Youth Health Improvement Initiative: Partnering with Private Insurers to Improve Adolescent Healthcare
|Rachel Wallace-Brodeur, MS, Med|
Quality Improvement Coach
Vermont Child Health Improvement Program
Barbara Frankowski, MD, MPH
Professor of General Pediatrics/Adolescent Medicine
Larner College of Medicine
Private insurers are often untapped partners and resources for clinical quality improvement work. Insurers are invested in quality health care and services that are cost-effective and cost-efficient. Through their quality improvement work, they disseminate standards of care to providers and promote health to their subscribers. Insurers are able to influence health care users through education and health promotion outreach and to support health care providers with patient population data and quality metrics.
In Vermont, the Vermont Child Health Improvement Program (VCHIP) partnered with private and public insurers to improve adolescent health. The Youth Health Improvement Initiative (YHII) at VCHIP is an ongoing project supported by the Vermont Maternal Child Health Department, which works with primary care practices to improve the quality of care for adolescents in Vermont. The YHII team realized their project had the potential to impact HEDIS measures (a primary quality metric for insurers) related to adolescent health. YHII approached the quality departments at VT Medicaid and the three major private insurers in Vermont: BCBS, Cigna, and MVP and proposed joining forces to improve adolescent care in Vermont and improve HEDIS measures. As insurers are required to do annual quality improvement projects, they saw this collaboration with YHII as an opportunity to increase the impact of their work and affect healthcare quality as assessed by the HEDIS measures.
The private insurers joined other YHII stakeholders and started aligning efforts around adolescent care. As stakeholders in the project, insurers had a voice in deciding the content focus for YHII's outreach each year. YHII worked with clinical practices to improve quality of care on topics including nutrition, drug and alcohol screening, and reproductive health. In addition to having a say in content, insurers also helped guide the selection of clinical sites. Each insurer provided a list of pediatric practices where it had a large patient population. YHII would target those practices for their QI work so that insurers would see the impact of improved care on their clientele. The YHII team benefitted from this partnership by receiving financial support from the insurers for the project work. The YHII team also suggested content for the insurers' subscriber newsletters that aligned with the project. For example, the YHII team suggested an article on the importance of the annual adolescent well visit and contributed content related to screening and confidentiality.
In this project, the YHII team used their expertise to change the behavior of providers on a range of topics related to adolescent care. Insurers supported that work by coordinating outreach to their consumers to promote the adolescent well visit and its various components and provided practices with Gap in Care reports. As a result of YHII's quality improvement work, insurers saw an improvement in HEDIS measures, such as chlamydia screening, in their population. Through this collaboration, YHII and the insurers had a greater impact on improving adolescent care than they would have had if they had worked in isolation.
Data Sharing with State Medicaid: A Spotlight on Michigan's Maternal Child Health (MCH) Epidemiology Section
McKane, DVM, MPH
Director, Lifecourse Epidemiology & Genomics
Department of Health and Human Services
Corona, MPH, CPH
Analyst, Child and Adolescent Health
Association of Maternal and Child Health Programs
The ability to easily access state Medicaid data to inform and evaluate public health programming could dramatically improve maternal and child health capacity for serving vulnerable populations. The Michigan Population Health Administration (PHA), where Michigan's maternal and child health and epidemiology programs are housed, has an ongoing collaboration with Michigan's Medical Services Administration that enables them to access state Medicaid data. To receive permission to access the data, the PHA must provide a justification as to why the data they are requesting will benefit Medicaid beneficiaries, which is a federal requirement. For any analysis that is beyond routine surveillance, an application, along with a data sharing agreement, must be submitted to the state's Internal Review Board.
What facilitated the creation of a standardized process for requesting access to Medicaid data?
The Population Health Administration and the Medical Services Administration, home to Medicaid, are housed within the same department—the Michigan Department of Health and Human Services (MDHHS). As such, Medicaid data are maintained within the MDHHS health services data warehouse. Additionally, Medicaid data are linked to abstracts of Michigan Vital records data, which are also maintained within the MDHHS warehouse. Although state and jurisdiction organizational structures vary, if a state's population health office and Medicaid office happen to be housed under the same department, or closely related departments, there is opportunity to pioneer a standardized data sharing process.
What are some examples of how Michigan's Population Health Administration has utilized this standardized data sharing process with the state Medicaid office?
The first project was linkage of asthma deaths in children to Medicaid claims, which found racial disparities in mortality among Medicaid adolescent enrollees. Although the examples listed below are not adolescent-specific, they serve as an exciting demonstration of how state public health programs are leveraging Medicaid data to tell stories about publicly-insured MCH populations in their state:
In addition, Michigan currently has several projects in various stages of the approval process, where they are linking Newborn Screening, Medicaid, Children with Special Health Care Needs (CSCHCS) and Vital Records data. The Newborn Screening program is planning to evaluate the time to enrollment in CSHCS among infants identified as having a CSHCS-eligible disorder through the Newborn Screening program. In addition, analysis of care patterns and health outcomes among sickle cell disease patients is also being considered.
Are there any limitations to leveraging the data sharing process?
For Michigan, one of the greatest limitations is lack of steady funding for Medicaid data analysis for MCH programs. Currently, Michigan's Newborn Screening program and Asthma prevention program are supporting the epidemiology section's analyst position. Uncertainty of funding makes it difficult to retain staff. The learning curve to work in the data warehouse with claims and enrollment data is steep and it takes approximately one year for the analyst/statistician to become proficient with the data.
Who can I contact for questions about the examples of Medicaid data sharing provided above?
