Patient-Centered Medical Homes and the Health of Ohio’s ...

Patient-Centered Medical Homes

and the Health of Ohio’s Adults and Children

Thomas Wickizer, Kenneth Steinman, Abigail Shoben, Deena Chisolm, Jeff Biehl, Lauren Phelps

#OMAS2015

1

Please note: This study examines survey respondents’ perceptions of

their health care and whether they reflect

“care consistent with a patient-centered medical home”

(CC-PCMH).

It does not assess whether individuals actually received

care from a certified or accredited PCMH.

WWW.GRC.OSU.EDU/OMAS 2

OUTLINE

• Highlights

• Background

• Methods

• Findings

• Conclusions / Implications


KEY HIGHLIGHTS • Lower income adults, whether on Medicaid or employer-sponsored

insurance (ESI) have similar access to CC-PCMH

• Lower income adults and children with CC-PCMH are less likely to have: – unmet health needs

– frequent emergency department visits

– misused prescription painkillers

• CC-PCMH is less common for African-Americans vs. whites

• CC-PCMH equally benefits African-Americans and whites – Less benefit for pregnant women


BACKGROUND


What is a PCMH?

• Patient-Centered Medical Home (PCMH):

a model of coordinated, comprehensive

primary care

– improve outcomes

– reduce costs

– increase patient/provider satisfaction


PCMH in Ohio • PCMH Education Pilot Project led 42 primary care

practices through a 2-year transformation process.

• Comprehensive Primary Care Initiative, with 61

practices in southwest Ohio (sponsored by CMS)

• $75 million State Innovation Model grant from CMS to

develop payment systems that will facilitate PCMH

development and practice.


PCMH in OMAS

• Respondents’ perspective

– Not assessing certified PCMH locations

– Care consistent with a PCMH – “CC-PCMH”

• Broad statewide perspective

– Across all health systems; include the uninsured


Research Questions

• Does Medicaid facilitate access to CC-PCMH?

• Is CC-PCMH associated with better health care?

• Does CC-PCMH reduce health disparities?


METHODS


Sample • 2015 Ohio Medicaid Assessment Survey (OMAS)

– 42,876 adults

– 10,122 proxy interviews of children

• Focus on Medicaid-covered and potentially Medicaid-eligible

• ≤138% FPL for adults

• ≤200% FPL for children


http://grc.osu.edu/omas/

(1) Has an appropriate, usual source of care (e.g., doctor’s office);

(2) Has a personal care provider (PCP; i.e., “a health professional who knows you well and is familiar with your health history”);

(3) Has seen this PCP in the past 12 months;

(4) PCP communicates well;

(5) Got urgent care (if needed) on the same/next day;

(6) Got after hours care (if needed) without a problem;

(7) Got specialist care (if needed) without a problem.

Defining CC-PCMH

12

Does not have

CC-PCMH

CC-PCMH

“yes” to all

“no” to any

Analyses • Multivariable logistic regression

– Adjust for demographic characteristics and health status (special health care needs; history of chronic conditions)

• Survey estimates, represent all Ohio

• Statistical significance, p<0.05

• Predicted probabilities: – predicted (not observed) values from statistical models

– “the estimated percentage of a hypothetical subpopulation predicted to have the outcome, assuming they have otherwise average characteristics”


FINDINGS


Findings


Who has CC-PCMH?

Does Medicaid facilitate access to CC-PCMH?

Is CC-PCMH associated with better health care?

Does CC-PCMH reduce health disparities?

Adults

Children

Findings


Which adults have CC-PCMH?


CC-PCMH varies by income, age and gender

22.9% 26.6%

31.8% 35.2% 35.7%

40.4% 39.9%

45.6%

50.8%

0%

25%

50%

75%

100%

unad

just

ed %

adults

with C

C-P

CM

H

Household income (%FPL)

17.7% 20.9%

29.6%

38.9%

46.8%

52.6%

28.0% 31.4%

39.6%

45.0%

51.1%

56.4%

19-24 25-34 35-44 45-54 55-64 65+

Adult age group

male female

State mean = 40.0%

“lower income”


CC-PCMH is similarly common in different regions

23.1%

27.4% 25.8%

29.2% 26.2%

24.0% 25.2%

0%

10%

20%

30%

40%

50%

1 2 3 4 5 6 7

%*

adults

≤138%

FPL w

ith C

C-P

CM

H

Medicaid Managed Care Region

*Predicted probabilities based on statistical models that adjust for demographic and other characteristics


CC-PCMH is similarly common in different types of counties

26.1% 25.7% 25.3% 27.8%

0%

10%

20%

30%

40%

50%

urban suburban rural Applachian rural non-

Applachian

%*

adults

≤138%

FPL w

ith C

C-P

CM

H

*Predicted probabilities based on statistical models that adjust for demographic and other characteristics.

Findings


Which children have CC-PCMH?

