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RIte Care’s Culture of Continuous RIte Care’s Culture of Continuous Improvement Improvement

Based on Research & Data AnalysisBased on Research & Data Analysis

Presentation to Presentation to Academy Health- State Health Research and Policy Interest GroupAcademy Health- State Health Research and Policy Interest Group

ByByMelinda ThomasMelinda Thomas

Project Manager, RI Affordable Health Care ProjectProject Manager, RI Affordable Health Care ProjectRI Department of Human ServicesRI Department of Human Services

June 25, 2005June 25, 2005

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OverviewOverview

•Understanding the Culture

•Applying Research and Data Analysis

•Lessons Learned

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Understanding the Culture

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Culture of Continuous ImprovementApproach

• Set Goals• Identify measurable

indicators• Establish a baseline• Implement Program

Intervention• Monitor Trends• Evaluate impact• Make midcourse

corrections

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Culture of Continuous Improvement Environment

– Insist on data driven policymaking and program design– Focus on data-based decision making prevents decision

making based on anecdotes and bias, which can be divisive and result in bad programs

– Openness to participation in data analysis and discussion at all levels. “If you’re interested, you’re welcome”

– Encouragement & support of any effort made to apply data analysis & research to program development

– Openness to critique– “seen as an opportunity for improvement”

– Respect for different standards and motivations of policy & program staff and academic researchers

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Cultural of Continuous Improvement Spanning Boundaries*

Policymakers/Program Staff

– Ease with generalization

– Pragmatic

– “Bias for Action”

* Based on Steve Shortell presentation at 2002 Academy Health Policy Conference

Researchers

– Emphasis on scientific rigor

– Stand- up to scrutiny

– Long timeline

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Applying Research & Data Analysis

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RIte CareRIte Care

Created in 1994 under Medicaid R&D waiver with the following goals:

1. Reduce uninsurance for low-income children and families

2. Improve access, service quality and health status for the covered population

3. Control the rate of growth in Medicaid expenditures for the eligible population

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Goal 1:

Reduce uninsurance for low-income children and families

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RIte Care Enrollment GrowthRIte Care Enrollment Growth

20,000

30,000

40,000

50,000

60,000

70,000

80,000

RIte Care Implemented Aug 94

Enrolled:

-TANF Families- Children 0 to 60 yrs. Up to 250% FPL-Pregnant Women up to 350% FPL

En

roll

men

t

Expansions

Outreach

May 97

Expanded to children 8 to 18 yrs. Up to 250%

FPL

April 99 – June 00

RIte Care Outreach Project

July 99

Expanded to undocumented

alien children and children up to 19

yrs.

April 96

Expanded to children 6 to 8 yrs. Up to 250%

FPL

Nov 98

Expanded to parents up to 185% FPL

Oct 98 Mail-in application

information

Oct 99

-Market Changes:

-Rate Changes

-HPHC Closes

July 00

Health Care Reform RI 2000 signed into law

Dec 00

Foster children transfer from fee-for-service to RIte

Care

May 01

RIte Share mandatory enrollment

begins

Begin 3% Premium share collection for 4,805 families and

Direct Member Reimbursement for

RIte Share

Feb 01

RIte Share voluntary

enrollment begins

Child Child

AdultAdult

Dec-95 Jun-96 Dec-96 Jun-97 Dec-97 Jun-98 Dec-98 Jun-99 Dec-99 Jun-00 Dec-00 Jun-01 Dec-01 Jun-02 Dec-02 Jun-03 Oct-03

Total 70,819 71,367 71,076 72,993 75,484 75,215 74,853 86,618 94,510 104,041 106,554 111,624 117,185 117,024 117,507 119,257 121,335

Child 47,454 48,662 48,884 50,321 52.042 52,208 52,046 56,628 61,533 67,638 69,254 72,817 76,379 76,085 76,151 76,957 78,394

Adult 23,365 22,705 22,192 22,672 23,442 23,007 22,807 29,990 32,977 36,403 37,300 38,807 40,806 40,939 41,356 42,300 42,941

Sept 03

Begin enrollment of Children with Special

Needs

Aug-02

Begin 5% Premium share collection

Jun 02

RIte Share enrollment tops 2,000

Nov 03

RIte Share enrollment tops 5,000

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Percent Uninsured Rhode Islanders Percent Uninsured Rhode Islanders All Ages-1994-2003All Ages-1994-2003

10

7.7

10.29.8

5.96.9

10.29.9

11.512.9

0

5

10

15

20

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Per

cen

t U

nin

sure

d

Data Source: Medicaid Research and Evaluation Project, RI Access ProjectUS Bureau of the Census, Current Population Surveys 1994-2003 (September estimates)

4th 5th

4th 1st

1st

Tied 1st

National Ranking8th 6th Tied 3rd 2nd

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Percent Uninsured Rhode Island Percent Uninsured Rhode Island Children Children

< 18 Years Old - 1994-2003< 18 Years Old - 1994-2003

7.6

5.24.74.5

2.4

6.97.9

6.3

9

12.5

0

5

10

15

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Per

cent

Uni

nsur

ed

Data Source: Medicaid Research and Evaluation Project, RI Access ProjectUS Bureau of the Census, Current Population Surveys 1994-2002 (September estimates)

2nd 1st

2nd 3rd

1st

3rd

National Ranking8th 25th

2nd 2nd

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RI saw a Decrease in Employer Sponsored Coverage 2000-2003

Erosion in employer-based coverage has resulted in an increase in the state's uninsurance rate. In 2000, 77.7% of the population was covered by employer-based insurance

and that percentage decreased to 68.4% in 2003.

