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New York State Vision for Women and Children’s Health
CareHudson Valley Regional Perinatal Forum
October 25, 2007
Foster Gesten, MDMedical Director
Office of Health Insurance Programs
Vision
• Medical home– Coverage and access
• Medical home improvement– Evidence based care– Decision supports– Patient/family engagement
• Improved health outcomes– Reduced/eliminated disparities
• Value
New York’s Medicaid Program Accounts for Nearly One-Third of All Health Care
Expenditures in the State
Commercial Insurance/Self Pay
$79.0B (49%)
Medicaid $48.7B (31%)
Medicare
$27.0B (17%)
Public Health $5.5B (3%)
Source: 2007 Health Care expenditures projected by DOB using actual 2004 data from the CMS, Office of the Actuary, National Health Statistics Group; 2007 NYS Economy projected by DOB based on NYS Personal Income data.
Medicaid Covers
• Over 4 million New Yorkers
• Over 85% of Medicaid enrollees are from working families
• Over 1.8 million children (CHPlus covers another 390,000 children)
• Medicaid covers one-half of all births
Medicaid Reform: Guiding Principles
• To operate Medicaid with the vision and discipline required of a health insurer that covers 4.5 million New Yorkers and does so with public resources exceeding $48 billion.– To ensure continuity of coverage. – To purchase value (high quality / fair cost).– To prevent waste and fraud.
• To leverage Medicaid’s role in the health care market place in order to advance universal coverage and reform New York’s health care delivery system.
Universal Coverage Starts with Medicaid, FHPlus & CHPlus
One Half of the Uninsured are Eligible for Medicaid, FHPlus or CHPlus
36%
27%
15%
22% Less than 100% FPL
100-200% FPL
201-300%FPL
Over 300% FPL
2.5 Million Uninsured
Reforming the Eligibility Process and Eligibility
Standards Began in Last Year’s Budget
• Elimination of documentation at renewal
• 12-month continuous for adults
• Expansion of CHPlus eligibility to 400% of the Federal Poverty Level
• FHPlus buy-in for employers
Reforming the Medicaid Eligibility and Renewal Process will Continue in This Year’s
Budget
As will Reform of Payment and Quality Standards
Medicaid is Becoming a Smart Purchaser
• The right care
• The right standards
• The right setting
• The right price
NY’s Health Care and Medicaid Expenditures are Among the Highest in the Nation
$4,867
$7,543 $7,458
$4,461 $4,147$2,891
$8,383
$0$2,000$4,000$6,000$8,000
$10,000
US MA NY PA FL TX CA
• New York’s health care spending per capita is among the highest in the nation.
• New York’s per enrollee MA spending is the highest in the nation, and almost triple that of California.
Notes: (1) Computed using data from Health Affairs 26, no. 6 (2007)(2) Computed using data from CMS 64 2004 and the
Kaiser Foundation
$5,283
$6,535$5,933
$5,483$4,601 $4,638
$6,683
$0
$2,000
$4,000
$6,000
$8,000
US MA NY PA FL TX CA
Total Per Capita Health Care Spending By State of Residence (2004)1
Total Per Enrollee MA Spending (2004)2
Relationship between costs and quality?
The Quality of Ambulatory Care Delivered to Children in the US
• Mangione-Smith, et al, in NEJM, October 11, 2007
• On average, children received about 46% of indicated care
• Varied from 92% to 34%, depending on clinical area evaluated
• Deficits in care are similar (although somewhat lower) than those found for adults
New York State’s Health System Ranks 22nd Nationwide, Lags Even Further in Quality
NY Placement Among the 50 States (Quartile)
DOMAIN(showing number of indicators in domain) Top Quartile
Second Quartile Third Quartile
Bottom Quartile
Nationwide Ranking in
Domain
ACCESS (4) 1 3 0 0 11th
QUALITY (14) 2 4 4 4 30th
AVOIDABLE USE /COSTS (9) 1 0 4 4 39th
HEALTH LIVES (5) 1 0 4 0 30th
ALL DOMAINS (32) 5 7 12 8 22nd
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
New York State Rankings
• 28th in Nation in percent low birth weight• 17th in Nation in percent preterm births
– Annie E. Casey Foundation/Kids Count• 26th in Nation in percent of children vaccinated• 37th in Nation in percent of children with
emotional/behavioral/developmental problems receiving mental health care
• 32nd in Nation in hospital admissions for pediatric asthma
• 13th in Nation in infant mortality– Commonwealth Fund State Scorecard
Improving Value Means
• Expanding Affordable Coverage
• Investing in Primary and Preventive Care
• Coordinating and Managing Care
• Improving Clinical Outcomes and Patient Safety
• Improving Transparency and Accountability
• Strengthening Program Integrity
Coordinating Care Improves Quality
50 47
39
59
39
16
55
64 6471
63
76
47
60
0
20
40
60
80
100
ChildhoodImmunization
Adolescent WellVisits
Cervical CancerScreening
Timely PrenatalCare
Diabetic HbA1CTesting
Diabetes HbA1CGood Control
AppropriateAsthma Care
Fee-for-Service Managed Care
Based on Study Conducted in 2000
Children’s Preventive Care (2005)
76
52
72
82
55
73
47
86
76
4944
72
48
7681
5954
0
10
20
30
40
50
60
70
80
90
100
ImmunizationCombo 2
431331
ImmunizationCombo 34313314
Lead Screening Well child 3-6years*
Adolescent wellcare*
Dental Visits (2- 21 yrs)*
Commercial Medicaid CHP* Well care data for Medicaid and Dental Visit data from 2006.
