Performance Improvement 2013-2014. Objective: Improve health care quality and patient safety

Health care reform promises to make insurance benefits newly available to many, eliminate inequitable treatment limits and financial requirements, and promote integrated primary and behavioral health care. Quality measures can help achieve the full promise of these reforms by providing feedback to payers and providers, and enabling greater transparency and accountability. This project identified and tested measures that addressed pharmacological treatment, psychosocial treatment, and physical health needs for individuals with schizophrenia that can be calculated solely from Medicaid claims data. The psychosocial treatment measure was eventually dropped because procedure codes used in claims data are ambiguous, lacking sufficient detail to reflect the actual service provided and these codes are not used consistently in different states and programs. Ten measures in the other domains were pilot tested using Medicaid Analytic eXtract (MAX) data. They addressed the following concepts: use of antipsychotic medications, antipsychotic medication possession ratio, diabetes screening, diabetes monitoring, cardiovascular health screening, cardiovascular health monitoring, cervical cancer screening, emergency department utilization for mental health conditions, and follow-up after mental health hospitalization within seven days and within thirty days.

Five of the ten proposed measures demonstrated significant variability in state-level performance, indicating general utility of the measures. Seven of the ten proposed measures demonstrated evidence of either construct or convergent validity.

Report Title: Developing Quality Measures for Medicaid Beneficiaries with Schizophrenia: Final Report http://aspe.hhs.gov/daltcp/reports/2012/schqm.shtml

Agency Sponsor: OASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Kirsten Beronio, 202-690-6443

Contract Performer: Mathematica Policy Research, Inc.

Record ID: 10218 (June 26, 2013)

A project was initiated to evaluate national Children's Health Insurance (CHIP) data and conduct case-studies in 10 states. The study also examined the Medicaid program in three of the selected states, how state CHIP programs have developed over time, the influence of key design features on the enrollment and health care experiences of eligible children, and current program and policy issues.

CHIP and Medicaid have contributed to reducing the number and percentage of children without insurance; the rate of growth is influenced by economic conditions, increasing more during economic downturns. CHIP programs are diverse, and program design choices continue to evolve. The quality of care received by children in Medicaid and CHIP is improving and compares favorably to care received in private plans, but further improvements can be made.

Report Title: Interim Report to Congress: Children's Health Insurance Program: An Evaluation (1997 – 2010)
http://aspe.hhs.gov/health/reports/2012/CHIPRA-IRTC/index.shtml
Agency Sponsor: OASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Rose Chu, 202-401-6119
Performer: Mathematica Policy Research
Record ID: 9639 (September 1, 2013)

Since the Institute of Medicine published its landmark study “To Err is Human” in 2000 estimating that up to 98,000 deaths in hospitals result from medical errors, much attention has been paid to medical errors in the hospital setting. Despite a shift towards increasing delivery of care in the outpatient setting, comparatively little is known about the occurrence of medical errors in ambulatory care settings.

This study assessed current literature on ambulatory patient safety events, and found that, while there were many activities occurring in the outpatient setting to address safety, systematic reporting and evaluation of ambulatory events occurring across the entire spectrum of ambulatory care at a national level was needed. The project explored policy levers to enhance the healthcare system's ability to accurately and reliably measure and track these events. Levers identified included:  prioritizing specific areas within ambulatory care to focus on initially, standardizing definitions and taxonomies, exploring electronic health records as an important data source, and extending the culture of safety from inpatient to ambulatory settings.

Report Title: Infrastructure, Tools and Data Needed to Measure Ambulatory Care Patient Safety Events
Agency Sponsor: OASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Pierre Yong, 202-690-8384
Performer: The Lewin Group
Record ID: 9741 (October 1, 2012)

This project developed, implemented and evaluated a healthcare provider resource in an effort to promote use of the 2008 Physical Activity Guidelines for Americans (PAG), the Dietary Guidelines for Americans 7th edition (DGA) and health literacy principles.

A healthcare providers' guide/curriculum was developed according to the PAG and DGA, pilot tested locally, and implemented in selected sites nationwide. The guide/curriculum was evaluated for usability, and for effectiveness in promoting positive behavior change.

Report Title: A Healthcare Provider Resource Based Upon the Dietary Guidelines for Americans and Physical Activity Guidelines for Americans
Agency Sponsor: OASH, Office of the Assistant Secretary for Health
Federal Contact: Rick Olson, 240-453-8256
Performer: American Institutes for Research (AIR)
Record ID: 9855 (December 31, 2012)

In 2009, community health centers funded by the Health Resources and Services Administration provided primary and preventive care to about 19 million patients across the United States. This study examined clinical quality among the nation's community health centers and health center characteristics associated with performance excellence. Six measures were examined: first-trimester prenatal care, childhood immunization completion, Pap tests, low birth weight, controlled hypertension, and controlled diabetes. The top 25 percent performing centers were compared with lower performing (bottom 75 percent) centers on these measures.