72.8

70.2

72.8

75.9

77.7

73.9

69.368.4

65

70

75

80

1996 1997 1998 1999 2000 2001 2002 2003

Per

cen

t u

nin

sure

d

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Rhode Island’s RIte Care strategy reduced uninsurance rates significantly through 2000 and helped contain the increase between 2000 and 2003

Since 2000 strategy is focused on stabilizing caseload and preventing erosion in employer sponsored health care

RIte Share – 6000 members, half the cost Access to affordable health care for small

employers and their employees

RIte Care StrategyRIte Care Strategy

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105,000

110,000

115,000

120,000

125,000

130,000

RIte Care Base

Total RC/RS

RIte Share Stabilizes Growth in RIte Share Stabilizes Growth in RIte CareRIte Care

Goal 2:Improve access, service quality and

health status for the covered population

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• Oversight and monitoring of Health Plan contracts • site visits • encounter data analysis

• Health Plan Performance incentives

• Trend access, quality and health outcome indicators for all enrollees

Methods

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Performance Incentive Performance Incentive ProgramProgram

• Three types of performance goals:– Access– Clinical– Administrative

• Performance goals were selected to represent:– key areas of Health Plan performance - age and gender of the RIte Care

population

• Use of HEDIS measures plus other measures specific to the population, such as lead screening

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Performance Category

1999 2000 2001 2002 2003 2004

Administrative 60.1% 71.5 % 65.9 % 83.7 % 79.8 % 74.8%

Access 65.7 % 61.8 % 44.0 % 73.2 % 75.8 % 81.5%

Clinical 63.1 % 57.8 % 68.2 % 68.6 % 65.8 % 59.5%

Overall 63.3 % 62.0 % 60.6 %

73.2 % 71.6 % 69.2%

Percent of Potential Incentive Payments Percent of Potential Incentive Payments Received by the Health Plans by Years Received by the Health Plans by Years Shows Significant Overall ImprovementShows Significant Overall Improvement

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40455055606570758085

1999 2000 2001 2002 2003 2004

Year

Administration Access Clinical Overall

Percent of Potential Incentive Percent of Potential Incentive Payments Received by Health Plans Payments Received by Health Plans

Over Six YearsOver Six Years

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Six-year Trend of Performance Six-year Trend of Performance Incentive Payments Shows Overall Incentive Payments Shows Overall

ImprovementImprovement

50

55

60

65

70

75

80

85

1999 2000 2001 2002 2003 2004

Administration Access Clinical Overall

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Monitoring Trends

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Percent of Women with Short Interval BirthsPercent of Women with Short Interval Births(<18 months) by Insurance Status 1993-(<18 months) by Insurance Status 1993-

20022002

27.8 27.528.7 28.2

40.8

28.629.8

30.728.9 29.7 30.3

31.3

2827.526.6

28.430.2

27.2

38.2

30

20

30

40

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Private Medicaid

Data Source: Medicaid Research & Evaluation ProjectVital Statistics Birth File 1993-2001 – (n=111,865)

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Percent of Women who Received Percent of Women who Received Adequate/Adequate+ Prenatal Care by Adequate/Adequate+ Prenatal Care by

Insurance Status 1993-2002Insurance Status 1993-2002

72.1

83.2 83.6 83.5

55.8 58.163.4

67.5 69.2 70.9 73.2 73 73.8 72.1

81.580.980.574.6

71.377.6

40

60

80

100

120

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Private MedicaidData Source: Medicaid Research & Evaluation ProjectVital Statistics Birth File 1993-2001 – (n=111,865)

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15%

88%

79%

0%

20%

40%

60%

80%

100%

National Medicaid RIte Care 1997 RIte Care 2003

National Medicaid RIte Care 1997RIte Care 2003

RIte Care Lead Screening Rates RIte Care Lead Screening Rates ImproveImprove

Percent of Two Year Olds with Timely Recommended Percent of Two Year Olds with Timely Recommended ScreeningScreening

* **

* GAO report + NHANES estimates** Patrick Vivier, MD, Phd, 1997

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Comparison of Lead Screening and Lead Poisoning Comparison of Lead Screening and Lead Poisoning Rates for RIte Care and Commercially Insured Rates for RIte Care and Commercially Insured

Children Children Enrolled in the Same Managed Care OrganizationEnrolled in the Same Managed Care Organization

20032003  

Measure Commercial RIte Care

Lead Screening    

Percent Ever Screened

87 % 88 %

Percent Never Screened

13 % 12 %

Lead Poisoning    

Percent ≥ 10 ug/dL 7 % 17 %

Percent < 10 ug.dL 93 % 83 %

Source: O’Hare, C. et. al. Lead Screening and Lead Poisoning in Medicaid and Commercially Insured Children Enrolled in the Same Managed Care Organization, American Public Health Association Poster Session, 2003.

