1 minnesota medical home project: evaluation feasibility study saturday, june 7, 2008 shrig meeting,...
TRANSCRIPT
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1
Minnesota Medical Minnesota Medical Home Project: Home Project:
Evaluation Feasibility Evaluation Feasibility StudyStudy
Saturday, June 7, 2008 Saturday, June 7, 2008
SHRIG Meeting, Academy Health SHRIG Meeting, Academy Health
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DRAFT2
What is a Medical Home Model of Care?
Healthy People 2010 Measures• Family/Professional Partnership• Comprehensive Health Care• Access to Health Insurance/Financing• Early/Continuous Screening• Access to Community Services• Transition to Adult Life
Minnesota Medical Home Project• Coordination of Care
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DRAFT3
Who are Children with Special Health Care Needs (CSHCN)?
Era Terminology Scope
1930s-60s Crippled Children
Orthopedic impairments
1970s-80s Handicapped Children
Above plus developmental disabilities, other physical conditions
1990s
(Newacheck PW, 2007)
Children with Special Health Care Needs
Above plus emotional and behavioral conditions
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DRAFT4
Children with Special Health Care Needs……..
”…have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally (DHHS, 2004).”
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DRAFT5
What is the Minnesota Medical Home Project (MMHP)?
• Goal: provide comprehensive patient-centered care to children with special health care needs
• MNCSHN Section, MN Department of Health + partners
• Formed in 2004 with 11 primary care teams from practices around Minnesota
• Healthy People 2010 Objective 16-23
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6
MN MN Medical Medical Home:Home:
20 Teams 20 Teams and and
GrowingGrowing……Slide credit: Carolyn Allshouse, MCSHCN/MDH
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DRAFT7
MMHP Evaluation Components:
1) Family Perception Survey
2) Medical Home Index - MDH/MCSHN
3) Time Study - DHS/PMQI
4) 2001/2005 National CSHCN Survey
5) Evaluation Feasibility Study – DHS/PMQI
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DRAFT8
What is an Evaluation Feasibility Study?
Determine whether the impact of the medical home model of care on the health service utilization and costs of care of Medicaid-enrolled children with special health care needs is feasible to assess.
Impact = More Appropriate Care
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DRAFT9
Study Participants
Medical Home children (n = 513)
intervention group; identified by providers
9 clinics throughout Minnesota
Two comparison groups of CSHCN identified from
Minnesota Medicaid administrative data
“Internal”: same clinics, different MDs (n = 732)
“External”: no contact with Project (n = 15,042)
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DRAFT10
Study Inclusion Criteria
0-18 years old
CSHCN status identified by a Project provider or by Minnesota Health Care Programs’ (MHCP) administrative claims data
enrolled for a minimum of one month per year in MHCP; all 3 years of the study
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DRAFT11
Analysis Methods
Repeated measure mixed design multivariate regression analysis
Re-run analysis on random sample of the comparison groups
All statistical models controlled for differences in age, gender, race/ethnicity, metro/non-metro status, parental marital status, and health status across study groups.
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DRAFT12
Preliminary Results
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13DRAFT
Severity Weight Across Time by Study Group
0
0.2
0.4
0.6
0.8
1
1.2
Baseline (03/01/03-01/29/04) Year 1 (03/01/04-02/28/05) Year 2 (03/01/05-02/28/06)Study Period
Ave
rag
e A
CG
v6.
