Possible Incentive Metrics: Public Health Recommendations Katrina Hedberg, MD, MPH Health Officer & State Epidemiologist April 18, 2014
Context • Improve population health, improve care, lower (long-term) costs • Address leading causes of death/ illness; health disparities • Evidence-based interventions – In clinic – In community • Data exist/ national metrics established Public Health Division 2
Process • Public Health Division medical epidemiologists/ evaluation experts • Content areas: infectious disease, chronic disease, injury, maternal/ child health • Feedback from PHD director, OHA content experts, the PHD Health Transformation Steering committee Public Health Division 3
Population Health Definitions • Health Care Delivery (Clinic focus) – Panel of patients: eligible, enrolled – Patients with specific conditions or utilization • Public Health (Community-wide) – Defined by time, place, person – Indicators are at community level Public Health Division 4
More Public Health Terms • Data Sources: – Vital Records (birth, death) – Health Surveys (BRFSS, OHT) – ALERT (immunization registry • National guidelines – Healthy People 2020 – Preventive Services Task Force (Community Guide, Guide to Clinical Preventive Services) Public Health Division 5
Incentive Metrics • Tobacco Use • Obesity • Teen Pregnancy • Influenza Vaccination • HPV Vaccination • HIV screening Public Health Division 6
Incentive Metrics • Tobacco Use • Obesity • Teen Pregnancy • Influenza Vaccination • HPV Vaccination • HIV screening Public Health Division 7
Behaviors that Kill Oregonians 7000 Tobacco 1500 1400 Obesity Alcohol Public Health Division 8
Tobacco Use Prevalence • Metric: Percent CCO enrollees >18 years of age who report smoking • Data source: BRFSS; CAHPS • Benchmark: – HP2020--12% smoking prevalence in adults; – 1115 Medicaid waiver– 25% adult smoking prevalence Public Health Division 9
Cigarette smoking prevalence 30% �������������������� �������������������� 25% 20% 15% 10% 5% 0% 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Adults 8th Graders Public Health Division 10
Cigarette Use by Insurance Oregon, 2012 40 35 Medicaid Other Insurance 30 25 Range: 23%-42% 36% percent 20 15 10 13% 5 0 Public Health Division 11
Rationale • Medicaid patients >2.5 times more likely to smoke • Smoking costs Oregon: – $1.3 Billion overall in medical costs – $374 Million for Medicaid medical costs • Cessation is evidence-based according to US Preventive Services Task Force Public Health Division 12
Operationalization • Assess smoking status • Advise to quit • Evidence-based smoking cessation Rx • Tobacco-free campuses • Partner with LHD tobacco control Public Health Division 13
Community Tobacco Control • Limit access • Vending machines • Placement of cigarettes • Increase price • Smoke-free Air Policies • Media Public Health Division 14
Obesity Prevalence • Metric: Percent of CCO enrollees >18 years with a Body Mass Index > 30 based on measured height and weight • Data source: BRFSS; CAHPS • Benchmark: – HP 2020– 30% obesity in adults Public Health Division 15
Obesity in Oregon Adults and 8th Graders New BRFSS weighting method began in 2010. 30.0 25.0 20.0 Percent 15.0 10.0 5.0 0.0 Adults 8th Graders Public Health Division 16 Source: Oregon BRFSS and Oregon Healthy Teens Survey
Oregon Diabetes Prevalence New BRFSS weighting method began in 2010. 10.0% 9.0% 8.0% 7.0% Percent 6.0% 5.0% 4.0% 3.0% 2.0% Oregon US 1.0% 0.0% Public Health Division 17
Obesity by Insurance Oregon, 2012 45 40 35 Medicaid 30 Other Insurance 40% percent 25 20 15 10 26% 5 0 Public Health Division 18
Rationale • Medicaid patients >1.5 times more likely to be obese • Medical costs: – $1.6 Billion for medical care overall – $333 Million for Medicaid medical care • Premature deaths: 1,400 Oregonians/ yr Public Health Division 19
Operationalization: MPOWER • Monitor: obesity, chronic dz, exercise, diet • Promote: healthy eating/ active living • Offer: evidence-based support (e.g. weight watchers) • Warn: dangers of fats, sugar-sweet drinks • Enforce: laws (e.g. breast-feeding space) • Raise: price of unhealthful foods Public Health Division 20
Public Health Division