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Immunization Rates for Children Immunization Rates for Children Enrolled in RIte Care Exceed the Enrolled in RIte Care Exceed the

National AverageNational AverageImmunization Rates for 19- to 35-month-Immunization Rates for 19- to 35-month-

olds: olds: US, RI and to RIte CareUS, RI and to RIte Care Overall* DtaP% Hib% Hepatitis B% MMR% Polio%

National (CDC)

76 81 93 84 91 91

Rhode Island (CDC)

81 89 96 87 95 96

RIte Care 81 87 94 88 91 95

 *Overall status includes all vaccines except hepatitis B Source: Vivier P.M. et. al. “An analysis of the immunization status of pre-school children enrolled in a statewide Medicaid Managed Care Program,” The Journal of Pediatrics, 139(5), November 2001, 624-

629.

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Infant Mortality Rate Declines in Rhode Infant Mortality Rate Declines in Rhode Island Island Infant Mortality by Insurance StatusInfant Mortality by Insurance Status

1990-19991990-1999

10.6

7.2 7.1 6.86

5.34.7 4.7

5.4 5.3

77.27.2

9.910.7

8.5

4.8 5.4

6.4 6.4

2

4

6

8

10

12

14

90 91 92 93 94 95 96 97 98 99

Public (n=325) Private (n=470)

Data Source: Medicaid Research & Evaluation ProjectCenter for Child & Family Health, Department of Human ServicesLinked Birth Death File 1990-99, Division of Family Health, Department of Health (n=905)Deaths per 1000 births to Infants 0-364 days – 3 year moving average

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Rhode Island’s Neonatal Mortality Rate Rhode Island’s Neonatal Mortality Rate DeclinesDeclines

Neonatal Mortality by Insurance StatusNeonatal Mortality by Insurance Status 1990-19991990-1999

6.2

4.8 4.9 4.84.6

4 3.9 4 4.23.9

4.54.74.5

6.36.2

5.4

3.84.4

5.2 5.1

2

4

6

8

90 91 92 93 94 95 96 97 98 99

Public (n=325) Private (n=470)

Data Source: Medicaid Research & Evaluation ProjectCenter for Child & Family Health, Department of Human ServicesLinked Birth Death File 1990-99, Division of Family Health, Department of Health (n=905)Deaths per 1000 births to Infants 0-364 days – 3 year moving average

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Rhode Island’s Postneonatal Mortality Rate Rhode Island’s Postneonatal Mortality Rate Declines Declines

for Publicly Funded Birthsfor Publicly Funded BirthsRhode Island Postneonatal Mortality by Insurance StatusRhode Island Postneonatal Mortality by Insurance Status

1990-19991990-1999

4.3

2.4 2.2

1.5 1.4

0.8 0.81.3

1.9

2.52.52.7

3.6

4.5

3.1

1.41 11.2 1.3

0

1

2

3

4

5

6

90 91 92 93 94 95 96 97 98 99

Public (n=325) Private (n=470)

Data Source: Medicaid Research & Evaluation ProjectCenter for Child & Family Health, Department of Human ServicesLinked Birth Death File 1990-99, Division of Family Health, Department of Health (n=905)Deaths per 1000 births to Infants 0-364 days – 3 year moving average

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Goal 3:Control the rate of growth in Medicaid

expenditures for the eligible population

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RIte Care: Cost-EfficientRIte Care: Cost-Efficient

“ A few states have revamped their organizational and management systems to ensure better access to medical care while keeping costs under control. Rhode

Island stands out in this respect.” Governing Magazine, Feb 2004

Comparison of PMPMs

$-

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

$350.00

Jul-94 Jul-95 Jul-96 Jul-97 Jul-98 Jul-99 Jul-00 Jul-01 Jul-02 Jul-03

Period

PM

PM

s w

ith

Re

ten

tio

n

$-

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

$350.00

RIte Care PMPM Risk Share FFS equivalent PMPM Copay-Adjusted RI Commercial

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Lessons Learned

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“Lessons for other States” Building Quality into RIte Care: How RIte Care is Improving

Health Care for Its Low-Income Populationsby Sharon Silow-Carroll*

• Start Early to Establish a Baseline

• Use the Data in a Variety of Ways

• Integrate Research into the Medicaid Program

• Use Interdisciplinary Team

• Ensure Access to Data• Acknowledge Trade-offs

in Subsidizing Private Health Coverage

• Supplement Research and Evaluation with Outside Funding

• Monitor Long Term Goals

*Field Report, The Commonwealth Fund, January 2003