28.5% 32.5%

35.3% 36.6% 38.9%

35.8%

42.5% 41.8%

49.1%

0%

25%

50%

75%

100%

unad

just

ed %

child

ren w

ith C

C-P

CM

H

Household income (as %FPL)


CC-PCMH varies by income and age

“lower income”

52.2%

41.9% 38.5%

35.8%

<1 1-5 6-12 13-18

Child age group

State mean = 39.2%


CC-PCMH is similarly common in different regions

34.3%

39.5%

35.6%

31.4% 31.7%

35.9% 34.5%

0%

10%

20%

30%

40%

50%

1 2 3 4 5 6 7

%*

child

ren ≤

200%

FPL

with C

C-P

CM

H

Medicaid Managed Care Region



CC-PCMH is less common in rural non-Appalachian counties

vs. those in rural Appalachian counties

34.4% 37.9% 38.8%

32.6%

0%

10%

20%

30%

40%

50%

urban suburban rural

Appalachian

rural non-

Appalachian

%*

child

ren ≤

200%

FPL

with C

C-P

CM

H

*Predicted probabilities based on statistical models that adjust for demographic and other characteristics.

Findings


Does Medicaid facilitate access to CC-PCMH

among adults?


CC-PCMH is similarly common for lower income adults

covered by Medicaid or other types of insurance

29.4% 31.3%

29.4% 27.7%

9.0%

0%

10%

20%

30%

40%

50%

Medicaid Medicare & other govt Employer-Sponsored Private/Other Uninsured

%*

adults

≤138%

FPL

with C

C-P

CM

H



Medicaid, 298,000

Medicare, 176,000

employer-sponsored,

96,000

private/other, 47,000

uninsured, 20,000

Estimated number of lower income adults with

CC-PCMH, by insurance type/status

Nearly half of lower income adults with CC-PCMH have Medicaid

Findings


Which adults have CC-PCMH?

Does Medicaid facilitate access to CC-PCMH

among children?

Is CC-PCMH associated with better health care?

Does CC-PCMH reduce health disparities?


CC-PCMH is less common among lower income children

with Medicaid versus those with employer-sponsored insurance


34.7%

42.0%

31.8%

20.8%

0%

10%

20%

30%

40%

50%

Medicaid Employer-Sponsored Private/Other Uninsured

%*

child

ren ≤

200%

FPL

who

hav

e C

C-P

CM

H


Most components of CC-PCMH are equally common

among lower income children with Medicaid versus ESI


95% 91% 95% 90%

80%

96% 92% 95% 92% 85%

0%

25%

50%

75%

100%

Has an appropriate usualsource of care

Has a personal careprovider (PCP; of those

who have an appropriateusual source of care)

Has seen PCP in the past12 months (of those who

have a PCP)

Has good communicationwith PCP (of those who

have seen PCP in past 12months)

Got specialist carewithout a problem

(of those who needed it)

%*

child

ren ≤

200%

FPL

with o

utc

om

e

Medicaid Employer-Sponsored

difference

not

significant

difference

not

significant

difference

not

significant

difference

not

significant

difference

not

significant


Lower income children with Medicaid are less likely than those with ESI

to get needed urgent care or after hours care without a problem


78%

57%

83%

64%

0%

25%

50%

75%

100%

Got urgent care same or next day


Got after hours care without a problem


%*

child

ren ≤

200%

FPL

with o

utc

om

e

Medicaid Employer-Sponsored


Medicaid, 323,000

employer-sponsored,

98,000

private/other, 19,000

uninsured, 7,000

Estimated # of lower income children with

CC-PCMH, by insurance type/status

Nearly ¾ of lower income children with CC-PCMH have Medicaid

Findings


Is CC-PCMH associated with better health care

among adults?

M


Lower income Medicaid adults with CC-PCMH

are less likely to have unmet health needs

19.2%

31.0%

0%

25%

50%

%*

adults

≤138%

FPL

with u

nm

et

heal

th n

eeds

Has CC-PCMH Does not have CC-PCMH

*Predicted probabilities based on statistical models

that adjust for demographic and other characteristics.


Lower income Medicaid adults with CC-PCMH

are less likely to have frequent emergency department visits

13.2%

4.3%

23.0%

9.5%

0%

10%

20%

lower income Medicaid adults

with special health care needs


without special health care needs

%*

Medic

aid a

dults

≤138%

FPL

with fre

quent

(3+

) ED

vis

its

in t

he p

ast

year


*Predicted probabilities based on

statistical models that adjust for

demographic and other characteristics.


