66 82 39 12 4 1 10 20 30 40 50 60 70 80 90 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Members Tested First Lead Assay Date

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• ~77% (504) of children and ~12%(415) of women are now tested for lead.
• Six children (0.9%) have been identified with high lead levels.
• Four of them got retested and have current lead levels below 5 µg/dL (normal).
• A steady number of children got their first lead assay test between April 2014 to August 2015.

We see an increasing trend with more children who got their first lead test in the last six months.

• ~62% of members had a PCP visit and ~44% had a PCP visit for preventive service after

4/1/2014 and after their first lead test based on the most current medical claims data.

• 241 (25%) of members were later excluded (on monthly basis) because they self-reported not

being affected by the Flint water crisis (most of them indicated that they have well water or

• ther types of water systems).

Conclusion

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• Several efforts, nationally and regionally, are currently ongoing to address the public health

crisis in Flint caused by contaminated water

• Our investigation demonstrated how medical claims data can be used to reach all

potentially affected members, especially young children and pregnant women, to encourage them to seek lead assay testing.

• Medical claim is another low cost tool that can be used in the middle of public health crisis

as well as for monitoring long term health outcomes.

Implications

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• Neurodevelopmental testing
• Utilization for behavioral health diagnoses

Future Surveillance Activities for At Risk Children and Adults

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Thank you!!

Questions?