Community Healthy Diet Policies • Access – Vending machines (work / school) • Availability of choice – Restaurant / store locations / farmers’ markets • Public Education – Menu labeling • Cost – Tax sugar-sweetened beverages / fast food – Price incentives / subsidies for healthy foods Public Health Division 22
Teen Births • Metric: Rate of pregnancy in CCO enrolled females 15-17 years • Data source: MMIS • Benchmark: – HP 2020– 36.2 per 1,000 teens Public Health Division 23
Teen Pregnancy (15-17 yrs) Rate per 1,000 females age 15–17 years 35 30 25 20 15 10 5 0 Source: Oregon Birth Certificate Data; Induced Termination of Pregnancy Database
Teen Pregnancy Rates by Race / Ethnicity, 2010 Non-Latino White Non-Latino African American 50.00 Pregnancy per 1,000 Females Hispanic/Latino 40.00 30.00 20.00 10.00 0.00 Pregnancy Rate Birth Rate
Rationale • Teen pregnancy linked to: – Poverty, high school completion, child/ family well-being • Disparity, particularly in Hispanic and African American teens • Lower teen pregnancy lower health care costs Public Health Division 26
Operationalization • Assess reproductive health needs at adolescent well-child visit • Work with LHDs on teen pregnancy prevention • Support school-based health centers Public Health Division 27
Influenza Immunization • Metric: Percent of CCO enrolled patients 6 months - 64 years who received annual flu shot • Data source: MMIS; ALERT • Benchmark: – HP 2020– 80% for non-high risk; 90% for high risk Public Health Division 28
Public Health Division 29
Influenza Immunization • Current data: –CAHPS: 58.5% of adults 50-64 yrs –BRFSS 29.7% of adults18-64 years Public Health Division 30
Influenza Immunization Rates, Oregon 2013-2014 80% 70% 60% 50% 40% 30% 20% 10% 0% Source: Oregon Immunization Program, Oregon Health Authority
Rationale • 10%-20% population infected annually • US: – Hospitalizations: 55,000-430,000/ year – Deaths: 3,000-49,000/ year • Complications: <2 years and >65 years; chronic disease, pregnancy • School-aged kids spread infection • Vaccine: 73% effective Public Health Division 32
Operationalization • Offer flu vaccine to everyone 6 mo-65 yrs in the fall – Standing orders – Computerized reminders – Feedback to providers – Telephone reminders to patients – Expanding clinic hours/ locations Public Health Division 33
HPV Immunization • Metric: Percent of CCO enrolled females age 13 years who have received 3 doses of HPV vaccine • Data source: MMIS; ALERT • Benchmark: – HP 2020– 80% of females 13-17 years have received 3 doses of HPV vaccine Public Health Division 34
HPV Immunization • Current data: – 33% of Oregon females 13-17 years have received 3 doses Public Health Division 35
Rationale • Most common STD in US: 6.2 million new infections annually • Major cause of cervical dysplasia and cancer: annually 3500 cases of high- grade dysplasia in Oregon women 21- 29 yrs Public Health Division 36
Operationalization • Education of parents • Assess HPV vaccination status during adolescent visits • Reminder notices through ALERT • Provider-based vaccination coverage assessment by Immunization Program Public Health Division 37
HIV Screening • Metric: Percent of CCO enrollees 15-65 years with documentation of HIV screening ever • Data source: MMIS • Benchmark: – HP 2020– 18.9% of persons aged 15-44 yrs with HIV screening annually Public Health Division 38
HIV Screening by Race/ Ethnicity: Oregon, 18-64 year olds 70 60 50 percent 40 30 20 10 0 White Afric Amer Asian PI Amer Indian Latino
HIV Screening • Current data: – 37.5% of Oregon adults 18-64 years report having ever been screened Public Health Division 40
Rationale • 5,500 Oregonians are known HIV+; 250 new diagnoses annually • 500-1000 people unaware HIV+; source for 50%-70% new infections • 30%-40% of HIV+ diagnosed late stage • CDC; US Preventive Svc Task Force recommend universal HIV screening Public Health Division 41
Operationalization • Patient reminders for screenings • EHR reminders for HIV screening and documentation • Routinize HIV screening as part of medical care Public Health Division 42
Questions? Public Health Division
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