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

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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.

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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)

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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)

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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

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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

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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

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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

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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)

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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.

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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

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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)

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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

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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