Clinical care and outcomes among health centers were generally comparable to national averages. For instance, 67 percent of pregnant patients received timely prenatal care (national = 68 percent), 69 percent of children achieved immunization completion (national = 67 percent), and 63 percent of hypertensive patients had blood pressure under control (national = 48 percent). Depending on the measure, centers with more uninsured patients were less likely to do well, while centers with more physicians and enabling service providers were more likely to do well.

Report Title: Clinical Quality Performance in U.S. Health Centers
Agency Sponsor: HRSA, Health Resources and Services Administration
Federal Contact: Lydie Lebrun-Harris, 301-443-2178
Performer: Johns Hopkins University Bloomberg School of Public Health
Record ID: 10100 (December 31, 2012)

More than 1100 federally funded health centers provide primary and preventive care to about 20 million underserved patients in the United States. This study assessed racial/ethnic disparities in clinical quality among United States health centers, and examined whether performance on quality measures varied across three health center characteristics: health center patient volume, duration of health center funding, and extent of managed care penetration. Three indicators of clinical quality were examined: poorly controlled hypertension among adult patients, poorly controlled diabetes among adult patients, and low birth weight among newborns.

Poor diabetes control was more prevalent among Hispanic/Latino patients than non-Hispanic white patients. Non-Hispanic black/African American patients had statistically worse outcomes than non-Hispanic white patients. Health centers with larger patient volume fared better than their counterparts with smaller volume for all racial/ethnic groups. For Hispanic/Latino patients, more established health centers compared favorably to new health centers for all three outcomes. Health centers with some managed care penetration did better for diabetes and hypertension control relative to health centers without managed care penetration.

Report Title: Racial/Ethnic Differences in Clinical Quality Performance among Health Centers
Agency Sponsor: HRSA, Health Resources and Services Administration
Federal Contact: Lydie Lebrun-Harris, 301-443-2178
Performer: Johns Hopkins University Bloomberg School of Public Health
Record ID: 10101 (March 1, 2013)

This study conducted an evaluation of the Screening, Brief Intervention and Referral to Treatment (SBIRT) program. The program initiative is intended to assist States and Tribal Organizations in redesigning care that identifies, treats, and provides continued management support for persons with substance use problems in both community and specialist settings. There is an emerging body of research and clinical experience that supports use of the SBIRT approach as providing effective early intervention for those persons who are nondependent users of illicit drugs.

Findings included consistent and statistically significant reductions in patients' alcohol and illicit drug use following the receipt of SBIRT services. Additional findings suggested that SBIRT is an economically viable preventative service. SBIRT has a high likelihood of being sustained and of increasing the integration between the medical and specialty care systems.

Report Title: SBIRT Cohort 1 Cross-Site Evaluation Final Report
Agency Sponsor: SAMHSA, Substance Abuse and Mental Health Services Administration
Federal Contact: Willie Tompkins, 240-276-2899
Performer: SAMHSA
Record ID: 8878 (September 30, 2013)

 All Garrett Lee Smith Program grant recipients participate in a national cross-site evaluation. This participation allows for large sample comparisons of early intervention activities and the collection of information on the use of best and promising practices. Grantees have used program resources to develop a wide array of suicide prevention strategies and products tailored to best meet the needs of their communities. Activities are intended to increase awareness, knowledge, early identification, and linkage to treatment. The cross-site evaluation helps grantees track budgets, develop and implement these prevention strategies. Outreach and awareness (OA) activities were the most common program activity, with more than 98 percent of State/Tribal and Campus grantees implementing them in their communities across all years. Grantees spend the largest proportion of funds on OA activities and gatekeeper trainings. More than 95 percent of State/Tribal and Campus grantees provided training activities with their GLS Suicide Prevention Program funding. Slightly less than one-third of grantees implemented assessment and referral trainings in their communities.

From 2006 to 2012, more than 12,000 youths were identified at elevated risk of suicide. The rates of identification from screening decreased from 78 percent in FY 2009 to 55 percent in FY 2012, with a slight increase in the number of youth identified as at-risk for suicide by gatekeepers. Eighty percent of the youth at-risk for suicide identified by State grantees and 49 percent almost half of the youth identified by Tribal grantees were referred for mental health services.

Report Title: State/Tribal Youth Suicide Prevention and Early Program Cross-site Evaluation, Garrett Lee Smith Memorial Act Fiscal Year 2012 Annual Report

Agency Sponsor: SAMHSA, Substance Abuse and Mental Health Services Administration
Federal Contact: Richard McKeon, 240-276-1873
Performer: Macro International, Inc.
Record ID: 8727 (July 31, 2012)

This project provided a thought piece about what type of coordinated framework might be developed for evaluating the evidence the Department of Health and Human Services will receive from multiple delivery system reform initiatives planned and underway.

Researchers made recommendations addressing organizational and market variables likely to be associated with quality and cost performance for health care organizations participating in delivery reform initiatives, a review of national and regional data sets and data collection, and a conceptual framework for evaluating multiple delivery system reform initiatives. The project also explored the operational challenges of aggregating disparate information from administrative databases and for collecting additional data from providers.

