Improving Care and Outcomes in Uninsured Populations: The Invisible Disparity

Slide presentation from the AHRQ 2009 conference.

On September 15, 2009, Randall D. Cebul, M.D. made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (4.3 MB) (Plugin Software Help).


Slide 1

Improving Care and Outcomes in Uninsured Populations: The Invisible Disparity

AHRQ 2009 Annual Conference Research to Reform
 

Randall D. Cebul, M.D.
rdc@case.edu

 

Slide 2

Overview: Quality of Care Among the Uninsured

  • Without claims or EMRs, the quality of care and outcomes of the uninsured are largely invisible.
    • Yet we know they fare more poorly
  • Practice records-based measurement and public reporting are important for improving quality.
    • EMRs are useful: timely, granular, enable CDS
    • HIE (interoperable EMRs) would be even better
    • Linked to regional QI/consumer engagement (CE)/payment reform, better still
    • RWJF is supporting 15 communities to measure and report performance, undertake regional QI and CE

 

Slide 3

We know how many uninsured there are.

% Uninsured by Race/Ethnicity

  • White: 9
  • Black: 19
  • Asian: 18
  • Hispanic: 31

% Uninsured by Age

  • < 18: 10
  • 18-24: 29
  • 25-34: 27
  • 35-44: 19
  • 45-64: 14
  • 65+: 2

% Uninsured by income

  • $25k: 25
  • $25-49K: 21
  • $50-74K: 14
  • $75K+: 8

% Uninsured by Work Status

  • Full Time: 17
  • Part-Time: 25
  • Not Working: 26

15.4% (46M), growing: 26% if publicly insured are excluded

 

Slide 4

We know some of the financial and health consequences - to patients

  • Medical bill problems/paying off medical debt climbed from 34 percent to 41 percent in the U.S. between 2005 and 2007... 72 million (Commonwealth Fund)
  • Medical costs are the leading cause of personal bankruptcies (Himmelstein, AmJMed. 2009)
    • roughly half of all bankruptcy filers ('07) had OOP medical costs > $5000 before filing; 3/4 had insurance coverage
  • Lack of insurance leads to foregoing necessary care
    • IOM: 20,000 premature deaths annually
  • NONE OF THESE ARE VERY ACTIONABLE STATISTICS

 

Slide 5

"Poor Glycemic Control" Among Diabetics: The Uninsured do Worst

Supported by grant: R01 HS-015123, Agency for Healthcare Research and Quality

  • 6843 patients
  • One EMR-based system, same PCPs
  • Uninsured: 64% higher odds (95% CI: 1.32-2.03) of poor control
  • Adjusted for ASR, co-morbidities, smoking, show rates, income, site of care

 

Slide 6

Aligning Forces for Quality - 2008

Image: An image of the United States is shown with Minnesota, Wisconsin, and Maine highlighted.

 

Slide 7

AF4Q in Northeast Ohio

OUR MISSION

Better Health Greater Cleveland is a multi-stakeholder partnership that improves the health and value of health care provided to people with chronic medical conditions in Northeast Ohio.

We are committed to:

  • Improving care and outcomes of all people with chronic conditions
  • Eliminating disparities in health observed among disadvantaged populations by insurance, race, education and income; and
  • Transparency across collaborating organizations, and, through public reporting of patient care data, with our community.

 

Slide 8

Measurement Matters

  • Public reports every 6 months
    • NQF endorsed, locally vetted measures
  • Diverse practice organizations and sites
    • "Care Alliance to Cleveland Clinic"
    • 8 organizations, 54 sites (42 reporting), 500+ PCPs (361 reporting) - virtually all SNPs, all FQHCs
    • Paper-based practices manually abstracted ..
  • Region-wide Achievement and Change by:
    • Insurance(M'care, commercial, M'caid, uninsured), Race (W, B, H, Other), Income and Education (addresses geo-linked to census)
    • Practice site achievement and change by insurance

 

Slide 9

Diabetes - 2008

A chart showing Diabetes in 2008 is shown.

 

Slide 10

19% Increase in Uninsured, 2007 to 2008

  • Medicare: +2.3
  • Commercial: -6.0
  • Medicaid: -4.6
  • Uninsured: +19.1

 

Slide 11

Vs. HEDIS. Uninsured do ok - compared to Medicaid

REGIONAL ACHIEVEMENT (2008) COMPARED TO NATIONWIDE HEALTH PLAN AVERAGES (2007) ON HEDIS COMPREHENSIVE DIABETES CARE MEASURES

MeasureGroupMedicareCommercialMedicaidUninsuredOverall
HbA1c testingRegion
National
95.0
88.1
93.1
88.1
91.7
77.3
90.8
NA
93.4
--
Poor HbA1c
Control (>9)*
Region
National
12.3
29.0
18.8
29.4
26.3
47.9
35.8
NA
19.3
--
Eye ExamsRegion
National
69.6
62.7
62.0
55.1
44.2
49.9
48.5
NA
61.5
--
LDL-C ScreeningRegion
National
89.9
85.7
89.4
83.9
75.0
70.8
77.4
NA
86.8
--
LDL-C Control
(<100)
Region
National
61.3
46.8
53.8
43.8
38.3
31.3
36.7
NA
53.0
--
Monitoring
Nephropathy
Region
National
91.8
85.7
89.4
80.6
86.6
74.4
87.0
NA
89.7
--
Blood Pressure
Control (<130/80)
Region
National
38.5
31.7
38.6
32.1
36.1
29.5
31.7
NA
37.5
--
Blood Pressure
Control (<140/90)
Region
National
66.1
58.9
71.3
63.9
59.7
55.5
62.6
NA
67.3
--

*Lower rates are better for this measure.

 

Slide 12

Overall, we're improving on our composite measures

Outcomes

  • 2007: 36
  • 2008: 38

Care Processes

  • 2007: 39
  • 2008: 47

 

Slide 13

And most practices have better outcomes and better care processes

Image: A graph showing the Worse Outcomes/Better Processes, Better Outcomes/Better Processes, Worse Outcomes/Worse Processes, and Better Outcomes/Worse Processes.

 

Slide 14

But our Uninsured are not Improving

Overall: Better/Better

  • Medicare
  • Commercial
  • Mdicaid

Worse:

  • Uninsured

 

Slide 15

Thank you

Visit our website:
www.betterhealthcleveland.org

Current as of December 2009
Internet Citation: Improving Care and Outcomes in Uninsured Populations: The Invisible Disparity. December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/cebul/index.html