lisa raiz, william hayes, keith kilty, tom gregoire, christopher holloman ohio employer and ohio...
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SNAPSHOT OF DETERMINANTS FOR AN ENHANCED PRIMARY
CARE HOME INITIATIVE: CURRENT STATUS OF PRIMARY
CARE AND POLICY CONSIDERATIONS
Lisa Raiz, William Hayes, Keith Kilty, Tom Gregoire, Christopher Holloman
Ohio Employer and Ohio Family Health Research Conference
July 29, 2011
Agenda
Project Aims Defining Primary Care Expanded Focus Aim 1 Aim 2 Policy Considerations Next Steps
Project Aims
1. To estimate the proportion of Ohioans who have, or do not have, primary care
2. To examine the association between having, or not having, primary care and unmet health needs, health status and health outcomes
3. To develop an operational definition of Enhanced Primary care Home specific to Ohio policy, rules and laws
Defining Primary Care1. Usual source of care
a. yes/no
2. Place care is receiveda. Clinic or health center
b. Doctor’s office or HMO
c. Hospital emergency room
d. Other
3. Levels of care usea. Enhanced use
b. Limited use
c. No use
Three Levels of Primary Care Use
1. Enhanced use Received a routine check-up during
previous year
2. Limited use No routine check-up; visited a doctor during
previous year
3. No use No routine check up; did not visit a doctor
during previous year
Sociodemographic Variables
Chronic Conditions
Not chronic
Chronic mental health
Other chronic
Insurance
Medicare
Medicaid
Dual eligibles
Private ESI
Other private
Uninsured
Region
Appalachia
Rural, non-Appalachia
Suburban
Metropolitan
Race/Ethnicity
Asian
Black
Hispanic
White
Age
18-24
25-34
35-44
45-54
55-64
Sex
Female
Male
SES
<100%FPL
101-138%FPL
139-150%FPL
151-200%FPL
201-250%FPL
>300%FPL
Logic Model
1 2
ER
Usual Source of Care
Yes
No
Physician
Other site
Outcomes related to health care utilization or health events, such as
unmet need, BMI smoking status, alcohol use access to specialist hospital visits stable with diabetes ER visits care coordination
need
Population of interest
Limited use (saw doctor in last year, no checkup)
Enhanced use (had checkup in last year)
Compare populations by income, region, insurance type, age, race/ethnicity, sex Insured/uninsured has 6 categories: ESI, other private, Medicaid, Medicare, dual eligible, and uninsured
No use (not see doctor in last year and no checkup)
Clinic
Limited use (saw doctor in last year, no checkup)
Enhanced use (had checkup in last year)
No use (not see doctor in last year and no checkup)
3
Expanded Focus
INDIVIDUALS WITH CHRONIC
CONDITIONS
Patient Protection and Affordable Care Act
Title II: Role of Public ProgramsSubtitle I: Improving the Quality of Medicaid
for Patients and Providers○ Section 2703: State Option to Provide Health
Homes for Enrollees with Chronic Conditions○ Eligible individuals:
Eligible for State assistanceHas at least:
- 2 chronic conditions- 1 chronic condition and is at risk of having a second
chronic condition; or- 1 serious and persistent metal health condition
Chronic Conditions
Populations with chronic conditions Not chronicChronic mental healthOther chronic
Risk Factors:○ Currently smokes cigarettes○ Positive response to any episodes of binge
drinking
Chronic GroupsGroup Variable Total 0-100%FPL 101-138%FPL
Chronic Groups
2008Not chronicChronic mental healthOther chronic
2010Not chronicChronic mental healthOther chronic
71.3% 6.4% 22.3%
71.4% 8.2%20.4%
62.0%14.0%24.0%
63.1%14.2%22.7%
67.4% 9.3%23.3%
67.3%12.0%20.7%
Aim 1
What is the proportion of Ohioans who have primary care?
What is the proportion of Ohioans who have primary care, based on sociodemographic variables?
What variables are associated with an increased likelihood of having primary care?