Perinatal Health
• Prenatal Care
• Birth outcomes
• NICU
• Disparities
• PCAP
Women’s Prenatal Care (2006)92
76
86
70 69
0
10
20
30
40
50
60
70
80
90
100
Timeliness of Prenatal Care Postpartum Care Frequency of Ongoing PNC(81% or more)*
Commercial Medicaid
*Not collected for Commercial.
Women’s Perinatal Health (2005)
5.1
8891
7.6
71
93
0
10
20
30
40
50
60
70
80
90
100
Low Birth Weight Rate* Prenatal Care in the FirstTrimester
High Risk Deliveries at Level 2-4Facilities
Commercial Medicaid
*A low rate is desirable.
81
59
84
68
61
86
70
69
0 50 100
Timelinessof PNC
PostpartumVisits
Frequencyof Ongoing
PNC
Medicaid 2006Medicaid 2004Nat. Avg 06
Women’s Prenatal CareCommercial Medicaid
91
80
92
78
92
76
0 50 100
Timelinessof PNC
PostpartumVisits
Frequencyof OngoingPNC (81%or more)
Comm 2006Comm 2004Nat. Avg 06
Low Birth Weight• Adjusting for demographic, clinical and
social risk factors:– In Medicaid Managed Care, Black
women are 2.5 times more likely to have a LBW delivery, compared to White women.
– In commercial managed care, Black women are 2.3 times more likely to have a LBW delivery, compared to White women.
2005 Upstate NYS Women with a current preterm or low birthweight
(LBW) delivery• There were 18,012 cases of preterm (<37
weeks) or LBW (<2500g) delivery, or 14.5% of all payers. – 5.6% of these 18,012 cases had a previous
preterm delivery – as indicated on the birth certificate.
• There were 6,680 cases of preterm or LBW delivery, or 15.4% for Medicaid (FFS/MMC).– 7.2% of these 6,680 cases had a previous
preterm delivery – as indicated on the birth certificate.
2005 Upstate NYS Medicaid (FFS/MMC) Women with a previous
preterm delivery
• 27% had a current low birthweight delivery (<2500g) as compared to 23% for total payer.
• 32% had a current preterm delivery (<37 weeks) which was the same for total payer (32%).
• 7% had a current very preterm delivery (<32 weeks) as compared to 6% for total payer.
• 65% received prenatal care in the first trimester as compared to 77% for total payer.
• A women is 3X (OR 3.1) more likely to have a LBW infant if there is a previous preterm birth
What is Promising?
• Aggressive, systematic identification of high risk with associated care coordination and management of medical and psychosocial factors– Healthy Babies (Philadelphia)– Healthy Beginnings (Monroe Plan)– Others: Alpha Maxx (Tennessee)
Healthy Beginnings
• Identification– Mandatory prenatal registration form with payment incentive
• Stratification– Coordination between perinatal health and behavioral health
• Outreach– Use of internal and external/community outreach
• Intervention– Targeted psychosocial intervention to high risk teens– Care management software to coordinate/support activities
• Results– Nearly 50% reduction in NICU admissions– ROI of ~2.5
Creating a Statewide Approach
• Medicaid has an important leadership role/opportunity
• We can do better• Identification and Coordination are key
– Within health plans– For women in FFS
• Pilot project– Draft registration form– Internal and external stakeholders– Budget and infrastructure
Percent Admission to the NICU – All NYS Births by Payor
55.5
66.5
77.5
88.5
99.510
2003 2004 2005
TotalTotal MedicaidFFSMMCComm IndemityComm MC
Multiples removed
NICU Mortality
• Vermont Oxford Network
• CMS Improvement Initiative
• NICU Module of SPDS
• VS/SPARCS Matched File– Adjusting for relevant clinical variables, how
much variation in mortality do we see?– How might this relate to health disparities?– How do we best support improvement?
Medicaid NICU Costs (2005 SPARCS)
• ~11.6% of deliveries result in NICU admits
• Account for ~50% of delivery costs
• Average DRG for NICU $17,622 vs $2427 for non-NICU stay
Note: White, Black, Asian and Hispanic categories are mutually exclusive.
