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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.