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Managed Care, Medicaid, and Public Health: Building Collaborations That Work
Gail Janes, Ph.D., M.S., Health Scientist, Epidemiology Program Office, Centers for Disease Control and Prevention/U.S. Department of Health and Human Services, Atlanta, GA.
Pomeroy Sinnock, Ph.D., Associate Director for Science, Division of Public Health Systems, Public Health Practice Office, Centers for Disease Control and Prevention/U.S. Department of Health and Human Services, Atlanta, GA.
Cornelia D. Gibbons, L.M.S.W., Director, Office of Planning, South Carolina Department of Health and Environmental Control, Columbia, SC.
Pomeroy Sinnock explained the National Public Health Performance Standards Program, which is an effort to develop local and State-based performance standards, systematically collect and analyze performance data, and improve systemwide performance.
The 450-item local instrument was pilot tested in Texas, Florida, Ohio, and Missouri in
1999; it is currently being field-tested in several other States. It will be available nationally in 2001. The State instrument has been pilot-tested in Florida, Ohio and Missouri; it will be field-tested in Spring 2000. Both tools are designed to require the participation of multiple entities.
One area examined in the local instrument is substantial partner involvement in the
local public health system. Mr. Sinnock noted that this could serve as an eye-opener in starting to develop collaborations. Partner indicators include:
- Local health departments.
- Managed care organization (MCOs).
- Primary care clinics.
- Social service providers.
- Civic organizations.
- Professional organizations.
- Local businesses.
- Neighborhood organizations.
- Faith institutions.
- Transportation providers.
- Educational institutions.
- Public safety and emergency response groups.
- Emergency health agencies.
- Nonprofit advocacy groups.
The Assessment Initiative: Partnering with Private Providers is a project in which the Centers for Disease Control and Prevention (CDC) works with States over 5 years in assessing health status, resources, and needs through partnerships between public and private healthcare purchasers and providers. The six participating States are: Massachusetts, Minnesota, Missouri, New York, North Carolina, and Oregon. Each State determined specific areas to examine. Gail Janes provided examples of what several States have accomplished through this partnership.
The Massachusetts Health Assessment Partnership (MHAP) is comprised of the State agencies in charge of public health, Medicaid, and the hospital discharge registry; the four largest MCOs; and the Massachusetts Health Quality Partnership (which includes the medical society, hospital association, and business roundtable). Its efforts on Secondary Prevention of Coronary Artery Disease had three goals:
- Identify risk factors for secondary onset.
- Assess barriers to treatment and prevention.
- Develop a data-collection methodology for assessing risk factors and barriers that is both reliable and easy to use.
To do this, MCOs identified the eligible patient population, the health department supported the survey administration and analysis, and both collaborated on creating the survey instrument and in developing clinic- and population-based interventions. For the Maternal and Child Health Assessment Initiative, MHAP has sought to improve the measures of maternal and child health
status and healthcare by linking birth certificates, MCO administrative and Health Plan Employer Data and Information Set (HEDIS) data, State hospital discharge files, and MCO claims data.
In the New York Assessment Initiative's project, Improving State and Local Assessment Capacity, local health departments, community-based organizations, and provider groups worked together to draft strategies for use of provider-level data. The Initiative's project on Public Uses of Provider Data worked on both community and State levels. The community level sought to better target services, and the State level sought to enhance the quality of clinical care by creating reports on managed care performance on child and adolescent care, including a consumer guide.
The Minnesota Assessment Initiative's project, Minnesota Health Status Report
focused on using linked data on key health-status indicators. Medicaid agency representatives, provider groups, representatives of academic institutions, and local health departments used these data to prioritize and strategize on health-related issues. The Population Health Assessment Work Group—made up of provider groups, academics, county health departments, and State agencies—established working groups for consensus-based decisionmaking on tobacco, diabetes, and maternal and child health.
Critical factors in partnering with MCOs and private players include:
- Managed care penetration, which affects the ease of getting MCOs to the table.
- Medicaid managed care.
- A history of collaboration.
- Maturity of the managed care market, because MCOs feeling "under siege" will avoid taking on new initiatives.
- Regulatory environment.
- Open minds.
Nela Gibbons described how South Carolina has used measurement to improve its services. She stressed, "Data is your tool and your best friend. You can use it with
legislators, funders, and peers."
With a Robert Wood Johnson Foundation grant, the State built the Masterfile system, a warehouse linking data from all State agencies, nursing facilities, hospital emergency rooms (ERs), home health agencies, and provider groups. These data have had multiple uses. For example, it was determined that in Aiken, South Carolina, welfare beneficiaries' homes and child care centers were located away from bus routes, making it extremely difficult for beneficiaries to hold jobs. These data were presented to the county government, which then reworked the bus system to connect the beneficiaries, childcare centers, and downtown jobs.
Making a difference means first knowing what to do and what to measure. Planning and managing for results allow an organization to focus strategically around goal attainment, to demonstrate accountability through evidence-based decisionmaking, and to identify partnerships needed to achieve those goals. The planning process involves working backward through:
- Goals: Statements of long-term changes in health status and the environment.
- Outcomes: Benefits or changes in health status that lead to the desired goals
(there must be a causal link).
- Strategies: Policies developed to encourage the types of activities that will lead to the desired outcomes.
- Activities: Actions carried out (typically by front-line staff) shown to have a causal link to the desired outcomes.
South Carolina has a goal that children and youth be healthy and ready to learn. This has led to outcomes for various entities; multiple players are necessary to meet these outcomes. In choosing among outcomes to pursue, the State Department of Health and Environmental Control (DHEC) considered the following questions:
- What outcomes are critical to achieve our goal?
- What outcomes are "nice to have" but not critical?
- Do the outcomes reflect the causal chain? Are there gaps?
- What outcomes are the responsibility of this agency? Are we achieving those goals?
As an example of this process, the outcomes of the Department of Health and Environmental Control—Provider Partnerships were described. In this program, public health nurses work with participating physicians' offices to enable them to take on larger numbers of Medicaid children. Since the program's inception in 1995, children served have had the following measurable outcomes: better EPSDT (Early and Periodic Screening, Diagnostic, and Testing) compliance rates, more overall physician visits, and lower overall ER use. The money saved by the lower ER rates has been used to increase reimbursements to participating physicians.
Mays GP, Halverson PK, Miller CA. Assessing the performance of local public health systems: a survey of state health agency efforts. J Public Health Manage Pract 1998;4(4):63-78.
Planning and managing for results: an overview. Columbia(SC): South Carolina Department of Health and Environmental Control;2000 Mar.
Turnock BJ. Accrediting public health organizations: "the ducks is on the pond!" J Public Manage Pract 1998;4(4):vi-vii.
What gets measured, gets done. Atlanta(GA): National Public Health Performance Standards Program;1999 Nov.
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