All Not chronic Chronic mental health
Other chronic
0
10
20
30
40
50
60
70
80
90
100
2008 - Yes2008 - No2010 - Yes2010 - No
Usual Source of Care:Chronic Conditions
% with a usual source of care
Usual Source of Care: Insurance Type
All
Med
icare
Med
icaid
Dual E
ligibl
e
Privat
e ESI
Oth
er P
rivat
e
Uninsu
red
0
10
20
30
40
50
60
70
80
90
100
2008 - Yes2008 - No2010 - Yes2010 - No
% with a usual source of care
Usual Source of Care:Region of Residence
All
Appala
chia
Rural
Non-A
ppala
chia
Subur
ban
Met
ro0
20
40
60
80
100
2008 - Yes2008 - No2010 - Yes2010 - No
% with a usual source of care
Usual Source of Care:Age
All Age 18-24
Age 25-34
Age 35-44
Age 45-54
Age 55-64
0
10
20
30
40
50
60
70
80
90
100
2008 - Yes2008 - No2010 - Yes2010 - No
% with a usual source of care
Usual Source of Care:Race and Ethnicity
All White Black Asian Hispanic0
10
20
30
40
50
60
70
80
90
100
2008 - Yes2008 - No2010 - Yes2010 - No
% with a usual source of care
Usual Source of Care: Socioeconomic Status
All <100%
FPL
101-138% FPL
139-150%FPL
151-200% FPL
201-250% FPL
251-300% FPL
>300%
FPL
0
10
20
30
40
50
60
70
80
90
100
2008 - Yes2008 - No2010 - Yes2010 - No
% with a usual source of care
Place Care is Received 11 response categories (if usual source of care)
Clinic or health centerDoctor’s office or HMOHospital emergency roomHospital outpatient departmentMilitary hospitalsDoes not go to one place most oftenBooks/internet/hotlineHospitalUrgent careFamily member or friendSome other place
Place Care is Received - 2008Doctor’s Office or HMO: 73.6% all Ohioans
>73.6%
MedicarePrivate ESINot chronicRural – Non AppSuburban35-4445-5455-64WhiteFemale201-250%FPL251-300%FPL>300%FPL
60%-73.5%
Other privateOther chronicAppalachiaMetro25-34AsianMale101-138%FPL139-150%FPL151-200%FPL
50-59.9%
MedicaidDual eligibleChronic mental health18-24<100%FPL
40-49.9%
UninsuredBlackHispanic
Place Care is Received - 2010Doctor’s Office or HMO: 72.5% all Ohioans
>72.5%
MedicarePrivate ESIOther privateNot chronicRural – Non AppSuburban45-5455-64WhiteFemale201-250%FPL251-300%FPL>300%FPL
60%-72.4%
Other chronicAppalachiaMetro25-3435-44Male101-138%FPL139-150%FPL151-200%FPL
50-59.9%
MedicaidDual eligibleChronic mental health18-24AsianHispanic<100%FPL
40-49.9%
UninsuredBlack
Increased by >4%Decreased by >4%
Place Care is Received - 2008Clinic: 13.1% all Ohioans
>20%
MedicaidDual eligibleUninsuredChronic mental healthBlackAsianHispanic (>30%)<100%FPL
13.2-19.9%
Other privateOther chronicAppalachiaMetro18-2425-34Male101-138%FPL139-150%FPL151-200%FPL201-250%FPL
<13.1%
MedicarePrivate ESINot chronicRural non-AppSuburban35-4445-5455-64WhiteFemale251-300%FPL>300%FPL
Place Care is Received - 2010Clinic: 14% all Ohioans
>20%
MedicaidUninsuredChronic mental healthBlackHispanic (>30%)<100%FPL
14.1-19.9%
Dual eligibleOther privateOther chronicAppalachiaMetro18-2425-3445-54AsianMale101-138%FPL139-150%FPL151-200%FPL
<14%
MedicarePrivate ESINot chronicRural non-AppSuburban35-4455-64WhiteFemale201-250%FPL251-300%FPL>300%FPL
Increased by >4%Decreased by >4%
Place Care is Received - 2008Emergency Room: 5.8% all Ohioans
<5.8%
MedicarePrivate ESIOther privateNot chronicRural – Non AppSuburban45-5455-64WhiteAsianFemale201-250%FPL251-300%FPL>300%FPL
5.8-9.9%
Other chronicAppalachiaMetro25-3435-44HispanicMale139-150%FPL151-200%FPL
10-14.9%
Dual eligibleChronic mental health18-24Black101-138%FPL
>15%
MedicaidUninsured<100%FPL
Place Care is Received - 2010Emergency Room: 5.2% all Ohioans
<5.2%
MedicarePrivate ESIOther privateNot chronicAppalachiaRural – Non AppSuburban45-5455-64WhiteFemale151-200%FPL201-250%FPL251-300%FPL>300%FPL
5.2-9.9%
Other chronicChronic mental healthMetro18-2425-3435-44HispanicMale101-138%FPL
10-14.9%
MedicaidDual eligibleBlack<100%FPL139-150%FPL
>15%
Uninsured
Increased by >4%Decreased by >4%
Place Care is Received:Chronic Conditions -
2008
All
Not c
hron
ic
Chron
ic m
enta
l hea
lth
Oth
er ch
ronic
0
20
40
60
80
100
ClinicDoctorEROther
% with
% with place for care
Place Care is Received: Insurance Type - 2008
All
Med
icare
Med
