Washington State Health Care

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Washington State Health Care
Governors GMAP Forum

Department of Health
Health Care Authority
Department of Social and Health Services

July 11, 2007
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What have we accomplished since November GMAP?

• We continue to work on ensuring more kids have
  access to health insurance coverage
• Basic Health enrollment increased to 106,079 as
  of June 2007.
• Legislation this session will 1) fund a patient
  navigator pilot to help address cultural and
  ethnic health disparities, 2) implement
  third-party liability requirements under federal
  legislation, 3) overhaul childrens mental health
  program, and 4) expand eligibility for children.
• We established a Central Citizenship Verification
  unit in response to federal legislation.
• Healthy Options expanded into additional counties
  (e.g. Molina into Thurston County) but kept
  premium increases for CY07 at 2.35.
• We continue to make progress on improving making
  Washington one of the top ten healthiest states
  in the nation
• National Immunization Survey data available this
  fall. Washingtons ranking will be released at
  that time.
• Two new vaccines (rotavirus and human papilloma
  virus (HPV) ) and an additional dose of an
  existing vaccine (varicella) added to the
  program.
• February 2007 vaccine distribution switched to
  national third party system. Expected benefits
  reduce vaccine spoilage, increase state and local
  help, safer handling, give providers the vaccine
  and information/education they need to immunize
  their clients on-time.
• May 2007 Washington and Oregon jointly hosted
  first Northwest Immunization Conference for
  public and private health care professionals.
• Adult smoking continues to decline. Washington
  now has the fifth lowest rate in the nation.
• December 2006 DOH assisted Local Health
  Jurisdictions implementing the smokefree public
  places law (I-901) which has led to sharp
  declines in secondhand smoke exposure among
  workers and patrons in restaurants and bars.
• Middle school youth who report cigarette use
  continues to decrease. 2006 had lowest rate of
  tobacco sales to youth in the past 10 years.
• Community Health Care Collaborative recently
  awarded 1.4 million in grants to 10 non-profit
  community-based health care organizations around
  the state.
• Washington Wellness Works fully launched. HCA
  has hired staff, Wellness Coordinators trained in
  over 80 agencies. 4.3 of employees have
  completed the Health Risk Assessment between
  January and May 2007.

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What have we accomplished since November GMAP?

• We continue to increase the use of evidence based
  care to bring better health outcomes and
• satisfaction to consumers
• Health Technology Assessment Program is
  operational. One review completed
  (Upright/positional MRI). Two more technologies
  selected for review (Lumbar fusion discography,
  Pediatric bariatric surgery).
• Chronic Care Management Pilot Washington was a
  pioneer state in disease management. Its newest
  phase will try to identify clients at high risk
  for chronic care and who will benefit the most
  from early intervention with better quality care
  and more efficient service delivery.
• DSHS Staff Wellness Volunteer effort has
  blossomed into regular exercise classes, periodic
  health fairs, intranet support, etc.
• We continue with initiatives to reduce the rate
  of increase in total health care spending
• Health Information Infrastructure Advisory Board
  submitted recommendations for a health record
  bank system. State Health Information
  Collaborative awarded 930,000 to providers and
  hospitals to initiate or enhance electronic
  medical records systems throughout the state.
• Created the Northwest Prescription Drug
  Consortium for Rx purchasing. Washington
  Prescription Drug discount card launched in March
  2007. As of May 23rd, 46,627 people have
  enrolled.
• UMP launched disease management program for
  asthma chronic obstructive pulmonary disease
  (COPD).
• PEBB co-pay plan RFP released March 2007. Aetna
  is the apparently successful bidder.

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Proposed Slate of Core Measures
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Proposed Slate of Core Measures
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1.1 Childrens state subsidized programs
enrollmentBasic Health Enrollment Increasing

• Plan of Action to Increase Enrollment
• Manage workload to maximize enrollment, changed
  application processing to daily priority.
• Update web site to encourage applicants
• Work with community partners and sponsors
• Enlist help and suggestions from contracted
  health plans, DSHS and ESD
• Distribute post-it notes to provider offices and
  community partners
• Tell-a-friend notice in December Hot Policy
  Page and November billing statements 
• Message in November Program Update, distributed
  to community partners and posted on Web site
• Updating phone message and phone tree to be more
  applicant-friendly

Source HCA Basic Health Program
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1.1 Childrens state subsidized programs
enrollmentExpansion of Childrens Medical
Coverage in DSHS programs
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3.1 Two year old immunization rates for
MedicaidWhat percent of two year olds served by
Medical Assistance are being immunized?
Healthy Options plans continue to post gains in
immunization rates for two-year-old children.