Report Title: Analysis of HHS Delivery System Reform Efforts and ACA Mandates
Agency Sponsor: OASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Susan Bogasky, 202-401-0882
Performer: CDM Group/Brandeis
Record ID: 9743 (August 1, 2012)

This project tracked and analyzed state implementation of the Affordable Care Act through qualitative analysis based on site visits that included discussions with state officials, insurers, and providers. The project sought to determine what states were doing to establish State-Based Exchanges or State Partnership Exchanges, or to prepare for cooperation with Federally-Facilitated Exchanges. The study focused on what states were doing to prepare for the expansion of Medicaid eligibility and enrollment in 2014. It also sought to determine how states are integrating Medicaid, CHIP, and Exchange eligibility and enrollment processes, and whether they planned to establish Basic Health Plans).

Results of site visits indicated that for Arkansas, Florida, Ohio and Texas implementation of market reforms would be difficult with some opposition by political leaders, especially for Medicaid expansion. States indicated they have little legislative authority to enforce market rules. Feedback from issuers showed reluctance to participate in the Small-Business with Health Options Program (SHOP) with little known about the requirements. Feedback from providers demonstrated some activity with respect to medical homes but also major issues concerning physician shortages and scope of practice laws for physician extenders.

Report Title: Urban Institute Qualitative and Quantitative Deep Dive on Four States.
Agency Sponsor: OASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Thomas Musco, 202-690-7272
Performer: Urban Institute
Record ID: 9747 (September 1, 2012)

The study sought national and state level simulation modeling of the number of consumers in different market segments and persisting rates of uninsured, levels of participation on and off Exchanges in the individual and small group markets, and relative changes in pricing under various Affordable Care Act implementation scenarios.

The researchers concluded that the Affordable Care Act will lead to an increase in insurance coverage and significantly higher enrollment in the non-group market. The researchers also found large variation in the effects for non-group premiums across states. However, data limitations and uncertainties about insurer behavior made estimates uncertain, particularly when considering outcomes for the non-group market. Overall, the analysis suggests that comparisons of average premiums with and without the Affordable Care Act may overstate the potential for premium increases. The Affordable Care Act was found to have little effect on small group enrollment or premiums. Finally, in a sensitivity analysis for three states, it was found that not expanding Medicaid leads to lower overall insurance coverage compared to the Medicaid expansion scenario and, for some states, higher premiums in the Exchanges.

Report Title: RAND modeling of consumers, premiums and products, http://www.rand.org/content/dam/rand/pubs/research_reports/RR100/RR189/RAND_RR189.pdf (published report)
Agency Sponsor: OASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Ken Finegold, 202-401-6644
Performer: RAND
Record ID: 9755 (September 28, 2012)

Researchers analyzed nondiscretionary visits to hospital emergency departments to assess the impact of the expansion of dependent coverage under the Affordable Care Act. A differences-in-differences methodology measured the impact of the expansion on private insurance coverage and uninsurance among individuals aged 19 to 25, as compared those 26 to 31 who were not directly affected by the dependent coverage provisions. The IMS Health proprietary hospital claims data base, reweighted to be nationally representative, was used for the analysis.

After the Affordable Care Act provision took effect, private coverage of nondiscretionary visits to emergency departments by young adults increased by 3.1 percentage points as compared with similar visits in the control group. The percentage of visits by uninsured young adults also fell significantly. The rates of nondiscretionary visits that were covered by Medicaid or other non-private insurers remained relatively steady throughout the study period. The coverage expansion led to an estimated 22 thousand visits to emergency departments by newly insured young adults and $147 million in associated costs that were covered by private insurance plans during a 1-year period (http://www.flickr.com/photos/hhsgov/8904203550/in/set-72157633968047018).

Report Title: The Early Impact of ACA Reforms: Dependent Coverage Analysis. (Published: “Insurance Coverage of Emergency Care for Young Adults under Health Reform,” New England Journal of Medicine, May 30, 2013, http://www.nejm.org/doi/full/10.1056/NEJMsa1212779).
Agency Sponsor: OASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Ken Finegold, 202-401-6644
Performer: Rand Corporation
Record ID: 9756 (June 30, 2012)

The study documented program success in efforts to improve access to services for individuals living with sickle cell disease and carriers of the sickle cell gene mutation by improving and expanding patient and provider education and improving/expanding the continuity and coordination of service delivery.

The program developed and implemented promising models. The program integrated primary and specialty care with community-based support services in a medical home designed to meet the unique needs of individuals living with sickle cell disease or carriers and their families. The program achieved positive trends and outcome in Hydroxyurea therapy, written care plans, and assistance with referrals and communication with providers.

Report Title: Demonstration Program for the Development and Establishment of Systematic Mechanisms for the Prevention and Treatment of Sickle Cell Disease: Identifying Promising Practices Fiscal Year(s) 2006-2010
Agency Sponsor: HRSA, Health Resources and Services Administration
Federal Contact: Edward Ivy, 301-443-9775
Performer: RTI International
Record ID: 9854 (December 20, 2011)