Download II - CityMatCH

Preconception Health
Policy and Finance
Anne Rossier Markus, JD, PhD, MHS
Associate Research Professor, Department of Health Policy
The George Washington University
2007 CityMatCH Urban MCH Leadership Conference
August 26-28, 2007
Denver, Colorado
Outline - Access to Quality
Preconception Care
CDC Recommendation:
To Improve Health Insurance Coverage of Preconception Care
especially for low-income women who may be at
higher risk for adverse birth outcomes


CDC Select Panel’s Workgroup on Financing of
Preconception Care
CDC Action Steps
– Improving the Design of Medicaid Family Planning
Waivers
– Monitoring, and Tying Payment to, Quality of
Preconception Care through the HEDIS Measurement
System
CDC Select Panel’s Workgroup on
Financing of Preconception Care:
Findings and Recommendations
March 9, 2007
Workgroup Membership

Co-Chairs:
– GWU SPHHS Department of Health Policy
– Dartmouth-Hitchcock Medical Center Department of Pediatrics
– CDC Workgroup Lead

Members:
–
–
–
–
–
–
JIWH; KFF
AGI; ACOG; MOD
NACCHO
ASTHO; NCSL
AMCHP; NACHC; National Healthy Start Association
CDC; HRSA-MCHB; CMS
Working Parameters
1. Vision for Preconception Care
2. Definition of Preconception Care
3. Standard of Preconception Care
BUT
4. Mixed private and public financing
system with lack of universal coverage of
women of reproductive age
1. Vision for Preconception
Care



All women of childbearing age have
health coverage
All women of childbearing age are
screened prior to pregnancy for risks
related to outcomes
Women with a prior adverse
pregnancy outcome have access to
intensive preconception care to reduce
their risks
2. Definition of
Preconception Care
A set of interventions that aim to
identify and modify biomedical,
behavioral, and social risks to a
woman’s health or pregnancy outcome
through prevention and management,
emphasizing those factors which must
be acted on before conception or early
in pregnancy to have maximal impact.
3. Standard of Preconception
Care & Core Components
Health Promotion
& Counseling
Assessment &
Screening
Medical & reproductive history;
Genetic & family history;
Environmental & occupational
exposures; Family planning and
pregnancy spacing; Nutrition, folic
acid intake, and weight
management; Medications;
Substance use (alcohol, tobacco
and illicit drugs); Infectious
diseases; Psycho-social (e.g.,
depression, domestic violence,
housing)
Healthy weight; Nutrition;
Preventing STD & HIV
infection; Family planning
methods; Abstaining from
tobacco, alcohol, and illicit
drug use before and during
pregnancy; Consuming folic
acid; Controlling pre-existing
medical conditions (e.g.,
diabetes); Risks from
prescription drugs; Genetic
conditions
Brief
Interventions
Immunization
Smoking cessation
Alcohol misuse
Weight management
Family planning
Folic acid
Source: Kay Johnson, March 2007
4. Mixed Financing & Lack of
Universal Coverage of Women
of Reproductive Age
All Women Ages 15-44
(N = 61.7 million, 2003)
3%
Poor Women Ages 15-44
(N = 9.1 million, 2003)
2%
12%
21%
37%
41%
Medicaid
Private
64%
Uninsured
Other
Sources: US Current Population Survey, AGI, KFF.
20%
March 9 Meeting Objectives

Discuss and reach consensus on key attributes of a high
performing system of preconception care financing
(public and private)

Discuss options for Medicaid coverage

Discuss the roles of public health programs (i.e., Health
Centers, Title X Family Planning, Title V MCH Block
Grant, Healthy Start)

Discuss next steps
Key Attributes of a High
Performing System of
Preconception Care Financing







Eligibility
Enrollment and Transition between Financing
Arrangements
Benefits and Coverage Rules
Cost-Sharing
Access to Community Providers
Privacy, Confidentiality and Access to Health
Information
Quality and Provider Compensation
Eligibility (consensus)