0-B
ased
Sev
erit
y W
eig
ht
External; n = 15042
Internal; n = 732
Medical Home; n = 513
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14DRAFT
Severity Across Years for Most Healthy (Bottom 50%tile)
in Baseline Year
0
0.1
0.2
0.3
0.4
0.5
0.6
Baseline(03/01/03-01/29/04)
Year 1(03/01/04-02/28/05)
Year 2(03/01/05-02/28/06)
AC
G S
erv
eri
ty W
eig
ht
External; n = 7973 Internal; n = 333
Medical Home; n = 225
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15DRAFT
Severity Across Years for Middle Percentile (GT 50 - LT 75)
in Baseline Year
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Baseline (03/01/03-01/29/04)
Year 1 (03/01/04-02/28/05)
Year 2 (03/01/05-02/28/06)
AC
G S
ever
ity W
eigh
t
External; n = 2315 Internal; n = 138 Medical Home; n = 55
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16DRAFT
Severity Across Years for
Most Severe/Chronic (Top 25%tile) in Baseline Year
0
0.5
1
1.5
2
2.5
Baseline (03/01/03-01/29/04)
Year 1 (03/01/04-02/28/05)
Year 2 (03/01/05-02/28/06)
AC
G S
ever
ity W
eigh
t
External; n = 4754 Internal; n = 261 Medical Home; n = 233
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17DRAFT
Health Condition Over Time
Association with Intervention StatusOdds Ratio (95% CI)
Measure:Health Condition Worsening Between Baseline Year and Year 2
Results: Total Population
Comparison Group 0.4 (0.3 to 0.5)
Medical Home Group Reference (Odds Ratio = 1)
Results: Only the “Healthy” Children in the Baseline Year
Comparison Group 0.3 (0.2 to 0.4)
Medical Home Group Reference (Odds Ratio = 1)
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DRAFT18
Medical Home Children: PMPM Inpatient Admissions
Hypothesized effect of the intervention
Observed direction Year 2 – Baseline -28.55 admissions per
1000 member months
Significant? yes, p = <.0001
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19DRAFT
Inpatient Admissions by Study Group (PMPM Adjusted Rate)
0
0.01
0.02
0.03
0.04
0.05
0.06
Baseline (03/1/03-02/29/04)
Year 1 (03/01/04-02/28/05)
Year 2 (03/01/05-02/28/06)
Study Period
PM
PM
Ad
just
ed R
ate
External Sample n=513
Internal Sample n=513
Medical Home Sample n=513
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DRAFT20
Medical Home Children: PMPM Emergency Department Visits
Hypothesized effect of the intervention
Observed direction Year 2 – Baseline -8.0 visits per
1000 member months
Significant? no, p = .418
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21DRAFT
Emergency Department Visits by Study Group (PMPM Adjusted Rate)
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
Baseline (03/1/03-02/29/04) Year 1 (03/01/04-02/28/05) Year 2 (03/01/05-02/28/06)Study Period
PM
PM
Ad
just
ed R
ate
External Sample n=513
Internal Sample n=513
Medical Home Sample n=513
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DRAFT22
Medical Home Children:PMPM Well Child Visits
Hypothesized effect of the intervention
Observed direction Year 2 – Baseline -68.5 visits per
1000 member months
Significant? yes, p = <.0001
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23DRAFT
0
0.05
0.1
0.15
0.2
0.25
Baseline (03/1/03-02/29/04) Year 1 (03/01/04-02/28/05) Year 2 (03/01/05-02/28/06)
Study Population
PM
PM
Ad
just
ed R
ate
External Sample n=513
Internal Sample n=513
Medical Home Sample n=513
Well Child Visits by Study Group (PMPM Adjusted Rate)
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DRAFT24
Medical Home Children:PMPM Dental Visits
Hypothesized effect of the intervention
Observed direction Year 2 – Baseline +23.7 visits per
1000 member months
Significant? no, p = .813
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25DRAFT
Dental Visits by Study Group (PMPM Adjusted Rate)
0
0.02
0.04
0.06
0.08
0.1
0.12
Baseline (03/1/03-02/29/04) Year 1 (03/01/04-02/28/05) Year 2 (03/01/05-02/28/06)