icaid
Dual E
ligibl
e
Privat
e ESI
Oth
er P
rivat
e
Uninsu
red
0
10
20
30
40
50
60
70
80
90
100
ClinicDoctorEROther
% with place for care
Place Care is Received: Insurance Type - 2010
All
Med
icare
Med
icaid
Dual E
ligibl
e
Privat
e ESI
Oth
er P
rivat
e
Uninsu
red
0
10
20
30
40
50
60
70
80
90
100
ClinicDoctorEROther
% with place for care
Place Care is Received:Region of Residence - 2008
All
Appala
chia
Rural
Non-A
ppala
chia
Subur
ban
Met
ro0
102030405060708090
100
ClinicDoctorEROther
% with place for care
Place Care is Received:Region of Residence - 2010
All
Appala
chia
Rural
Non-A
ppala
chia
Subur
ban
Met
ro0
20
40
60
80
100
ClinicDoctorEROther
% with place for care
Place Care is Received:Race and Ethnicity -
2008
All White Black Asian Hispanic0
10
20
30
40
50
60
70
80
90
100
ClinicDoctorEROther
% with place for care
Place Care is Received:Race and Ethnicity -
2010
All White Black Asian Hispanic0
10
20
30
40
50
60
70
80
90
100
ClinicDoctorEROther
% with place for care
Place Care is Received: Socioeconomic Status -
2008
All <100%
FPL
101-138% FPL
139-150%FPL
151-200% FPL
201-250% FPL
251-300% FPL
>300%
FPL
0
10
20
30
40
50
60
70
80
90
100
ClinicDoctorEROther
% with place for care
Place Care is Received: Socioeconomic Status -
2010
All <100%
FPL
101-138% FPL
139-150%FPL
151-200% FPL
201-250% FPL
251-300% FPL
>300%
FPL
0
10
20
30
40
50
60
70
80
90
100
ClinicDoctorEROther
% with place for care
Logic Model
1 2
Emergency Room 5.8%
Usual Source of Care
Yes 91.1%
No 8.1%
Physician
73.6%
Other site
7.5%
Outcomes related to health care utilization or health events, such as
unmet need, BMI smoking status, alcohol use access to specialist hospital visits stable with diabetes ER visits care coordination
need
All age 18 and over Ohioans 2008
Limited use (saw doctor in last year, no checkup)
25.3%
Enhanced use (had checkup in last year)
62%
Compare populations by income, region, insurance type, age, race/ethnicity, sex Insured/uninsured has 6 categories: ESI, other private, Medicaid, Medicare, dual eligible, and uninsured
No use (not see doctor in last year and no checkup)
17.1%
Clinic
13.1%
Limited use (saw doctor in last year, no checkup)
24.3%
Enhanced use (had checkup in last year)
58.6%
No use (not see doctor in last year and no checkup)
12.8
3
Logic Model
1 2
Emergency Room
15.2%
Usual Source of Care
Yes 90.1%
No 8.0%
Physician
50.8%
Other site
11.1%
Outcomes related to health care utilization or health events, such as
unmet need, BMI smoking status, alcohol use access to specialist hospital visits stable with diabetes ER visits care coordination
need
Medicaid 2008
Limited use (saw doctor in last year, no checkup)
24.8%
Enhanced use (had checkup in last year)
67.2%
Compare populations by income, region, insurance type, age, race/ethnicity, sex Insured/uninsured has 6 categories: ESI, other private, Medicaid, Medicare, dual eligible, and uninsured
No use (not see doctor in last year and no checkup)
12.4%
Clinic
23%
Limited use (saw doctor in last year, no checkup)
23%
Enhanced use (had checkup in last year)
64.7%
No use (not see doctor in last year and no checkup)
8%
3
Logic Model
1 2
Emergency Room
11.1%
Usual Source of Care
Yes 93.4%
No 6.2%
Physician
58.3%
Other site
10.2%
Outcomes related to health care utilization or health events, such as
unmet need, BMI smoking status, alcohol use access to specialist hospital visits stable with diabetes ER visits care coordination
need
Chronic mental health
2008
Limited use (saw doctor in last year, no checkup)
32.6%
Enhanced use (had checkup in last year)
64.3%
Compare populations by income, region, insurance type, age, race/ethnicity, sex Insured/uninsured has 6 categories: ESI, other private, Medicaid, Medicare, dual eligible, and uninsured
No use (not see doctor in last year and no checkup)
11%
Clinic
20.4%
Limited use (saw doctor in last year, no checkup)
27.8%
Enhanced use (had checkup in last year)
61.2%
No use (not see doctor in last year and no checkup)
3.2%
3
Aim 2
What is the relationship between having primary care and ER use?
