OPQC Learning Session: High Risk Moms & Infants. Mary Applegate, MD, FACP, FAAP Medical Director, Ohio Department of Medicaid September 2016

Transcription

1 OPQC Learning Session: High Risk Moms & Infants Mary Applegate, MD, FACP, FAAP Medical Director, Ohio Department of Medicaid September 2016

2 OLD: 9/19/2016 2

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4 Collaboration, Cooperation & Coordination Microsystems are the building blocks that come together to form Macro-organizations Macrosystem Mesosystem Microsystem

5 It takes a village

6 High Risk Population Efforts: Observations NICU infants» BSI, hospital processes Mothers at Risk for Preterm Birth» EED, hospital processes» Progesterone hospital & * outside hospital processes Addicted Infants» NAS hospital processes Addicted mothers» *pre-hospital processes Technology dependent infants» hospital processes, *post-hospital processes 9/19/2016 6

7 How DO We Get Off the Ground Floor? Step back for broader perspective Set audacious goals (Cut preterm births by 50%, End racial disparities) Think about high level pieces of work (Key Driver) & partners Then drill down Patiently Result? A different solution & direction collectively Examples 9/19/2016 7

8 Making Ohio 8 Better Ohio Minds Matter: Safer Prescribing of Antipsychotic Medications for Ohio s Youth Measures: Antipsychotic (AAP) medications in children less than 6 years of age 2 or more concomitant AAP medications for over 2 months duration. 4 or more psychotropic medications in youth <18 years of age Foster Care Mandate 2012 Conduct Research & Build Collaborative Partnerships Conduct Initial Pilot Launch Collaborative Pilots & Family/Patient Empowerment Effort Demonstration 2016 Establish Best Clinical Practice with Shared Decision Making Lessons Learned Guide Systems Reform Evaluation Sustainability through HEDIS measures in MCP contracts Burning platform

9 Making Ohio 9 Better Learning from Systems Observations Behavioral Health Systems Re-Design

10 Date Milestones in Progesterone Performance Improvement Effort July 2013 MCPs coverage expanded to statewide Presumptive eligibility for Pregnant women Enhanced Maternal Care Requirements integrated into Managed Care Plan Provider Agreement October 2013 Go Live--Ohio Benefits self-service portal January 2014 Medicaid Expansion women under 138% of FPL newly eligible under ACA May 2014 Vital Statistics linked to Medicaid Claims to Identify High Risk Women based on previous preterm birth October 2014 CMS approval of redesigned federally mandated performance improvement project Dec 2014 June 2015 Managed Care Plans trained on QI process and appropriate use of Progesterone for High Risk Women Spring 2015 Progesterone performance improvement project (Medicaid MCPs and OPQC affiliated sites) begins Community-based infant mortality budget initiatives in to address health equity issues Minimize Medicaid and MCP disenrollment due to annual redetermination July-September 2015 Clinicians communicating pregnancy status ( skinny form ) MCPs assigning care managers Care Manager responsible for notifying county of pregnancy to ensure ongoing eligibility November 2015 All 23 OPQC sites use the skinny communication form identifying progesterone candidates Removal of PA on all forms of Progesterone and associated Home Health Visits Feb 2016

11 OPQC Progesterone Project Reductions in % of Births < 32 Weeks to Mothers on Medicaid with History of Previous PTB 21% decrease in Participating Hospitals * 21% IMPACT: This equates to 33 fewer babies < 32 weeks born to mothers in the Medicaid program, 26 of whom were African- American ODH Birth Registry Monthly Data January 2012 February 2016

12 Death Rates Per 100,000 for Drug Poisoning (All Manner), by Year, Ohio vs. US, Rate per 100,000 persons 30 US Rate 25 Ohio Rate Source: ODH 2000 Office 2001 of 2002 Vital Statistics

13 Drug Overdose Epidemics in Ohio, Prescription drugs led to a larger overdose epidemic than illicit drugs ever have. Heroin & Rx opioids Heroin Crack Cocaine 0 JCAHO establishes pain standards & modified

14 Unintentional Drug Overdose Deaths of Ohio Residents by Specific Drug(s) Involved, * NUMBER OF DEATHS 1,600 1,400 1,200 1, cocaine benzodiazepines heroin Prescription Opioids* Fentanyl (illicit and prescription) Prescription Opioids not including Fentanyl; Fentanyl was not captured in the data prior to 2007 as denoted by the dashed line Source: ODH Bureau of Vital Statistics; Analysis Conducted by ODH Injury Prevention Program 14