Cover all women during their reproductive life span
(from menarche to menopause)
Cannot set arbitrary limits based on age
Cannot impose coverage limits or waiting periods based
on pre-existing conditions
Cannot use an asset test
Must provide subsidies for women whose family incomes
are considered low (e.g., < 200% FPL)
Enrollment & Transition

Public financing:
– Enrollment at the point of care, through outstationing,
and in other locations convenient to consumers
– Continuous enrollment until circumstances change,
requiring review (e.g., change in income)
– Loss of private coverage should be an immediate
qualifying event for public coverage

Private financing:
– Portability of coverage
Benefits & Coverage Rules

Equivalent to the existing standard of preconception care
– Screening/assessment
– Counseling/health education and promotion
– Interventions/treatment

No arbitrary limits or exclusions

Provided by any licensed HCW within scope of practice

Medical necessity standard promotes (i) attainment and
maintenance of optimal health in reproductive years and
(ii) correction and amelioration of physical or mental
conditions that could adversely affect reproductive health
Cost-Sharing



No deductibles for services identified as
primary preventive care
Use of co-payments and/or coinsurance only
if affordable
Availability of direct subsidies for communitybased providers that serve low-income
women to help offset the cost of cost-sharing
and to furnish enabling services
Access to Community
Providers


Provider network in the community should be
adequate to furnish covered services
Participation of community health providers
should be allowed
Privacy, Confidentiality and
Access to Health Information


Patients and health care providers should
have full and ready access to health
information necessary for treatment and
payment, in a secure and interoperable
environment
Systems should exchange essential
information to measure population health
with public health agencies
Quality & Provider
Compensation


Appropriate compensation for providers up to
their scope of practice
Compensation guided by principles of quality
performance, with regular and systematic
measurement of process and outcome of care
– Existing measures (e.g., HEDIS postpartum care)
– New measures (e.g., reproductive health plan,
minimum number of visits, screening tools)
Options for Medicaid Coverage
Federal and State Levels


“Women” as a new optional eligibility category
State’s choice to (i) cover some or all women not
currently covered and (ii) determine scope of
benefits essential to wellness – e.g.,
Full Medicaid benefits
 Preventive preconception package
 Family planning

Roles of Public Health Programs
Public Health Programs



Title X FP programs serve ~4.6 million
women of childbearing age (FP education;
contraceptives; pregnancy tests)
Title V MCH services block grant programs
serve ~2.5 million pregnant women
(prenatal, delivery, and postpartum care
for low income, at-risk pregnant women)
Health centers serve ~4.5 million women
of childbearing age and provide prenatal
care to some 330,000 pregnant women
Other Programs (Cont.)


HRSA’s Healthy Start program serves
high-risk pregnant women in 99
communities in 38 States, the District of
Columbia, and Puerto Rico
(interconception activities)
WIC serves ~8 million women during
pregnancy and postpartum (nutrition
screening and counseling; supplemental
food; referrals to health services)
Federal and State Levels



Programs need augmented federal appropriation
Within existing funds, opportunities to embed
preconception care into existing services
Need to monitor and disseminate promising
practices at the state and local level
Next Steps
Products and Activities

Revise and distribute principles for financing
preconception care

Develop prototype fact sheets for federal and state
advocates

Prepare an update on preconception benefits within
Medicaid family planning waivers

Publish a special issue of Women’s Health Issues

Work with selected state/local leaders on advocacy
Improving the Design of Medicaid
Family Planning Waivers
US Women of Child-Bearing Age,
2006


