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NAHDOCDC COOPERATIVE AGREEMENT

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Impact of public health nurses on utilization among foster care children ... Utilization in areas with community and school-based public health clinics ... – PowerPoint PPT presentation

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Title: NAHDOCDC COOPERATIVE AGREEMENT


1
NAHDO-CDC Cooperative Agreement Webinar -
Medicaid Data An Essential Public Health Data Set
September 22, 2004
2
Overview
  • Significance of Medicaid Data to Public Health
  • Denise Love, NAHDO
  • Medicaid Data vs. Public Health Data Sets
  • Jeffrey Geppert, Stanford University
  • Applied Lessons
  • Nevada, Christopher Thompson
  • Utah, Wu Xu

3
Significance Medicaid Data and Public Health
  • Medicaid provides coverage to over 44 million
    Americans
  • Jointly funded by federal and state governments
  • Second largest and fastest growing component of
    expenditures (general funds and all spending
    sources) (NASBO 2003)
  • The largest source of health care financing for
    people with disabilities (NHIS)

4
Significance Medicaid Data and Public Health
  • Provide primary care and other services to
    Medicaid beneficiaries
  • Change in safety net role in respond to increase
    enrollment in Medicaid managed care (e.g., Early
    and Periodic Screening, Diagnosis, and Treatment
    Program (EPSDT) services)
  • Emphasis on disease prevention and health
    promotion
  • Developing partnerships with Medicaid

5
Medicaid Data Sharing and Integration
  • Medicaid provides data about an important
    population
  • Data requests must fit within HIPAA exemptions to
    circumvent requirements for individual
    authorization
  • Medicaid and public health need to coordinate and
    evaluate their joint and respective interests and
    requirements to make data sharing work for them
    and the public interest

6
Permission Encouragement for Data Partnerships
  • Interagency agreement between HRSA, CDC and then
    HCFA, issued October 1998.
  • To facilitate collaborations for intrastate data
    sharing between State Medicaid and State Health
    Agencies.
  • Includes model agreement that covers all Federal
    Medicaid requirements.

7
Permission Encouragement for Data Partnerships
  • Change especially for Medicaid from use of
    Medicaid data only for direct administrative
    purposes of Medicaid and only by Medicaid staff.

8
Potential Barriers to Data Partnerships
  • Confidentiality, Privacy, Security concerns
    regarding linkage of existing data internally
    between and within programs of same states
    public health and health services, and sometimes
    social services.
  • Institutional Inertia Most but not all recognize
    change from prior Medicaid specific policy,
    regarding administrative use only.

9
Potential Barriers to Data Partnerships
  • May have state laws, regulations or policies -
    dating from original Federal guidance - that
    still slow or limit ability to link datasets,
    even though Federal guidance has changed.
  • Confusion around HIPAA

10
Standards for Privacy of Individually
Identifiable Health Information (45 CFR Parts 160
and 164 Sec. 164.512)
  • PHI may be disclosed by a covered entity without
    consent or authorization
  • To a public health authority authorized by
    law..for purposes of preventing, controlling
    disease, injury, disability, vital events ...and
    conduct of public health surveillance and
    investigations

11
Technical Capacity Issues
  • Knowledge of structure and content of databases
    to be linkedMedicaid is often many separate
    files.
  • Knowledge of content data clinical coding,
    programmatic variables.
  • The availability of analytic software and ability
    to use it properly to make matches.
  • Data Warehouse approach is successful in some
    states (alternative to dataset-by-dataset,
    case-by-case linkage)

12
Medicaid program questions
  • Utilization of health care services
  • Pre- and post-natal care
  • Ambulatory care sensitive conditions
  • Preventive services
  • Among beneficiaries with chronic and acute
    conditions
  • FFS and managed care

13
Medicaid program questions
  • Health promotion and disease prevention
  • Prevalence of diabetes, asthma
  • Diagnosis and treatment of STDs, TB and HIV
  • Disease surveillance and environmental health
  • Diagnosis and treatment of mental health and
    alcohol/drug abuse

14
Medicaid program questions
  • Program Evaluation
  • Impact of public health nurses on utilization
    among foster care children
  • Home visitation and education programs
  • Utilization in areas with community and
    school-based public health clinics

15
Medicaid data differ from public health data sets
  • Advantages
  • Wide range of conditions
  • Treatment in addition to diagnosis
  • Variations in intensity and cost
  • Access to care
  • Outcomes of care (morbidity and mortality)
  • Long-term outcomes (5-year, 10-year)

16
Medicaid data differ from public health data sets
  • Advantages (continued)
  • Samples versus the universe
  • Self-report versus objective
  • Longitudinal versus panel
  • Trends over time
  • Impact of change in policy on individuals rather
    than populations
  • Exogenous sources of variation

17
Medicaid data differ from public health data sets
  • Claims data vs. event data
  • Requests for payment from providers for
    inpatient, physician, pharmacy, etc.
  • Separate files and formats
  • Data linkage
  • Claims and individual line items
  • ICD-9-CM diagnosis and procedure, CPT, NDC coding