• Analysis
• Statistically significant improvement from 2004
  to 2005.
• In 2005, the previous measure (Combo 1) was
  retired and a new measure, Combo 2 was reported. 
  The Combo 2 measure adds varicella (chicken pox
  vaccine). 
• Washingtons Board of Health was one of the last
  states in the nation to adopt varicella as a
  requirement for school entry.  As a result, the
  chicken pox antigen is a lower performer than all
  other antigens and caused reduction in overall
  performance. 
• Action items
• Continue incentive payments to health plans for
  improvements in immunizations.
• Require health plans to continue performance
  improvement projects for rates falling below 75
  in 2007.

The childhood immunization measure assesses
enrolled children two years of age who received
all age-appropriate immunizations against
Diphtheria, Tetanus, Whooping Cough, Polio,
Measles, Mumps, Rubella, Influenza, Hepatitis B
and Chickenpox. National Committee for Quality
Assurance (NCQA) average data for 2006 will be
available in the fall.
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2.3 Increase the proportion of children who
receive all vaccines that are recommended to
80What Percentage of Toddlers are Completely
Immunized?

• Analysis
• Vaccine series rate percentage of children that
  got all
• recommended vaccines on-time
• 78 of Washingtons toddlers now get the right
  immunizations at the right time
• The differences in those immunized to those not
  immunized cannot be explained by race, gender,
  ethnicity or social characteristics

Goal Washington will be one of the top ten
healthiest states in the nation Measure
Increase the proportion of children who receive
all recommended vaccines (series) Target 80
by 2010

• Actions To Reach Current Rates
• Parent focused
• Educating parents about immunizations
• Sending parents reminders to schedule check-ups
• Provider focused
• Educating providers about vaccines
• Distributing vaccine assuring providers have
  vaccine when the child needs it
• Getting providers to use the CHILD Profile
  registry as a clinical judgment tool
• Visiting provider offices rates analysis and
  best practice consultation
• Population focused
• Identifying under-immunized groups as well as
  annually identify vaccines with lower rates
• Increasing data in the CHILD Profile registry for
  better tracking and more accurate community and
  state rates

Data Source National Immunization Survey,
children 19 35 months of age
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2.4 Increase coverage levels for required
vaccines for children entering kindergarten to
95What are We Doing to Improve the Overall Rate?
Goal Washington will be one of the top ten
healthiest states in the nation Measure
Increase/maintain immunization coverage levels
for individual vaccines Target 90 by 2010

• Analysis
• 2002 2005, 4th DTaP rate increased 7.4
• 2002 2005, Chickenpox rate increased 11.5
• Individual vaccines can decrease overall
  immunization rate
• Action items
• 4th DTaP media purchasing by summer of 2007
• Mailing of 4th DTaP information to 85,000 parents
  of children 18 months of age per year 2007 and
  2008
• Partnering with WA Health Foundation to extend
  their media buy through June 2007
• Implemented new Chickenpox school entry
  requirement in 06-07 school year updating
  requirement to 2 doses for the 08-09 school year
• Mailing of Chickenpox information to 85,000
  parents of children age one 2007 and 2008

Data Source National Immunization Survey
DTaP Diphtheria, Tetanus and Acellular
Pertussis C. Pox Chickenpox (Varicella)
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2.4 Increase coverage levels for required
vaccines for children entering kindergarten to
95Are Kindergarteners Protected From
Vaccine-preventable Disease?
Goal Washington will be one of the top ten
healthiest states in the nation Measure
Increase coverage levels of required vaccines for
entering kindergarten Target 95 by 2010

• Analysis
• Kindergarten immunization rates since 1998
  provide mixed results
• School and day care immunization requirements
  increase immunization rates
• Washington exemptions are highest in nation at 5
• In Washington it is easier to exempt a student
  than immunize
• Actions
• Expand school use of CHILD Profile registry from
  111 to 200 out of 296 districts by September 2008
  