Please contact Patricia McKane, Division Director, McKaneP@michigan.gov
Minnesota Health Plan Chlamydia Screening Collaborative:
A Case Study
The Minnesota Health Plan Chlamydia Screening Collaborative was created to increase screening among sexually active adolescents and young adults. This was a performance improvement project among four Minnesota health plans: Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, and UCare (supported by Stratis Health). The Collaborative worked with clinics in a variety of ways to positively impact chlamydia screening rates.
- Periodic online provider training (archived training).
- Compiled a provider toolkit to help clinics and providers across the state improve their clinic processes and awareness of the issue.
- Targeted outreach to clinics. Using Minnesota Community Measurement data, each health plan partner identified and supported clinics in their network through targeted outreach and use of the toolkit to improve chlamydia screening rates.
In addition, the Collaborative recognized the need to partner with existing organizations and collaboratives working on chlamydia screening. This included supporting the Minnesota Chlamydia Partnership (a collaboration between public health, health care, community organizations, and youth organizations) to implement their Minnesota Chlamydia Strategy.
For an overview of this effort, see the NIHCM 2013 webinar, Adolescents and STDs – A call to action for providers and health plans.
Five Areas Where State Title V MCH Programs and Medicaid Agencies Can Partner to Improve Adolescent Health
Medicaid and State Title V Maternal and Child Health (MCH) programs have a long history of providing health care services and support to children and adolescents. Medicaid and the Children's Health Insurance Program (CHIP) covered 34 percent of adolescents in 2016.[i] State Title V programs promote the health of adolescents through a variety of activities including policy and standards setting, provider training, and support for school-based health centers. The federal Title V MCH Services Block Grant includes a statutory requirement for coordination with Medicaid, in addition to other requirements, thereby underscoring the importance of partnerships between Title V and Medicaid.[ii] States are engaging in and have numerous opportunities to collectively promote adolescent health. Here are just five of them to consider:
1. Understanding the important role that Medicaid/CHIP play in providing health care to adolescents and where state Title V programs can collaborate to help fill any gaps in coverage. The Early and Periodic Screening, Diagnostic and Treatment services, or EPSDT, is the Medicaid coverage benefit for children and adolescents. It provides a comprehensive array of prevention, diagnostic, and treatment services for low-income youth up to age 21.
2. Ensuring the unique needs of adolescents are considered in contracts with Medicaid managed care (MMC) organizations. State Medicaid programs are increasingly using managed care delivery systems to provide health care services to Medicaid beneficiaries, including adolescents. In a recent NASHP analysis, NASHP found that nearly all states (47 states and Washington, D.C.) use some form of managed care to serve Medicaid enrollees.[iii] Risk-based managed care is the most common model used by 37 states.[iv] State MMC contracts outline the services, supports, and quality of care that a managed care organization provides to Medicaid beneficiaries.
3. Promoting adolescent health through Title V and Medicaid quality measurement. States have the option of implementing performance measurement, incentives or improvement projects – often as part of broad health system transformation efforts – to promote access to preventive services for children and adolescents. In a recent NASHP analysis of states' use of child preventive services measures in Medicaid, over half of the states use a child and adolescent well visit measure as part of state Medicaid agency efforts to promote quality measurement. Similarly, over three-quarters of state Title V programs (39 states) are actively promoting and tracking preventive medical visits for adolescents.
4. Establishing policies in Medicaid managed care contracts to transition adolescents with special health care needs to adult-serving programs. As children and youth with special health care needs (CYSHCN) become young adults, it is important to take steps and provide resources to begin transitioning their care from pediatric providers to adult providers.[v] Support for CYSHCN and families transitioning from pediatric to adult health care services has been a longstanding priority for state Title V CYSHCN programs. In 2016, 32 state Title V programs selected "pediatric-to-adult health care transition" as one of their 15 national performance measures to improve, with a majority of those states choosing to focus on improving the transition process for CYSHCN.[vi]
5. Including data sharing on the utilization of preventive services for adolescents in Interagency Agreements (IAAs) between Medicaid and Title V. State Medicaid programs are required to enter into Interagency Agreements (IAAs) with state Title V programs.[vii] Including provisions in IAAs for the exchange of specific types of data (e.g., Medicaid claims data, population health data, and performance outcome measures) can be a valuable tool to determine the current rate of preventive services among adolescents and identify areas for targeted improvement efforts. In addition to data sharing, there are numerous other state strategies for strengthening Medicaid and Title V programs through IAAs
[i] Among those ages 12-17. Source: Current Population Survey (CPS) Annual Social and Economic (ASEC) Supplement, 2016. https://www.census.gov/data/tables/time-series/demo/income-poverty/cps-hi/hi-08.html
[ii] U.S. Department of Health and Human Services, State MCH-Medicaid Coordination: A Review of Title V and Title XIX Interagency Agreements (2nd Ed). (Washington, DC: U.S. Department of Health and Human Services, 2008).
[iii] Kate Honsberger and Karen VanLandeghem, State Medicaid Managed Care Enrollment and Design for Children and Youth with Special Health Care Needs: A 50-state Review of Medicaid Managed Care Contracts (Washington, DC: National Academy for State Health Policy, October 2017).
[v] American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians, Transitions Clinical Report Authoring Group, "Supporting the health care transition from adolescence to adulthood in the medical home," Pediatrics. 128 (June 2011): 182-200, http://pediatrics.aappublications.org/content/pediatrics/early/2011/06/23/peds.2011-0969.full.pdf
[vi] Margaret McManus, et al. Aligning National Title V Performance Measures On Transition, Medical Home, Preventive Care, And Insurance: Suggested Strategies For States (Washington, DC: The National Alliance to Advance Adolescent Health, March 2016)
[vii] Section 509(a)(2) of Title V of the Social Security Act and Section 1902(a)(11) of Title XIX