According to the US Census Bureau, there
are nearly 62 million women age 15-44
34% are low-income (<200% of poverty)
100
50
US Women Age 15-44, By Poverty Level
66
16
18
< 100%
100-200%
0
> 200%
Source: http://www.census.gov/hhes/www/cpstc/cps_table_creator.html
Insurance Coverage of US Women
of Child-Bearing Age, 2003
All Women Ages 15-44
(N = 61.7 million, 2003)
3%
Poor Women Ages 15-44
(N = 9.1 million, 2003)
2%
12%
21%
37%
41%
Medicaid
Private
64%
Uninsured
Other
Sources: US Current Population Survey, AGI, KFF.
20%
Uninsured Women by Age, 2004
17%
30%
26%
18-24
25-34
35-44
45>
27%
Total: 19.5 million
Source: Salganicoff, A., Ranji, U., and Wyn, R. Women and Health Care: A National
Profile, Kaiser Family Foundation, Washington, DC, July 2005
Uninsured Women of Childbearing
Age (15-44) by Educational
Attainment, 2006
11%
29%
26%
No high school
diploma
High school or
equivalent
Some college, less
than 4-year degree
Bachelor's degree or
higher
34%
Total: 12.4 million
Source: US Census Bureau, Current Population Survey, Annual Social and Economic
Supplement, 2006 http://www.census.gov/hhes/www/cpstc/cps_table_creator.html
Uninsured Women of Childbearing
Age (15-44) by Parental Status,
2006
41%
Parent
Non-parent
59%
Total: 12.4 million
Parent is defined as having 1 or more related children under age 18
Source: US Census Bureau, Current Population Survey, Annual Social and Economic
Supplement, 2006 http://www.census.gov/hhes/www/cpstc/cps_table_creator.html
Uninsured Women of Childbearing
Age (15-44) by Income, 2006
39%
<200% FPL
> 200% FPL
61%
Total: 12.4 million
Source: US Census Bureau, Current Population Survey, Annual Social and Economic
Supplement, 2006
http://www.census.gov/hhes/www/cpstc/cps_table_creator.html
Uninsured Women of Childbearing
Age (15-44) by Employment, 2006
6%
39%
Children/Armed
Forces/Not in Labor
Force
Employed
Unemployed
55%
Total: 12.4 million
Source: US Census Bureau, Current Population Survey, Annual Social and Economic
Supplement, 2006
http://www.census.gov/hhes/www/cpstc/cps_table_creator.html
Girls, Adolescent Girls, and
Women’s Eligibility for Medicaid
Mandatory Populations

Children below federal
minimum income levels
–
–
Ages 1-6: 133% FPL
Ages 6-19: 100% FPL

Adults in families with children
(Section 1931 and TMA)

Pregnant women <133% FPL

Disabled SSI beneficiaries
Optional Populations

Children above federal
minimum income levels

Children ages 19-21

Adults in families with children
(above Section 1931
minimums)

Pregnant women >133% FPL

Disabled (above SSI levels)

Disabled (under HCBS waiver)

Medically needy
Income Eligibility Levels for
Medicaid for Pregnant Women,
2006
Number of States
20
13
and
DC
8
4
1
1
2
1
133% 150% 166% 175% 185% 200% 250% 275%
Source: Kaiser Family Foundation, 2006 http:www.statehealthfacts.org
Income Eligibility Levels for
Medicaid for Women as Parents,
2006
Number of States
30
23
14
<50%
FPL
9
51-100%
FPL
4 5
6
&
DC 6
101150%
FPL
151200%
FPL
Non-working parents
1
&
0 DC
201250%
FPL
1 1
275%
FPL
Working parents
Source: Kaiser Family Foundation, 2006 http:www.statehealthfacts.org
Medicaid Defined Benefits
“Mandatory” Items and Services











Physicians services
Laboratory and x-ray services
Inpatient hospital services
Outpatient hospital services
Early and periodic screening,
diagnostic, and treatment
(EPSDT) services for
individuals under 21
Family planning and supplies
Federally-qualified health
center (FQHC) services
Rural health clinic services
Nurse midwife services
Certified nurse practitioner
services
Nursing facility (NF) services
for individuals 21 or over
“Optional” Items and Services















Source: KFF, 2005.


