Ivory Towers, Golden Domes, and Healthcare April 22, 2008

1. Ivory Towers, Golden Domes, and HealthcareApril 22, 2008 Caroline Carney Doebbeling, MD, MSc Director of Health Quality, Policy Research, and Strategic Planning Indiana Office of Medicaid Planning and Policy Research Scientist Regenstrief Institute, Adult Health Services Research Associate Professor of Internal Medicine and Psychiatry, Indiana University School of Medicine

2. Both Sides of the Fence

3. Today’s Talk • Brief overview of Medicaid • Quality Program and Directions • Policy Program and Directions • Research Opportunities

4. OMPP Organizational Chart

5. Current FSSA Coverage Vehicles for MH Services FPL In 2008, 100% FPL for a family of four is $21,200. MEDWorks Buy-in 250% Hoosier Healthwise Under CMS Review 200% SCHIP 2 Expansion Parents of CHIP Children & Childless Adults HAP SMI or SED Healthy Indiana Plan 185% Medicare 150% Traditional Medicaid SCHIP 1 Pregnancy Services Only MEDWorks 133% Care Select 100% Parents of traditional Medicaid Children & Childless Adults 70-80%* Medicare-Medicaid Dual Eligible 23% 1-5 6-18 19-20 Pregnant 21-64 65+* Disabled Blind* Age <1 * Aged, Disabled, and Blind income eligibility is driven by SSI standards rather than FPL

6. Home & Community Based Waivers • Indiana has eight home and community based waivers: • Developmentally Disabled • Aged and Disabled • Medically Fragile Children • Autism • Traumatic Brain Injury • Assisted Living • Support Services • Seriously Emotionally Disturbed (Children)

7. Indiana OMPP Quality History • Focus based on financial outcomes • Little governance of policy process • Quality programs limited to Hoosier Healthwise membership • Data driven decisions limited by lack of encounter claims data • External consultants charged with development and implementation of quality programs • Pregnant women smoking cessation • Behavioral health/physical health communication form

8. Where Were We?“If we are to learn to improve the quality of decisions we make, we need to accept the mysterious nature of our snap judgments”Malcom Gladwellfrom Blink: The Power of Thinking Without Thinking, 2005 • Vision of new leadership at FSSA and OMPP • Data driven, not emotional or reactive decisions • Annual HEDIS reports • Quarterly process measures

9. The Way Forward • Institute of Medicine’s Crossing the Quality Chasm report • Safe • Effective • Patient-centered • Timely • Efficient • Equitable

10. Critical Appraisal • Team Building Approach • Health plans • Other government agencies • Stakeholders • Academics • Data Structure • Encounter claim study and rehabilitation of process • Linking OMPP Units • Reorganization placed Data, Strategic Policy, Policy Research and Program Evaluation with Quality and Outcomes unit • Target areas of Concern to State • Cross-cutting throughout all of OMPP • Neonatal and child health • Behavioral Health • Preventive Care • Chronic Disease

11. Encounter Claims and the Attempt to Measure Quality • Limited delivery of encounter claims by plan • <5% estimated behavioral health • Sporadic pharmacy claims • Efforts of data group led by Ryan McCartney, Operations by Randy Miller, and Quality to correct

12. Life of a Claim: Fee for Service

13. Life of a Claim: Capitation

14. Antidepressant Medication Management Optimal Practitioner Contacts for Medication Management Benchmarks: Benchmark data based off of NCQA/HEDIS percentiles, ranking 139 Medicaid health plans. Frequency: Members 18 years of age and older diagnosed with a new episode of depression and treated with antidepressant medication, and who had at least three follow-up contacts with a practitioner coded with a mental health diagnosis during the 84-day (12-week) Acute Treatment Phase. Exposure: Patients 18 years and older with continuous enrollment 120 days prior to the Index Episode Start Date through 245 days after the Index Episode Start Date. Previous Year Performance: 7.8%

15. Breast Cancer Screening Frequency: Women 40–69 years of age who had a mammogram to screen for breast cancer. Exposure: Women 42–69 years of the measurement year. With continuous enrollment for the measurement year and the year prior to the measurement year. Each reported date contains 12 calendar months of experience. • Notes • Continuously enrolled in Medicaid. • Administrative Data. Source: MedInsight. Data prepared by OMPP DMA

16. CMHC per Capita SpendMedicaid Rehabilitation Option Mean = $3,778 Source: Medicaid Incurred Claims Data SFY2007

17. Medicaid Mental Health Spendby Category of Service and Age Source: Medicaid Incurred Claims Data 2007.

18. Core-PAC & E-PAC 360 degrees of policy review • Core-PAC • Internal working group and invited external reviewers • Issues sent from OMPP executive team or Policy Evaluation Team for further research and context • Should this be implemented? If so, what are implications • Evidence, populations, intended and unintended consequences, economic analyes • E-PAC • Community and Government Stakeholders • Health Plans • Academics • OMPP and other state agency officials • Charge to “sign-off” on policy for statewide implementation

19. Current Topics • The Never List • Hospital Acquired Conditions • Autism Services • HPV Vaccination for 19-26 y/o • Intensive Feeding Programs • Medication Reminder Systems • ER Diversion Grant

20. Regenstrief Institute Projects Making Use of Indiana Medicaid Data • Clinical Use in INPC • Point-of Care Applications (McDonald, Overhage) • OMPP Projects • Various Projects by new Quality/Outcomes/Statistical Analysis team (Carney Doebbeling, Rosenman, Jones) • Public Health Use • Indiana State Department of Health / Indiana Joint Asthma Coalition (Rosenman)

21. Research Use Improving Laboratory Follow-up by Delivering an Enhanced Medication List to Outpatient Physician Practices (Simonaitis, et al) Does Collaborative Care for Vulnerable Elders Delay Institutionalization?—GRACE and PREVENT studies (Callahan et al) Measuring the Effect of Pharmacy Co-Pays on Health Utilization for Persons with Serious Mental Illness (Carney Doebbeling, et al) Health Care Access for Delinquent Youth(Aalsma, et al) Designated Medical Events Associated with Medication Use, in a Community-Wide Database(Rosenman, Overhage) Estimating Prenatal Syphilis Screening Rates In Indiana(Rosenman, et al) Structured Project Labeling Improves Detection of Drug Intolerance Issues(Schadow) Regenstrief Institute Projects Continued

22. Purdue and Other Collaborations • Laura Sands • Joseph Thomas • Butler University • Will you be next??

23. Next Steps • Research that benefits the citizens of Indiana and beyond • Research that is timely to the needs of OMPP • Research conducted in the proper context of OMPP, the data being used, and the healthcare climate • Administrative data studies to implementation • Partners in Research • Prenatal Care, Early Childhood • Preventive Care • Chronic Disease • Waiver Populations • Behavioral Health • New policy outcomes

24. The How Emily Hancock Manager of Policy Research Directs the Core PAC and E-PAC meetings and initiatives Liaison with Medicaid Medical Advisory Cabinet External Research Liaison Advise, review, write, edit Publication with OMPP approval and authorship, as appropriate

25. Questions?