• Identify solutions for overuse of exemptions and
  strategies for reducing convenience exemptions
  by July 2008
• Implement 2007 federal immunization schedule in
  State Board of Health rule on immunization
  requirements by July 2008

Individual Rates Improve Between Toddler and
School Age
98 99 00 01 02
03 04 05
Data Source WA DOH, Immunization Program CHILD
Profile, 05/07
DTaP Diphtheria, Tetanus and acellular Pertussis
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2.6 Percent of 10th graders who reported smoking
in the last 30 days High School Smoking Recent
Data Drives Fresh Approaches

• Analysis
• Results as of 2006
• Cigarette smoking among all youth is still down
  by about half 65,000 fewer smokers in WA since
  1999
• Achieved original 10th grade goal set a new goal
  in 2007
• Declines continue among middle school youth but
  have stalled among high school youth
• 1 billion saved in future health care costs
• Challenges
• High school youth smoking rates have leveled off
  and may be beginning to rise, similar to the
  nation
• Inconsistent enforcement of school and community
  anti-tobacco policies
• Other tobacco product use (cigars, mini cigars,
  flavored cigarettes, cloves) is dramatically up
  among high school youth

Goal Washington will be one of the top ten
healthiest states in the nation Measure Decrease
proportion of youth cigarette smokers (10th
grade) Target 10 by 2010 (revised 2007)
Achieved Original Goal! Now a Troubling
Development

• Actions
• Convene focus groups across the state to
  understand changes in tobacco use and plan
  program activities by Fall 2007
• Identify model practices for tobacco free campus
  policy implementation with pilot projects at
  least 9 selected high schools beginning October
  of 2007
• Expand advertising campaign in the Fall of 2007
• Partner with Legacy Foundation for expanded media
  buy of successful Truth campaign by Fall 2007
• Include other tobacco products messaging in our
  state prevention media campaign

Data Source Healthy Youth Survey, Biennial (even
years) statewide classroom, paper and pencil
survey of youth (Grades 6, 8, 10, 12)
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2.7 Reduce the percent of adults who report
smoking every day or some days to 16.5 or less
by 2010Adult Smoking Clear Gains and
Continuing Challenges

• Analysis
• Results as of 2006
• More than 235,000 fewer adults smoking and at
  least 75,000 adults spared an early death
• More than 68,000 tobacco users helped by Quit
  Line
• 1.8 billion saved in future health care costs
• Smoking during pregnancy down by 29 since 1998
• Challenges
• More than 40 of mothers who quit smoking relapse
• Smoking rates for low income, low education
  some racial groups are higher and not declining
• Smoking related Medicaid costs 651 million a
  year
• Actions
• Enhance Quitline pregnancy protocols and
  promotion among Medicaid Mothers by August 2007
• Expand access of nicotine replacement medications
  to underinsured smokers through the Quitline by
  Fall 2007
• Adjust cessation advertising to better target low
  income smokers through partnership with Legacy
  Foundation EX campaign by Spring of 2008
• Expand innovative partnership with Head Start to
  screen and refer smokers for services by June 2008

Goal Washington will be one of the top ten
healthiest states in the nation Measure Decrease
the proportion of adults smoking
cigarettes Target 16.5 by 2010 Measure
Decrease the proportion of pregnant women smoking
in last trimester Target 8 by 2010
Now 5th Lowest in the Nation
Smokers
Goal (16.5)
Higher Rates Among Medicaid Mothers
Smokers
Data Sources Behavioral Risk Factor
Surveillance System Annual statewide telephone
survey of adults
Pregnancy Risk Assessment Monitoring System
Annual survey of post-partum mothers
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2.8 Rate of health risk assessment completion
among state employeesHRA Completion Gaining
Ground

• Strategies for Increasing Health Risk Assessment
  (HRA) Uptake
• Monthly HRA completion rate reporting to
  agencies.
• Agencies will get agency specific aggregate HRA
  results at end of year.
• Quarterly face-to-face training and monthly phone
  training to spread best practices from both other
  agencies and the private sector.
• Wellness Coordinators are encouraged to meet
  regularly with Senior Leadership and to discuss
  HRA completion rate report.
• A virtual peer knowledge management network will
  be operational at the end of July.
• Washington Wellness website has direct links to
  each health plan HRA, and instructions on access.
  