Prescription drugs
Medical/remedial care furnished by licensed practitioners
Diagnostic, screening, preventive, and rehab services
Clinic services
Dental services, dentures
Physical therapy
Prosthetic devices, eyeglasses
TB-related services
Primary care case management
ICF/MR services
Inpatient/nursing facility services for individuals 65 and
over in an institution for mental diseases (IMD)
Inpatient psychiatric hospital services for individuals
under age 21
Home health care services
Respiratory care services for ventilator-dependent
individuals
Personal care services
Private duty nursing services
Hospice services
Purposes of Family Planning


Provide individuals with personal
choice in determining the number and
spacing of their children and in
preventing unintended pregnancies
Ensure individuals’ reproductive health
and well-being (through, e.g.,
prevention of STDs and HIV, routine
cancer screenings)
Unintended pregnancy in the
US


Unintended pregnancy includes
“Mistimed” (wanted to become pregnant
in the future, but not yet) and
“Unwanted” (did not want to become
pregnant now or in the future)
Associated with delayed PNC and
substance abuse during pregnancy, which
may lead to adverse birth outcomes
Unintended pregnancy in the
US (Cont.)

Of the 6.4 million pregnancies in US in
2001, 49% were unintended; of the 4
million births, 1.4 million were from an
unintended pregnancy
40% of women who had an unplanned birth
had used contraception during the month of
conception

More prevalent in poor and low-income
women
Rates of Unintended Pregnancy,
by Race/Ethnicity and Income,
2001
Unintended Pregnancies per
1,000 Women
180
160
140
120
All
White
Hispanic
Black
100
80
60
40
20
0
All
<100% FPL
>100% FPL
Source: Finer & Henshaw, 2006 Perspectives on Sexual and Reproductive Health, 38(2)
Basics of Medicaid FP Waiver
Programs


Under Section 1115 of SSA
Allows states to expand eligibility to women
who otherwise do not qualify for Medicaid
specifically for Medicaid FP services
– Can be based on loss of eligibility of women
postpartum or for any reason (e.g., starting a
job)
– Ineligibility due to income levels

First waiver approved by HHS in 1993 (SC)
26 States Have Medicaid Family
Planning Waivers

5 states—for women who have lost Medicaid
eligibility postpartum

2 states—for women who have lost Medicaid
eligibility for any reason

19 states—based on income; ~200% FPL
(2001: ~ 1.7 million clients served in 13 states)
Source: Guttmacher Institute, 2007 SPIB: State Medicaid Family Planning Eligibility
Expansions; Gold, 2003 “Medicaid Family Planning Extensions Hit Stride”
Services Provided Through
Medicaid Family Planning Waiver
Programs



Coverage of FP services and supplies
available to Medicaid enrollees in the
state
No cost-sharing
FP services and supplies reimbursed
90% by federal government; other
services (e.g. STD testing) reimbursed
at usual matching rate for the state
Source: Frost et al., 2006 “Estimating the impact of expanding Medicaid eligibility for
family planning services”
Evidence of Impact of FP Waivers
on Program Costs and Unintended
Pregnancies




Budget neutral but not always reduction in number of
unintended pregnancies (Edwards, Bronstein &
Adams, 2003)
CA program prevented 108,000 unintended
pregnancies in 1997-98 (Foster et al., 2004)
Simulation of income-based expansions to 200% and
250% of FPL found it would be cost-effective if
implemented nationally (Frost, Sonfield and Gold,
2006)
Income-based expansions are effective at reducing
births; save money or are at least budget neutral for
states; and are at least budget neutral nationally
(Lindrooth and McClullough, 2007)
Strengthening the Design of Family
Planning Waivers in Relation to
Preconception Care
A. Coverage & Payment of
Quality FP and Preconception
Care



What are the guidelines for a quality FP and
preconception care benefit (e.g., CMS, CDC,
ACOG/AAP)?
What are the services covered and paid by States
(e.g., survey of preconception benefits and CPT codes
recognized by states for reimbursement within FP
waivers)?
To what extent does state coverage and payment
reflect the standard of care and are there
opportunities for a core benefit to increase ability to
ensure quality?
Federal Guidelines for FP BenefitExist but Could be More Specific
to Preconception Care
CDC Recommendations:
Medical & reproductive
history; Genetic & family
history; Environmental &
occupational exposures;
Family planning and
pregnancy spacing;
Psycho-social assessment
Image reproduced from KFF, 2005 “Medicaid: A Critical Source of Support for Family
Planning in the US”
Examples of CPT Codes