Source: NYS Department of Health, Bureau of Biostatistics
New York State Pregnancy Rate per 1,000 Females Ages 15-17by Race/Ethnicity
1995 - 2004
0
50
100
150
Year
Rate
per 1
,000 f
emale
s (15
-17)
White NH 28.3 26.8 24.4 23.0 21.5 18.3 17.5 16.5 15.1 14.5
Black NH 119.5 117.1 102.6 99.3 94.8 90.5 85.7 82.5 76.3 71.0
Asian/PI NH 9.7 11.6 10.9 13.9 14.1 15.5 12.4 11.4 11.2 11.6
Hispanic 93.9 92.3 82.9 84.6 81.7 77.8 76.1 73.2 71.1 70.4
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Notes: 1)White, Black, Asian and Hispanic categories are mutually exclusive. 2)Unknowns are excluded.Source: NYS Department of Health, Bureau of Biostatistics
Percent of Births Receiving Early Prenatal Careby Race/ Ethnicity
New York State, 1995 - 2004
0
20
40
60
80
100
Year
Perc
ent
White NH 74.7 75.8 75.4 75.3 75.6 76.0 76.3 77.7 78.6 77.0
Black NH 49.4 50.9 51.0 51.5 52.5 55.3 56.3 58.3 60.5 60.9
Asian/PI NH 59.6 57.5 59.6 59.8 59.2 59.0 62.0 66.6 67.4 66.9
Hispanic 47.4 50.5 51.9 52.5 53.1 56.8 60.1 62.5 65.1 64.4
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Note: White, Black , Asian and Hispanic categories are mutually exclusive.Source: NYS Department of Health, Bureau of Biostatistics.
Percent of Births Under 2,500 Gramsby Race/ Ethnicity
New York State, 1995 - 2004
0
2
4
6
8
10
12
14
Year
Per
cent
White NH 6.0 6.2 6.4 6.3 6.5 6.5 6.4 6.6 6.6 6.7
Black NH 12.7 12.4 12.4 12.4 12.1 12.1 11.7 12.3 12.2 12.9
Asian/PI NH 6.7 7.0 7.5 7.4 7.4 7.0 7.4 7.7 7.8 7.6
Hispanic 7.7 7.6 7.7 7.7 7.6 7.3 7.5 7.5 7.4 7.4
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Note: White, Black, Asian and Hispanic categories are mutually exclusive.Source: New York State Department of Health, Bureau of Biometrics
Infant Death Rate per 1,000 Live Birthsby Race/ Ethnicity
New York State, 1995 - 2004
0
2
4
6
8
10
12
14
Rate
per 1
,000 B
irths
White NH 5.5 5.0 5.0 4.7 4.8 5.2 4.9 5.5 4.5 4.6
Black NH 12.8 12.0 11.1 10.0 10.1 11.5 9.9 9.7 11.3 11.1
Asian/PI NH 2.8 2.3 1.5 2.1 2.2 2.8 2.1 1.9 2.9 3.4
Hispanic 5.2 5.0 4.3 3.9 4.4 3.9 3.7 3.7 5.0 4.5
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Note 1)White Black and Hispanic categories are mutually exclusive. 2) 1994-1998 rates are based on ICD9 codes 630-676. Rates for 1999-2004 are based on ICD10 codes P00-P96.Source: New York State Department of Health, Bureau of Biometrics and Health Statistics
Maternal Mortality Rate per 100,000 Live Birthsby Race/Ethnicity
New York State, 1995 - 2004
0
20
40
60
80
Year
Rate
per 1
00,00
0 Birth
s
White NH 5.9 1.4 3.5 3.6 5.8 5.9 2.2 6.8 6.2 14.4 10.8
Black NH 27.3 34.6 26.2 29.0 24.6 40.0 58.5 57.8 40.0 57.1 50.2
Asian/PI NH 17.2 15.0 6.6 12.4 17.8 5.7 15.5 0.0 0.0 9.5 18.6
Hispanic 16.9 18.5 13.4 5.9 5.8 7.5 13.0 25.7 9.2 9.1 19.1
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Role of PCAP
• Managed care enrollment– But over 60% of pregnant women spend some part of their
pregnancy in FFS– How do plans and providers best coordinate care for high risk
women?
• Frozen rates for over 10 years– Budget initiatives to improve funding for primary, preventive care
• Challenges– Obesity– Services not in rate (17P)– Mental health – Preconception care
Focus
• Investment in primary, preventive care
• Coordination– Benefits– Providers– Programs
• Home visiting programs
• Intensive case management of high risk
Vision
• Medical home– Coverage and access
• Medical home improvement– Evidence based care– Decision supports– Patient/family engagement
• Improved health outcomes– Reduced/eliminated disparities
• Value
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