What is the relationship between having primary care and access to care from a specialist?
What is the relationship between having primary care and health status?
What is the relationship between having primary care and health outcomes?
Aim 2 ER use: number of ER visits Access to a specialist: degree of difficulty
seeing a specialist Health status: general health Health outcomes: number of hospitalizations;
BMI; smoking status, Diabetes control Unmet needs: not filled a prescription due to
cost; not get other health care needed, frequency of getting needed help coordinating care
Rating of health care
Having a Usual Source of Care is associated with:
MoreER visits *Hospital admissions *Control of diabetes *Satisfaction with
health care *
LessDifficulty seeing a
specialist *+Worse general health*Likely to smoke +Likely to report not
getting other needed care
Outcomes by Place Care is Received
Clinic v. ER Clinic v. Doctor ER v. Doctor
ER Visits
2008 more more more
2010 more ns more
Hospital admissions
2008 more ns more
Difficulty seeing a specialist
2008 more more more
2010 more ns more
Unmet Needs by Place Care is ReceivedClinic v. ER Clinic v. Doctor ER v. Doctor
Not filled a prescription due to cost
2008 more ns more
2010 more ns more
Not get other health care needed
2008 more ns more
2010 ns ns more
Select Variables by Place Care is Received
Clinic v. ER Clinic v. Doctor ER v. Doctor
General Health
2008 ns better better
2010 ns ns better
Health care rating
2008 better better better
2010 ns ns better
Smoking status
2008 more ns more
2010 more ns more
Policy Considerations Additional questions/revision of current
questions would promote better population level data on primary care and its association with outcomes
Policy Considerations Although the Hispanic population
continues to lag behind other racial and ethnic groups in having a usual source of care, they experienced a 6% increase between 2008 and 2010.Factors associated with this increase should
be investigated.
Reduction in use of ER as a usual source of care must address the primary factors associated with high ER utilization among Ohioans:
Uninsured (>15% in 2008 and 2010)
<100%FPLMedicaidDual eligibleAfrican American
Chronic mental health
18-24 101-138%FPL 139-150%FPL
Policy Considerations
Policy Considerations As income increases, a larger
percentage of Ohioans have a doctor as their usual source of care while smaller percentages have either a clinic or the ER
Policy Considerations For select unmet needs (not filling a
prescription due to cost; not getting other needed health care), having a usual source of care was critical in both 2008 and 2010.However, whether that usual source of care
was a clinic or a doctor did not matter.
Next Steps Development of multivariate models to
predict the likelihood of having primary care
Continued examination of the relationship between primary care and health outcomes and unmet needs
Comparison of findings to MEPS data
Appendix
All Female Male0
10
20
30
40
50
60
70
80
90
100
2008 - Yes2008 - No2010 - Yes2010 - No
Usual Source of Care:Gender
% with a usual source of care
Place Care is Received:Age - 2008
All Age 18-24
Age 25-34
Age 35-44
Age 45-54
Age 55-64
0
10
20
30
40
50
60
70
80
90
100
ClinicDoctorEROther
% with place for care
Place Care is Received:Age - 2010
All Age 18-24
Age 25-34
Age 35-44
Age 45-54
Age 55-64
0
10
20
30
40
50
60
70
80
90
100
ClinicDoctorEROther
% with place for care
All Female Male0
10
20
30
40
50
60
70
80
90
100
ClinicDoctorEROther
Place Care is Received:Gender - 2008
% with place for care
All Female Male0
10
20
30
40
50
60
70
80
90
100
ClinicDoctorEROther
Place Care is Received:Gender - 2010
% with place for care
Level of Care Use: Insurance Type - 2008
All
Med
icare
Med
icaid
Dual E
ligibl
e
Privat
e ESI
Oth
er P
rivat
e
Uninsu
red
0
10
20
30
40
50
60
70
80
90
100
% level of care use
Level of Care Use:Region of Residence
All
Appala
chia
Rural
Non-A
ppala
chia
Subur
ban
Met
ro0
102030405060708090
100
% with a usual source of care
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