99384/94 (12-17 yrs); 385/95 (18-39 yrs);
386/96 (40-64 yrs) -Preventive (no
symptoms), new/established patient
99420: Health risk assessment instrument
for MH/SA services
99501-Home visit for postnatal assessment
and follow-up care
96152- Health and behavior intervention
B. Coordination of FP
with Health Centers



2001 requirement for states with FP waivers to set up
formal arrangements with CHCs to provide primary
care services to enrollees in the FP programs
Enrollees must also be informed of how to access
primary care services at CHCs
Arrangements could be used to increase link between
family planning and preconception services
– Is coordination happening?
– What services are provided?
– How about primary care providers other than health
centers?
C. Seamless Coverage
with SCHIP



In FY06, 671,000 adults (parents, pregnant women,
and childless adults) were covered through SCHIP
In 2004, 17% (~3.3 million) of uninsured women were
ages 18-24, some of whom may be “aging out” of
SCHIP (>19) or Medicaid (>21)
SCHIP reauthorization
– What will become possible with the reauthorization statute?
– Medicaid expansion for children (e.g., 300% FPL) coordinated
with a new SCHIP option to cover young adults?
Monitoring, and Tying Payment
to, Quality of Preconception Care
through the HEDIS Measurement
System
CDC Recommendation

Maximize public health surveillance and
related research mechanisms to monitor
preconception health. Examples:
– National PRAMS, BRFSS, NSFG
– State and local PRAMS, Perinatal Periods of Risk,
Fetal-Infant Mortality Review, YRBS
– Title V performance indicators
– KFF survey

Maximize quality assurance mechanisms to
monitor and improve preconception health
– HEDIS
Receipt of Family Planning and
Reproductive Health Services
Among US Women Ages 15-44

According to the
2002 NSFG, the
majority of US
women ages 15-44
(72.7%) received at
least one family
planning or medical
service in the past
year
Receipt of services by
type of provider, 2002
56
8.8
12.6
2
Title X
clinic
Other
clinic
Private
MD/HMO
Source: Chandra et al., 2005 2002 National Survey of Family Growth
Other
Receipt and Provider of Family
Planning and Reproductive Health
Services Vary by Poverty Level
Percent of women age 15-44
who received at least one
family planning or
reproductive health service in
the past year, by poverty
73
74
Provider of services, by
poverty level
74
60
43
83
20
12
15
8
4
Title X
clinic
0-149% FPL
150-299%
FPL
300% + FPL
8
Other
clinic
0-149% FPL
2 2 2
Private
MD/HMO
Other
150-299%FPL
300% + FPL
Source: Chandra et al., 2005 2002 National Survey of Family Growth
Survey of MCH programs
Content of Health Care
Among US Women, 2004

Discussed with provider in the past 3
years:
31%
28%
31%
14%
had
had
had
had
discussed
discussed
discussed
discussed
their sexual history
STDs
HIV/AIDS
EC
Source: Kaiser Family Foundation, 2005 Women and Health Care: A National Profile
HEDIS Measurement
System

“The Healthcare Effectiveness Data and
Information Set (HEDIS) is a tool used by more
than 90 percent of America's health plans to
measure performance on important dimensions
of care and service”
– 3 main areas: Access/Availability of Care,
Effectiveness of Care, Use of Services

Voluntary reporting to NCQA by commercial,
Medicaid and Medicare plans (> 73% of all
HMOs/POS plans, and 80 PPOs), which serve
80 million Americans, with national benchmark
Source: http://web.ncqa.org/tabid/59/Default.aspx
Measures Reflect Evidenceand/or Consensus-Based
Clinical Practice

ACOG Guidelines
– To give practitioners the chance to offer advice and
assistance, women should see their health care
provider at least once between four and six weeks
after giving birth. The first postpartum visit should
include a physical examination and an opportunity
for the health care practitioner to answer parents'
questions and give family planning guidance and
counseling on nutrition.