15 EpiAid Data Results: OARRS Data Majority of heroin and fentanyl decedents not prescribed opioids at the time of death (~75%) However, over 60% of fentanyl and heroin decedents had a history of opioid prescription at some point in the 6-7 years preceding their death. Of those:» 50% were prescribed a max opioid dose of >= 50 MME» 35% were prescribed a max opioid dose of >= 90 MME 15

16 Medicaid Trends in Opioid Use: Gender & Age Groups 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Female Male All Female Male Source: Medicaid Claims and encounter data for calendar years , including all Medicaid claims paid through January Proportion of all eligible Medicaid beneficiaries ages with an opioid claim, by gender and age. 9/19/

17 Timeline: Opioid Prescribing Policy and Initiatives Law Enforcement Closure of pill mill pain clinics Regulatory tightening $3M invested in BH programs through local jails Enhanced training on heroin epidemic Addiction Treatment PP Enhanced training on overdose investigations Prevention Services Don t Get Me Started - an opioid abuse campaign Start Talking! youth drug prevention program, Drug court, housing investments OARRS integration into EHR Guiding Appropriate Prescribing Release of low-dose protocols: buprenorphine & Suboxone Opioid guidelines for emergency/acute care settings Drop Box Program Opioid guidelines for chronic, non-terminal pain Health Resource Toolkit for providers Mandatory Prescription Drug Monitoring Program Opioid guidelines for management of acute pain CDC guidelines Expanding Access to Treatment and Recovery Expanded use of MAT (Medication Assisted Treatment) SOLACE Project DAWN NAS treatment protocol development Legislation: first responders may administer naloxone SBIRT implementation grant MOMS Program develops best practices for opioiddependent mothers & newborns (NAS) Legislation to allow pharmacists to dispense Naloxone without an Rx More than 800 Ohio pharmacies offer naloxone without an Rx Medicaid Initiatives Coverage of MAT services Expansion of Medicaid coverage Development and monitoring of measures for opioid guidelines Behavioral Health Redesign Data transparency?build into valuebased purchasing?

18 Quarter Proposed Metrics for Ohio Guidelines for the Management of Acute Pain Outside of Emergency Rooms** Total Dispensed to Ohio Patients Total Opioid Doses per Quarter Acute Pain All Ohio Patients Acute Pain Acute Pain Acute Pain Total Patients w/ One Opiate Rx Average Units* per Rx Median Units* per Rx Average MED per Rx # of New Rx # of Refills Authorized ,209,367 65,005,666 1,269, , ,608, , ,878,652 69,557,428 1,290, , ,699, , ,569,758 67,259,765 1,289, , ,689, , ,404,281 68,923,642 1,279, , ,692, , ,140,901 63,994,883 1,239, , ,607, , ,155,531 70,795,398 1,283, , ,817, , ,982,798 66,283,613 1,284, , ,746, , ,351,431 61,462,971 1,255, , ,628, , ,295,997 59,578,844 1,198, , ,577, , ,555,743 67,003,562 1,223, , ,674, , ,965,312 58,447,099 1,202, , ,613, , ,410,470 67,227,653 1,215, , ,628, , ,574,887 54,142,565 1,181, , ,497, ,816 *Units - Solid dosage units only (eg. tablets, capsules, patches). Liquids and powders are not included. **For the purposes of these metrics, a prescription is considered to be for the management of acute pain if the patient not been dispensed an opioid prescription in the 90 days prior to the beginning of the given quarter

19 Number of Pain Episodes per 1,000 Beneficiaries [Ages 12-24] Back Ortho Abdominal Migraine Dental UTI Female Male Source: Medicaid Claims and encounter data for calendar year 2013, including all Medicaid claims paid through June

20 OHIO DEPARTMENT OF MEDICAID NAS inpatient hospitalization rate per 10,000 live births Ohio, % 1.4% 1.2% 1.0% Trends in Dependency and Poisoning [Ages and 12-64] N 2013 = 42,140 [12-64] System capacity crisis Rate per 10, % 0.6% N 2014 = 10,737 [12-24] % N 2013 = 3,155 [12-64] % 0.0% Ages Opioid dependence and abuse *Excludes poisoning by Ages Poisoning by opiates & related heroin narcotics* N 2014 = 1,425 [12-24] Source: Medicaid Claims and encounter data for calendar years , including all Medicaid claims paid through January Year Source: Ohio H Proportion of beneficiaries ages and who received a diagnosis of opiate dependency, abuse, or poisoning and had an opiate claim within the same year. 20

