lisa raiz, william hayes, keith kilty, tom gregoire, christopher holloman ohio employer and ohio...

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




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


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


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


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


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


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


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


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


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


Place Care is Received:Region of Residence - 2008

All

Appala

chia

Rural

Non-A

ppala

chia

Subur

ban

Met

ro0

102030405060708090

100

ClinicDoctorEROther


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


Place Care is Received:Race and Ethnicity -

2008


10

20

30

40

50

60

70

80

90

100

ClinicDoctorEROther


Place Care is Received:Race and Ethnicity -

2010


10

20

30

40

50

60

70

80

90

100

ClinicDoctorEROther


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


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


Logic Model

1 2

Emergency Room 5.8%


Yes 91.1%

No 8.1%

Physician

73.6%

Other site

7.5%



need

All age 18 and over Ohioans 2008


25.3%


62%



17.1%

Clinic

13.1%


24.3%


58.6%


12.8

3

Logic Model

1 2

Emergency Room

15.2%


Yes 90.1%

No 8.0%

Physician

50.8%

Other site

11.1%



need

Medicaid 2008


24.8%


67.2%



12.4%

Clinic

23%


23%


64.7%


8%

3

Logic Model

1 2

Emergency Room

11.1%


Yes 93.4%

No 6.2%

Physician

58.3%

Other site

10.2%



need


2008


32.6%


64.3%



11%

Clinic

20.4%


27.8%


61.2%


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


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


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


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


All Female Male0

10

20

30

40

50

60

70

80

90

100

ClinicDoctorEROther

Place Care is Received:Gender - 2008


All Female Male0

10

20

30

40

50

60

70

80

90

100

ClinicDoctorEROther

Place Care is Received:Gender - 2010


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


lisa raiz, william hayes, keith kilty, tom gregoire, christopher holloman ohio employer and ohio...

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