Guidelines for Perinatal Care – AAP & ACOG
– All health encounters during reproductive years
should include counseling on appropriate medical
care and behavior to optimize pregnancy outcomes.
CDC Recommendations

Specifically focused on pre-and interconception care

Essential part of primary and preventive
care

Not just a single visit/multiple visits, but the
process of care and interventions, which can
include a pre-pregnancy visit, multiple
postpartum visits, PNC, and an array of
other services and procedures (i.e.,
assessment, counseling, brief treatment)
Measures Link to Health
Risk Factors, Women, Ages
18-44, 2002







6% had asthma
50% were overweight/obese
3% had cardiac disease
3% were hypertensive
9% had diabetes
1% suffered from thyroid disorder
>80% (ages 20-39) had dental carries and
other oral diseases
Source: CDC, 2006.
Measures Link to Behavioral
Risk Factors, Women, Ages
18-44, 2003 & 2005




21.7% smoked (2005) and 11% of pregnant
women smoked (2003)
11% reported binge drinking in the last
month (2005) and 10% of pregnant women
drank alcohol (2003)
84% reported hearing of folic acid (of those
aware of folic acid, 19% knew it prevents
birth defects, 7% knew it should be taken
before pregnancy); 33% took a daily
multivitamin with folic acid (2005)
49% have unplanned pregnancies (2005)
Source: March of Dimes, www.marchofdimes.com/peristats, 2005; CDC, 2003
COLORADO PCPP, Percentage of
Women Receiving Appropriate
Care, 2004-2005
Timeliness of PNC
Postpartum Care
79.7
51.8
55
49.1
55.4
35.5
2004
2005
2004 HEDIS 50th
Benchmark
Source: HSAG, 2004-2005 External Quality Review Technical Report for Colorado
Medicaid Managed Care, Colorado Department of Health Care Policy and Financing
COLORADO Perinatal Focused
Study, Percentage of Women
Receiving Appropriate Care, 2004
CO Access
100
90
80
70
60
50
40
30
20
10
0
Timeliness of SA Screening
PNC
Tobacco
Cessation
Screening
Tobacco
Cessation
Education
RMHP
PCPP
Urinalysis
Prior
Preterm
with Culture
Preterm
Birth Risk
Testing
Delivery and Assessment
History
Evaluation
Chlamydia
Screening
Postpartum
Care
Source: HSAG, 2004-2005 External Quality Review Technical Report for Colorado
Medicaid Managed Care, Colorado Department of Health Care Policy and Financing
NEW YORK QARR, Percentage of
Women Receiving Appropriate
Care, 2004
Commercial
2004 Commercial National Average
Medicaid
2004 Medicaid National Average
100
90
80
70
60
50
40
30
20
10
0
Timeliness of PNC
Postpartum Care
Cervical Cancer
Screening
Chlamydia Screening
(ages 16-20)
Chlamydia Screening
(ages 21-25)
Source: HSAG, 2004-2005 External Quality Review Technical Report for Colorado
Medicaid Managed Care, Colorado Department of Health Care Policy and Financing
NEW YORK QARR, Percentage of
Medicaid Women Receiving
Appropriate Care, 2002-2004
90
80
70
60
50
40
30
20
10
0
2002
Timeliness of PNC
2004
2004 Medicaid National Average
Postpartum Care
Cervical Cancer
Screening
Chlamydia Screening
(ages 16-20)
Chlamydia Screening
(ages 21-25)
Source: HSAG, 2004-2005 External Quality Review Technical Report for Colorado
Medicaid Managed Care, Colorado Department of Health Care Policy and Financing
Using Existing HEDIS Measures –
Postpartum Visit

Postpartum care (access/availability of
care): % of deliveries that had a
postpartum visit on or between 21
days and 56 days after delivery
– 2005: Average % of women who received a postpartum visit 21-56 days after delivery was 81.5%
for commercial and 57% for Medicaid health
plans

Chance to provide preconception advice in
preparation for subsequent pregnancy
Source: National Committee for Quality Assurance, 2006 The State of Health Care
Quality 2006
Modifying Existing HEDIS
Measures for Preconception
Care – Preventive Visits



