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