21 How Can we Think About NAS and MOMS Differently with Sustainability in Mind?? A patient centered medical home for maternity population?? Episodes of Care for Medication Assisted treatment? How might the Re-Design of the behavioral health system impact the care and outcomes of these families? Do we have the data, content, evidence, partners, sequencing, scope intensity of ideal practice sufficiently delineated for an effective bundle? 9/19/

22 SUSTAINABILITY: Shift to population- and episode-based payment Payment approach Fee-for-service (including pay for performance) Episode-based Population-based: (PCMH, ACOs, capitation) Most applicable for Discrete services correlated with favorable outcomes or lower cost Acute procedures (e.g., CABG, hips, stent) Most inpatient stays including newborn deliveries, readmissions Acute outpatient care (e.g., broken arm) Primary prevention for healthy population Care for chronically ill (e.g., managing obesity, CHF)

23 v Value-Based Alternatives to Fee-for Service Fee for Service Incentive-Based Payment Transfer Risk Ohio s State Innovation Model (SIM) focuses on (1) increasing access to comprehensive primary care and (2) implementing episode-based payments Fee for Service Pay for Performance Patient- Centered Medical Home Episode- Based Payment Accountable Care Organization Payment for services rendered Payment based on improvements in cost or outcomes Payment encourages primary care practices to organize and deliver care that broaden access while improving care coordination, leading to better outcomes and a lower total cost of care Payment based on performance in outcomes or cost for all of the services needed by a patient, across multiple providers, for a specific treatment condition Payment goes to a local provider entity responsible for all of the health care and related expenditures for a defined population of patients

24 High performing primary care practices engage in these activities to keep patients well and hold down the total cost of care

25 Must pass 50% Ohio CPC Clinical Quality Requirements Category Measure Name Population Population health priority NQF # Pediatric Health (4) Women s Health (5) Adult Health (7) Behavioral Health (4) Well-Child Visits in the First 15 Months of Life Pediatrics 1392 Well-Child visits in the 3rd, 4th, 5th, 6th years of life Pediatrics 1516 Adolescent Well-Care Visit Weight assessment and counseling for nutrition and physical activity for children/adolescents: BMI assessment for children/adolescents Breast Cancer Screening Adults Cancer 2372 Cervical cancer screening Adults Cancer 0032 Adult BMI Adults Obestiy HEDIS ABA Controlling high blood pressure (starting in year 3) Adults Heart Disease 0018 Med management for people with asthma Both 1799 Statin Therapy for patients with cardiovascular disease Adults Heart Disease HEDIS SPC Comprehensive Diabetes Care: HgA1c poor control Adults Diabetes 0059 (>9.0%) Comprehensive diabetes care: HbA1c testing Adults Diabetes 0057 Comprehensive diabetes care: eye exam Adults Diabetes 0055 Antidepressant medication management Adults Mental Health 0105 Follow up after hospitalization for mental illness Preventive care and screening: tobacco use: screening and cessation intervention Initiation and engagement of alcohol and other drug dependence treatment Pediatrics Pediatrics Both Both Obesity, physical activity, nutrition Mental Health Substance Abuse HEDIS AWC 0024 Timeliness of prenatal care Adults Infant Mortality 1517 Live Births Weighing Less than 2,500 grams Adults Postpartum care Adults Infant Mortality 1517 Adults Infant Mortality Substance Abuse N/A Detailed requirement definitions will be posted on the Ohio Medicaid website Measures will evolve over time Measures will be refined based on learnings from initial roll-out Hybrid measures that require electronic health record (EHR) may be added to the list of core measures Hybrid measures may replace some of the core measures Reduction in variability in performance between different socioeconomic demographics may be included as a CPC requirement Note: All CMS metrics in relevant topic areas were included in list except for those for which data availability poses a challenge (e.g., certain metrics requiring EHR may be incorporated in future years)

26 Transparency in Data & Performance

27 Next Steps: Together Thank you Think Plan Collaborate Act Share (data, insights) Repeat 9/19/

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