Ambulatory or Preventive Visit (access/ availability of
care): Percentage of adults ages 20-44 who had an
ambulatory or preventive visit
– 2005: Average % of adults who received a
ambulatory or preventive visit was 92.7% for
commercial and 76.4% for Medicaid health plans
Stratification by gender
Chance to provide preconception advice in
preparation for initial and/or subsequent pregnancy
Other Possible HEDIS Measures
for Preconception Care

CDC recommendations list preconception risk
factors, these could be linked with existing HEDIS
measures. E.g.,
 Alcohol misuse: HEDIS measure Initiation and Engagement
of Alcohol and Other Drug Dependence Treatment
(stratified by ages 20-44 and gender?)
 Hep B: HEDIS measure Adolescent Immunization Status
(extended to ages 20-44 and stratified by gender?)
 STD: HEDIS measure Chlamydia Screening, Ages 16-25
(extended to age 44 and stratified by gender?)
 Smoking: HEDIS measure Medical Assistance with Smoking
Cessation (stratified by ages 20-44 and gender?)
Source: National Committee for Quality Assurance, 2006 The State of Health Care
Quality 2006
Other Proposed Measures of
Preconception Care Quality


Working group of OB/GYNs and
perinatologists proposed 90 potential
indicators for maternal quality of care
Indicators chosen for
preconception/interconception care:
Rubella status
Pap smear testing
Diabetic screening
Folic acid use
Korst et al., 2005 Maternal and Child Health Journal, 9(3)
NCQA Process to Add a
HEDIS Measure

7 months: Initial selection and development

9 months: Field testing

12 months: Revision, public comment, vote,
and addition to existing set of measures
TOTAL: 28 months
State Medicaid/SCHIP
EQRO Contracting



Development and validation of new
performance measures of preconception and
interconception care, as defined by state
Focus study on perinatal care, preconception
care, interconception care, as defined by
state
PIP on perinatal care, preconception care,
interconception care, as defined by state
P4P – Definition




Payor (public and private) strategies to
reorient payment incentives and instill
accountability by rewarding efforts to
improve quality
Part of broader quality improvement effort
Both financial and nonfinancial incentives
may be used to improve measurable
performance
Incentives should encourage and reinforce
use of evidence-based practices that
promote better outcomes efficiently
Source: Abramson, S. & Younger, K. Pay-for-Performance Literature Review,
Washington, DC: Department of Health Policy, GWU, SPHHS, May 2006.
P4P - Goals
Improve quality of care
 Reduce variation in patterns of care
 Facilitate access to care
 Integrate evidence-based medicine
 Improve efficiency
 Ensure accountability

Source: Abramson, S. & Younger, K. Pay-for-Performance Literature Review,
Washington, DC: Department of Health Policy, GWU, SPHHS, May 2006.
P4P – Evidence of Impact
on Quality


Limited evidence of direct impact on quality
One study by Rosenthal (2005)
– No impact of financial incentives for hemoglobin
A1c testing and mammography; small positive
increase in cervical cancer screening
– Lowest performers at baseline improved the
most, but received smallest share of bonus
payments; best performers at start were biggest
winners
Source: Abramson, S. & Younger, K. Pay-for-Performance Literature Review,
Washington, DC: Department of Health Policy, GWU, SPHHS, May 2006.
P4P - Incentive/Penalty
Arrangements

Financial
–
–
–
–
–

Challenge/bonus pools for performance rewards
Withhold/recoupment from payments
Auto-assignment
Enrollment frozen
Health plan non-renewal
Non-Financial
–
–
–
–
Public reporting (e.g., report cards, newspaper articles)
Public acclamation (e.g., public awards by Mayor)
Partnership between MCO’s and DHS staff with commitment to quality
Waiver of administrative requirements
Source: Abramson, S. & Younger, K. Pay-for-Performance Literature Review,
Washington, DC: Department of Health Policy, GWU, SPHHS, May 2006.
HEDIS and P4P




Good starting point for P4P measures
Nationally validated and comparable
measures
However, limited measures of
preconception and interconception
care
Focus is on process, not outcome
Source: Abramson, S. & Younger, K. Pay-for-Performance Literature Review,
Washington, DC: Department of Health Policy, GWU, SPHHS, May 2006.