Study Population
PMPM
Adj
uste
d R
ate
External Sample n=513
Internal Sample n=513
Medical Home Sample n=513
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26DRAFT
Any Well Child Year 2 Visit:
PredictorsOdds Ratio (95% CI)
Intervention Status
External Controls 0.9 (0.8 to 1.10)
Internal Controls 1.0 (0.8 to 1.3)
Medical Home Reference (Odds Ratio = 1)
Baseline PMPM Rate 8.5 (6.7 to 11.0)
Interaction Terms
Study Group X Age Group Wald Chi-Sq p=.004
Study Group X Baseline PMPM Wald Chi-Sq p=.05
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27DRAFT
Any Well Child Year 2 Visit:
Intervention Effect by AgeOdds Ratio (95% CI)
Intervention effect for ages 0 – 24 months
External Controls 0.5 (0.4 to 0.9)
Internal Controls 0.6 (0.3 to 1.02)
Medical Home Reference (Odds Ratio = 1)
Intervention effect for ages 2 – 6 years
External Controls 0.7 (0.5 to 0.998)
Internal Controls 1.06 (0.7 to 1.7)
Medical Home Reference (Odds Ratio = 1)
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28DRAFT
Any Dental Year 2 Visit:
PredictorsOdds Ratio (95% CI)
Intervention Status
External Controls 0.8 (0.6 to 0.9)
Internal Controls 0.8 (0.6 to 1.06)
Medical Home Reference (Odds Ratio = 1)
Baseline PMPM Rate 25.5 (19.2 to 40.0)
Race/Ethnicity
All other 0.7 (0.7 to 0.8)
White, Non-Hispanic Reference (Odds Ratio = 1)
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29DRAFT
Inpatient Admissions by Enrollee Care Plan Status
PMPM rate over time; medical home participants only; overall PMPM rate is not adjusted
0
0.02
0.04
0.06
0.08
0.1
0.12
Baseline (03/1/03-01/29/04) Year 1 (03/01/04-02/28/05) Year 2 (03/01/05-02/28/06)
Study Period
PM
PM
Adju
ste
d R
ate
No Care Plan n = 294
Care Plan Developed n = 219
Overall Rate n = 513
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30DRAFT
Emergency Department Visits by Enrollee Care Plan Status
PMPM rate over time; medical home participants only; overall PMPM rate is not adjusted
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
0.09
Baseline (03/1/03-01/29/04) Year 1 (03/01/04-02/28/05) Year 2 (03/01/05-02/28/06)
Study Period
PM
PM
Ad
juste
d R
ate
No Care Plan; n = 294
Care Plan Developed; n = 219
Overall Rate; n = 513
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31DRAFT
Professional Services
77%
Long-Term Care - 0%
Dental - 1%
Med Supplies 1%Inpatient - 10%
Pharmacy - 9%
Outpatient 2%
Fee-For-Service PMPM Costs: All Study Groups
Percent by Category of ServiceMarch 1, 2003 - February 28, 2006
*Only children with 4+ months FFS enrollment in each study year
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32DRAFT
0
500
1000
1500
2000
2500
3000
3500
BL YR1 YR2 BL YR1 YR2 BL YR1 YR2
External Internal Medical Home
Study Groups Across Evaluation Periods
PM
PM
Re
imb
urs
em
en
ts
Professional Services
InPatient
Pharmacy
OutPatient
Medical Supplies
Dental
Fee-For-Service PMPM Costs by Category of Service and Study Group
March 1, 2003 - February 28, 2006
*Only children with 4+ months FFS enrollment in each study year.
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33DRAFT
Fee-For-Service PMPM Costs: All Study Groups By Age of Child at Baseline
*All Categories of Service except long-term care
*Only children with 4+ months FFS enrollment in each study year.
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Mar 1, 2003 - Feb 29, 2004 Mar 1, 2004 - Feb 28, 2005 Mar 1, 2005 - Feb 28, 2006
Study Periods
Un
ad
jus
ted
PM
PM
Re
imb
urs
em
en
ts
0-2 year old2-6 year olds7-12 year olds13-18 years old
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34DRAFT
Fee-For-Service PMPM Costs: All Study Groups By Severity of Condition at Baseline*All Categories of Service except long-term care
*Only children with 4+ months FFS enrollment in each study year.