• Health plan representatives (UMP and GHC) have
  attended (with WA Wellness staff) various
  agencies events that have set up terminals for
  people to take HRA. Staff provides assistance
  with access questions.
• Incentives are encouraged at the agency level for
  HRA completion, but agencies often lack funding.
  The Demonstration Project funded thru Bill 5930
  will provide funding to 4-6 selected agencies
  that can be applied in part to incentives for
  completion.

Total Number of Employee HRA Completions 6757
(out of 158633) Top 7 Agencies DRS (actives)
63.9 HCA 45.9 Big Bend Community College
28.2 Tacoma Community College 27.6 State
Auditors Office 20.9 Governors office
20.4 DOH 19.6
Source Washington Wellness. Data includes active
and retired employees only, it does not include
dependents.
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4.1 Rate of PEBB premium increase compared to
Mercer National Large employer premium rate
increase

• Analysis
• 2007 PEBB premium increase (Bid Rate4.5) was
  below projections for the National health care
  trend (6.1).
• Action
• Continue to pursue procurement strategy that
  emphasizes higher quality and lower costs.

Revenue Growth PEBB premiums Uniform Medical
Plan (UMP) claims and Managed Care Organization
(MCO) premiums. National premium trend 2006
Mercer Survey. PEBB premium and Mercer Survey
figures are calendar year.
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4.2 Medical Assistance programs per capita
growth rate

• On a per capita basis, rates of growth in medical
  assistance expenditures compare favorably to the
  rates of growth in state personal income. Drop
  in Medical Assistance SFY06 per capita costs was
  due to change in hospital payment method.
• HRSA continues to closely monitor the impacts of
  several savings initiatives introduced in the
  05-07 biennium, as well as expenditure trends
  overall.

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4.3 Prescription drug program cost avoidance

• Analysis
• The Washington State Prescription Drug Program
  (PDP) reduced state prescription drug spending by
  roughly 44 million during the first 18 months of
  the 2005-07 biennium.
• Medicaid's fee-for-service program has avoided
  over 30 million in prescription outlays
• The Health Care Authority's Uniform Medical Plan
  avoided over 8.5 million and,
• Labor and Industries reduced prescription
  spending by more than 5 million during the
  18-month period.

Source WA Prescription Drug Program. FY 2006
only covers through 12/31/2006
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BackgroundSlides
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Reminding Parents to Get Immunizations

• Analysis
• 83 of parents get mailings
• Post Office automatic address correction 15 bad
  addresses
• No systematic tracking of families moving into
  state, following children through adoption or
  foster care placements
• Parents opting-out 0.1
• Assuring mailings arent sent to parents of low
  birth weight babies or otherwise vulnerable at
  birth 0.7
• Check the Early Notification of Childhood Death
  system to prevent mail to parents of deceased
  children
• Actions
• Monitor quarterly data to track trends
• Analyze percentage of parents sent reminders per
  county and develop strategies to improve
• Gather input from parents of lower socioeconomic
  status on use of materials and behavior change
  Fall 2007

Goal Washington will be one of the top 10
healthiest states in the nation Measure
Increase the proportion of parents sent CHILD
Profile health promotion materials Target 90
by December 31, 2008
CHILD Profile Mailings, 2002-2006
CHILD Childrens Health Immunizations Linkages
and Development
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Registry Increases Immunization Rates
Goal Washington will be one of the top 10
healthiest states in the nation Measure
Increase provider participation in the CHILD
Profile registry Target 85 by December 31,
2008

• Analysis
• Participation continues to increase
• Additional marketing and training resources
  should assist in reaching the goal
• Actions
• Continue to implement the Provider Recruitment
  Plan, based on statewide analysis
• Increase staffing to recruit, train and support
  provider participation
• Increasing user-base (schools, pharmacists,
  family planning clinics)
• Making the system work in various clinic
  situations (workflows, use with electronic
  medical records systems, data entry challenges)