18
Medicaid data differ from public health data sets
  • Rules for constructing an event
  • Claims and visits
  • Screening and conditions
  • Inclusions and exclusions
  • Episodes of care
  • Prevalence versus incidence
  • Censoring
  • Health care home

19
Medicaid data differ from public health data sets
  • Managed care and carve out services result in
    fragmented data
  • Eligibility versus enrollment
  • Enrollment and disenrollment
  • Managed care enrollment
  • Carve-out for mental health, pharmacy, dental,
    etc.
  • Changing eligibility

20
Medicaid data differ from public health data sets
  • Historical data may not reside in the data
    warehouse
  • Enrollment
  • Eligibility category
  • County of residence
  • Managed care or fee-for-service
  • Health care home

21
Case Study Prenatal Outcomes in Nevada
  • Center for Health Information Analysis,
    University of Nevada Las Vegas (CHIA)
  • Data sources Medicaid paid claims, Medicaid
    eligibility, managed care encounter and case
    management/risk assessment data for pregnant
    women

22
Case Study Prenatal Outcomes in Nevada
  • Project aims
  • Cost of care in 1Y by mother's length of
    enrollment in Medicaid and amount of prenatal
    care received
  • Effectiveness of the initial prenatal screening
    assessment in identifying high-risk pregnancies
  • Compare pregnancy outcomes (e.g. newborn costs
    and LOS) for Medicaid births to those of the
    general population
  • Effectiveness of FFS and MCO for high-risk
    pregnancies

23
Case Study Prenatal Outcomes in Nevada
  • Preliminary Findings
  • Lower newborn costs associated with managed care
    enrollment, length of Medicaid enrollment and
    prenatal risk assessment
  • Newborns born to mothers enrolled less than one
    month prior to giving birth were nearly 3 times
    as likely to be high cost
  • Nearly linear relationship between the length of
    enrollment (i.e. available for prenatal care) and
    newborn cost
  • When controlling for length of enrollment,
    newborn costs were slightly higher for mothers in
    managed care. The differences were generally
    small and may be due to the inclusion of
    capitated payments rather than costs based on
    encounters

24
Case Study Prenatal Outcomes in Nevada
  • Challenges
  • Linking mother records to newborn records (i.e.
    family versus individual identifiers)
  • 3 of the newborns account for 43 of the costs
    (1 of the newborns account for 25 of the costs)
  • Lack of managed care encounter data (under 25k)
    for outcomes and costs
  • Separately identifying the impact of Medicaid
    enrollment versus risk assessment

25
Utah Example 1 Using Medicaid Data for MCH
Reporting
  • Questions Medicaid low birth weight rate, etc.
  • Process
  • Data sharing agreement (1997)
  • Linking Medicaid eligibility to birth
    certificates (1998-1999)
  • MCH defined its business needs in Medicaid Data
    Warehouse (2000)
  • MCH analysts access Medicaid DW (2001)

26
Utah Example 2 Using Population Data to Support
Medicaid Program Evaluation
  • Questions Has the PCN 1115 waiver improved its
    enrollees health status? Impact on statewide
    uncompensated care?
  • Process
  • Designed the evaluation with Medicaid input to
    address their administrative needs
  • Used general population data as reference
  • Provided timely feedback to the PCN program. PCN
    timely adjusted their procedures and strategies.

27
Summary
  • Medicaid goals may be different than the public
    health entity goals
  • More program-oriented
  • Data access may be tied to benefit to Medicaid
    program
  • Outcome may not be a public report, but instead
    an internal discussion

28
Summary
  • Medicaid data differ from public health data
    sets
  • Claims data vs. event data
  • Rules for constructing an event
  • Managed care and carve out services result in
    fragmented data
  • Historical data may not reside in the data
    warehouse

29
Summary
  • Medicaid and ALL of its stakeholders must be
    involved at all stages
  • Policy/outcome question development
  • Research design
  • Interpretation of results
  • Implementation of interventions
  • Public health programs are stakeholders (chronic
    disease, injury, MCH, epidemiology, health
    planning)

30
Summary
  • Building trust between Medicaid and other state
    agencies essential for continued data access
  • State agencies should employ data sharing
    agreements to guide permissible data sharing and
    dissemination of Medicaid data (CMS-HRSA-CDC
    model)

31
Benefits to sharing Medicaid data (HRSA News
Brief 1999)
  • Encourage development of integrated state
    information systems
  • Assure appropriate, accessible, cost-effective
    care for underserved/vulnerable populations
  • Improve the technical capacity of states to
    analyze data from multiple sources for policy
    support/program evaluation
  • Promote measurement using common performance
    measures across programs
  • Better use of Medicaid encounter data to assist
    in public health surveillance and improve care
    for Medicaid enrollees

32
Resources
  • Federal Data Sharing Agreement
  • http//www.hcfa.gov/medicaid/smd10228.htm
  • Medicaid HIPAA Page
  • http//www.cms.hhs.gov/medicaid/hipaa/adminsim/
  • Medicaid Primer, Public Health Foundation
  • http//www.phf.org/Medicaid_primer.pdf
  • Medicaid Managed Care Statistics (CMS)
  • http//www.cms.hhs.gov/medicaid/mcaidsad.asp
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