0
500
1000
1500
2000
2500
3000
3500
Mar 1, 2003 - Feb 29, 2004 Mar 1, 2004 - Feb 28, 2005 Mar 1, 2005 - Feb 28, 2006
Study Period
Un
ad
jus
ted
PM
PM
Av
era
ge
Re
imb
urs
em
en
t
3_Most Severe
2_Moderate Chro
1_Minor Chronic
4_Healthy/Acute
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35DRAFT
Any Year 2 Health Services: Association with Medical Home Clinics
Any InpatientAdmissions
Any Emergency Department Visits
Medical Home Site
Care Coordinator Hours
Odds Ratio (95% CI)
Odds Ratio (95% CI)
Clinic A 0 4.72 (1.35 to 16.58) 0.60 (0.15 to 2.36)
Clinic B 4 3.65 (1.75 to 7.61) 1.19 (0.66 to 2.13)
Clinic C 5 2.62 (0.97 to 7.03) 0.42 (0.16 to 1.09)
Clinic D 16 1.85 (1.13 to 3.03) 1.33 (0.98 to 1.81)
Clinic E no CC 1.52 (0.33 to 7.11) 0.94 (0.32 to 2.73)
Clinic F no CC 1.16 (0.14 to 9.56) 0.48 (0.11 to 2.17)
Clinic G 24 0.95 (0.32 to 2.78) 1.70 (0.89 to 3.27)
Clinic H 0 0.78 (0.36 to 1.65) 1.74 (1.23 to 2.45)
Clinic I no CC ----- ----- ----- 0.90 (0.28 to 2.87)
All Non-MMHP Sites Reference Reference
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36DRAFT
Inpatient Admissions by Medical Home Status of Clinics
*overall PMPM rates are not adjusted
-0.02
0
0.02
0.04
0.06
0.08
0.1
0.12
BL YR1 YR2
Study Period
PM
PM
Adj
uste
d R
ate
n = 54
n = 15n = 17
n = 13
n = 39n = 33
n = 13n = 185
n = 144
overall non-MH; n = 15774overall MH; n = 513
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37DRAFT
Emergency Department PMPM Visits by Medical Home Status of Clinics
*overall PMPM rates are not adjusted
0
0.02
0.04
0.06
0.08
0.1
0.12
Baseline (03/1/03-01/29/04) Year 1 (03/01/04-02/28/05) Year 2 (03/01/05-02/28/06)
Study Period
PM
PM
Ad
jus
ted
Ra
te
n = 54
n = 15
n = 17
n = 13
n = 39
n = 33
n = 13
n = 185
n = 144
overall non-MH; n = 15774
overall MH; n = 513
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38
Preliminary Results: Potential Impact
Rates decreased over time IP Admissions Medical supply claims (steepest for MH)
Increased likelihood of any Year 2
dental visits
well-child visits for 0-6 year olds
Care plans associated with decreased IP admissions
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39
Preliminary Results: Learnings
“Appropriate care” measures multiple categories of servicedo not look at utilization/cost in isolation
CSHCN ascertainment methodology initial comparison group analysis
More standardization and/or data needed from the medical home teams
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40
Preliminary Analysis: Limitations
Selection Bias
Outcomes defined as cost and/or utilization offsets rather than quality of life, other externalities
Exposure Misclassification and Measurement Error
Administrative Data
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41
Preliminary Results: Feasibility?
Can the medical home program
be evaluated using
administrative data?
Answer:
Only provides a partial picture…..
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42
Future Research Directions
Revise control group ascertainment method
Relative weight analysis to better evaluate the overall impact of the MMHP
Develop CSHCN-specific performance measures
Standardize and measure medical home “exposure”
Evaluate the sensitivity/specificity of administrative data for CSHCN
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43
Acknowledgements
Funding Source/Grant Number
MNDHS and MCSHCN/MDH staff (Jon Huus, Jeff Tenney, Greg Gifford)
Medical home teams and participants
Tonga Nfor, MD
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Authors: Muree Larson-Bright, PhDAuthors: Muree Larson-Bright, PhD Susan CastellanoSusan Castellano Tonga Nfor, MDTonga Nfor, MD
Minnesota Department of Human ServicesMinnesota Department of Human ServicesPerformance Measurement and Quality Performance Measurement and Quality
ImprovementImprovementMaternal and Child Health AssuranceMaternal and Child Health Assurance
651.431.2635651.431.2635muree.larson-bright@[email protected]