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Policy Lessons Learned from Health Administrative Datasets: Improving Mental Health Care

M. Horvitz Lennon MD MPHRAND Corporation

CUTEHeart Workshop Health Services Research: From Data to Practice

December 11, 2014

Outline Role of health services research in the pursuit of optimal population health

Observational studies and administrative data – key health services research tools

Key targets of health services research in the US – focus on people schizophrenia & other serious mental illness

Research in the care received by Medicaid beneficiaries with schizophrenia – some examples

Lessons for Medicaid policymakers regarding care for people with schizophrenia

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AcknowledgmentsCo-investigator: Sharon-Lise Normand PhDData Analyst and Programmer: Rita VolyaFunding: NIMH

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Role of Health Services Research in the Pursuit of Optimal Population Health

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The 3 T’s Road Map to Transform US Health Care.. The “How” of High-Quality Care. Dougherty & Conway, JAMA 2008

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Health Services Research

Multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to, and quality and cost of health care, and ultimately our health and well-being (Academy for Health Services Research and Health Policy, 2000)

Health services research informs and evaluates health policy (Steinwachs, DM et al. Health services research: Scope and significance. In Patient Safety and Quality: An Evidence-Based Handbook for Nurses; Hughes, RG, Ed.; AHRQ 2008)

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Population-based Observational Studies & Administrative Data

Key Health Services Research Tools

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Observational Studies versus RCTs

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Observational studies Randomized controlled trials

Strengths Good external validityProvide evidence of effectiveness of treatments in the general populationMay be used to study:

rare events and effects of prolonged exposure to treatmentresearch questions that may not amenable to RCTsdelivery of care in routine practice

Excellent internal validityMeasure size of treatment effects withminimal bias – provide evidence of efficacy and safety of treatments in ideal conditions and for selected populations

Limitations Lower internal validityAssessment of comparative outcomes is prone to biasPopulation-level databases often lack detailed information on patients’ health status and health care (recommended and received)

Limited external validityLimited applicability to clinical practice:

do not provide evidence of effectivenesslimited ability to detect rarer events or those that emerge with prolonged exposure to treatments

Administrative Data

Data routinely produced and collected each time a patient uses health care, whether ambulatory or in the course of a hospital admission

Key data source for observational studies Widely used for health services research and epidemiologic studies

Main sources of administrative data in the US: data collected by public and private payers

Main sources of administrative data for research in serious mental illness care in the US: public payer data (Medicaid, Medicare, and Veterans Health Administration)

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Medicaid – the Program and the Data

Medicaid, a health insurance program… Financed jointly by federal and state governmentsAdministered by states Provides health insurance coverage to low-income and disabled individualsPolicies and benefits vary across states but are nearly identical for all beneficiaries in the state

Medicaid DataCollected by each state and submitted to the Centers for Medicare & Medicaid Services (CMS), a federal agency within the US Dept. of Health and Human Services States submit data to CMS on quarterly basis through the Medicaid Statistical Information System (MSIS)MSIS: Five distinct files of data organized as fiscal year data – data contain clinical, service use, and cost information

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Medicaid –the DataFile #1

Personal Summary: Eligibility and demographic characteristics for each person enrolled in Medicaid at any time during the quarter

Files #2-5: contain claims adjudicated for payment during the quarterInpatient: all services provided during inpatient carePharmacy: prescription drugs filled during outpatient careLong-term care: services provided in long-term care facilitiesOther Services: all other outpatient services

Standardized Coding Diagnoses: ICD-9Pharmacy: National Drug Codes (unique product identifier for human drugs)Services: Main: Healthcare Common Procedure Coding System (HCPCS) codes: level I (Current Procedural Terminology) describing traditional diagnostic and therapeutic services, and level II, describing non-physician services, both therapeutic and ancillary

Researchers can access state-level data and MAX data MAX data: Medicaid Analytic eXtract data extracted from MSIS by CMS

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Key Targets of Health Services Research in the US

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Institute of Medicine - 6 Aims of High Quality Health Care

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Focus on Equity: Racial/Ethnic & Geographic Health Care Disparities

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Schizophrenia -- a Burdensome and Costly Serious Mental Illness

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Heavy burden of disease -- early age at onset, chronicity, disability,

premature mortality

High direct and indirect costs to society

Although most people with schizophrenia are publicly insured in the US,

access to high-quality care is complicated by several factors:

Poor help-seeking, social disadvantage

Fragmentation of the US health care system

Unequal availability and accessibility of health care providers

Large sciences to services gap

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Key Targets of Research in US Health Care for People with Serious Mental Illness

Underuse – Clozapine; long-acting injectable antipsychotics; lithium; ECT (effectiveness)

Overuse – Antipsychotic polypharmacy (efficiency)

Misuse – Metabolic effects of widely used antipsychotics (safety)

Racial/Ethnic and Geographic Disparities in care (equity)

Temporal Trends –Are new evidence and policies & regulations improving care as usual?

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Some Examples of Research in the Care Received by Medicaid Beneficiaries with Schizophrenia

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Lessons for Policymakers Regarding Medicaid Care for People with Schizophrenia

First evidence that race/ethnicity does not modify the superior

effectiveness of clozapine

Additionally, in the 2000’s, underuse of clozapine remains a larger problem

for minority than white beneficiaries

First evidence that overall quality of care for Medicaid

beneficiaries with schizophrenia is poor

Additionally, quality has improved modestly through the 2000’s despite

intense focus on quality of care

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Lessons for Policymakers Regarding Medicaid Care for People with Schizophrenia

First evidence that care for Medicaid beneficiaries with

schizophrenia varies by race/ethnicity and place of residence

Quality of care and racial/ethnic disparities in quality vary among states

Quality of care, racial/ethnic disparities in quality, and access to innovations

vary within states

Quality of care improved modestly and variably across and within states in

the 2000’s - but racial/ethnic disparities in quality remained unchanged

Geographic variations in care can confound estimation of racial/ethnic

disparities because of uneven geographic distribution of minorities

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Possible Areas of Policy Action for Federal and State Decision-makers

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In communities where vulnerable populations live or localities with worst quality/equity performance:

Address socio-economic disadvantage

Improve quality of the health care infrastructure, including availability,

accessibility, and clinical & cultural competencies of specialists

Focus the attention of local policymaking bodies on the needs of their most

vulnerable residents

Educate vulnerable populations on the effectiveness and safety of treatments

and on self-advocacy & help-seeking skills