Data Source CHILD Profile contract reports to WA
Dept. of Health
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U.S. Immunization Exemption Rates School Year
2005-06
Source CDC School Immunization Survey
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Cost to Fully Immunize a Child Federal Contract
vs. Commercial Rate
Cost to Vaccinate Female Child, 2007
5 DTaP 107.20 4 IPV 91.20 2
Hep. A 57.50 3 Hep. B 64.11 3 HPV
362.25 4 Hib. 87.12 1 MCV-4
88.68 2 MMR 85.78 4 PCV-7 294.80 3
Rotavirus 200.82 1 Tdap 36.25 2
Varicella 149.12
5 DTaP 66.25 4 IPV 44.24 2 Hep.
A 24.50 3 Hep. B 28.50 3 HPV
290.25 4 Hib. 33.12 1 MCV-4
73.09 2 MMR 35.20 4 PCV-7 248.56 3
Rotavirus 165.15 1 Tdap 30.75 2
Varicella 118.30
Difference 467.97 per Child (female)
Data Source Center for Disease Control,
Vaccines For Children Price List
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What are we Doing to Improve the Overall Rate?

• Analysis
• 2002 2005, 4th DTaP rate increased 7.4
• 2002 2005, chickenpox rate increased 11.5
• Individual vaccines can decrease overall
  immunization rate
• Actions
• 4th DTaP media purchasing by summer of 2007
• Mail 4th DTaP information to 85,000 parents of
  children 18 months of age per year 2007 and 2008
• Partnering with Washington Health Foundation to
  extend its media-buy through June 2007
• Implement new chickenpox school entry requirement
  for 06-07 school year updating requirement to
  two doses for the 08-09 school year
• Mail chickenpox information to 85,000 parents of
  children age one in 2007 and 2008

Goal Washington will be one of the top 10
healthiest states in the nation Measure
Increase/maintain immunization coverage levels
for individual vaccines Target 90 percent by
2010
Targeted Interventions Improve Vaccine Rates
100 90 80 70 60 50

DTaP Diphtheria, Tetanus, Pertussis C.Pox
Chickenpox (Varicella) Hib Haemophilus
influenzae type b
Data Sources Washington HRSA Healthy Options,
2006 HEDIS Report National Immunization Survey
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8th Grade Smoking Rate Trending Slightly Lower
Ahead of the National Rate
(Healthy Youth Survey)
(Monitoring the Future Study)
Legend F Fall Survey Administration, S
Spring Survey Administration, SY Academic
School Year
Washington Data Source 1998, 2000 Survey of
Adolescent Health Behaviors.2002, 2004 Healthy
Youth Survey During the past 30 days, on how
many days did you smoke cigarettes? (Any days)
National Data Source 1998 to 2005 Monitoring the
Future Study (MTF), University of Michigan
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Washington 10th Grade Smoking Leveling Off Over
the Past 2 to 3 Years Similar to the Nation
(Healthy Youth Survey)
(Monitoring the Future Study)
(Youth Risk Behavior Survey)
Legend F Fall Survey Administration, S
Spring Survey Administration, SY Academic
School Year Washington Data Source 1998, 2000
Survey of Adolescent Health Behaviors.2002, 2004
Healthy Youth Survey During the past 30 days, on
how many days did you smoke cigarettes? (Any
days)
National Data Source 1999 to 2005 Youth Risk
Behavior Survey (YRBS), Centers for Disease
Control and Prevention, and 1999 to 2005
Monitoring the Future Study (MTF), University of
Michigan
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Washingtons Program Began in 2000,Rate of
Decline Has Been Steeper Compared to the Nation
Data Source Behavioral Risk Factor Surveillance
System (BRFSS)
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Tobacco Sales to Minors Continues Declining Trend
Technical Note Data presented were reported to
DOH as a result of annual random compliance
checks conducted in Compliance with the federal
Synar Amendment. Additional checks conducted by
local health or law enforcement are not included.
Data Source Washington State Department of
Health Synar Compliance Check Database 1996-2006
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Use of Cigarettes DecliningWhile Other Tobacco
Products Steadily Increase
Data Source 2000 Washington State Survey of
Adolescent Health Behaviors (WSSAHB), 2002, 2004
and 2006 Healthy Youth Survey