Improving Care and Outcomes in Uninsured Populations: The Invisible Disparity

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

*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