Lower income Medicaid adults with CC-PCMH (and who have special health care needs)

are less likely to misuse prescription painkillers




2.1%

1.0%

5.2%

1.6%

0%

5%

10%




without special health care needs

%*

Medic

aid a

dults

≤138%

FPL

mis

usi

ng

pre

scri

ption p

ainkill

ers

in t

he p

ast

year


difference not significant


Lower income Medicaid adults with CC-PCMH (and who have a history of chronic conditions)

are less likely to have an overnight hospital stay




23.8%

11.1%

30.3%

12.6%

0%

25%

50%


with a history of chronic conditions


without a history of chronic conditions

%*

Medic

aid a

dults

≤138%

FPL

who h

ave b

een h

osp

ital

ized

in t

he p

ast

year


difference

not

significant

Findings


Is CC-PCMH associated with better health care

among children?


Lower income children with CC-PCMH

are less likely to have unmet health needs




4.5%

8.9% 8.0%

15.2%

0%

10%

20%

all lower income Medicaid children lower income Medicaid children with special health care

needs

%*

child

ren ≤

200%

FPL

with u

nm

et

heal

th n

eeds



Lower income Medicaid children with CC-PCMH

are less likely to have frequent emergency department visits

3.7%

10.9%

6.7%

18.4%

0%

10%

20%

all low income Medicaid children low income Medicaid children with special health care needs

%*

Medic

aid c

hild

ren ≤

200%

FPL

with fre

quent

(3+

) ED

vis

its

in t

he p

ast

year






CC-PCMH is not associated with having an overnight hospital stay




3.7%

13.1%

4.0%

14.1%

0%

10%

20%

all low income Medicaid children low income Medicaid children with special health care needs

%*

child

ren ≤

200%

FPL

who h

ave b

een h

osp

ital

ized

in t

he p

ast

year


difference

not

significant

difference

not significant


Lower income Medicaid children with CC-PCMH

are more likely to have a well-child visit




90.9% 92.1%

74.9%

83.9%

0%

25%

50%

75%

100%

low income Medicaid children

WITHOUT special health care needs

low income Medicaid children


%*

Medic

aid c

hild

ren ≤

200%

FPL

hav

ing

a w

ell-

child

vis

it

in t

he p

ast

year


Findings


Does CC-PCMH reduce health disparities

among adults?


White adults are more likely to have CC-PCMH




42.1% 39.6%

44.7%

36.1%

28.4%

42.4%

36.6%

32.3%

37.5%

0%

10%

20%

30%

40%

50%

overall Medicaid ESI

%*

adults

who h

ave C

C-P

CM

H

White African-American Hispanic


For both white and African-American lower income adults,

those with CC-PCMH are less likely to have unmet health needs




20.4%

24.4%

32.6%

37.9%

0%

10%

20%

30%

40%

50%

White African-American

%*

adults

with u

nm

et

heal

th n

eeds



CC-PCMH is not associated with health care outcomes

among lower income pregnant women




17.7%

12.9%

43.2%

27.7%

9.9%

44.4%

0%

10%

20%

30%

40%

50%

has unmet health needs frequent (3+/year) emergency

department visits

overnight hospital stay

%*

pre

gnan

t w

om

en ≤

200%

FPL

with o

utc

om

e


difference

not

significant

difference

not

significant

difference

not

significant

Findings


Does CC-PCMH reduce health disparities

among children?


White children are more likely than African-American children

to have CC-PCMH




42.6% 39.8%

46.4%

37.6% 34.8%

41.3%

0%

10%

20%

30%

40%

50%

overall Medicaid ESI

%*

child

ren

who h

ave C

C-P

CM

H

White African-American


For infants from lower income homes, those with CC-PCMH

are less likely to have frequent emergency department visits,

but are just as likely to have an overnight hospital stay




3.7%

24.3%

6.8%

20.9%

0%

10%

20%

30%

40%

50%

frequent (3+/year) emergency department visits overnight hospital stay

%*

infa

nts

≤200%

FPL

with o

utc

om

e


difference

not

significant

Summary of Findings


Adults Children

Who has CC-PCMH? older, female,

higher income

younger,

higher income

Does Medicaid facilitate access

to CC-PCMH? = ESI; > uninsured < ESI; > uninsured

Is CC-PCMH associated with better

health care?

strong, consistent

associations

strong, consistent

associations

Does CC-PCMH reduce racial/ethnic

disparities?

White > Afr-Am;

CC-PCMH helps both;

weak/no effect for

pregnant women

White > Afr-Am;

CC-PCMH helps both;

weak effect for infants

CONCLUSIONS/IMPLICATIONS


Conclusions

• Medicaid is facilitating access to CC-PCMH

• CC-PCMH has robust associations with

favorable health care outcomes

• CC-PCMH may reduce certain health disparities


Policy Considerations • Medicaid expansion may have increased access to

CC-PCMH

• Improving access to urgent and after hours care may help facilitate Medicaid children’s access to CC-PCMH

• Care delivery models that promote CC-PCMH may improve health care outcomes

• Promoting CC-PCMH may help reduce health disparities

• OMAS can help monitor CC-PCMH


Thank You


Questions?


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