Although children covered by Medicaid and State Children’s Health Insurance Programs (SCHIP) often are at higher risk for many illnesses, increased infant mortality, and developmental delays, they can become lost in the health care system and not even the most devoted health care providers can find the time and resources to identify and find every child in need of health care services.
To address this problem, the Lawrenceville, NJ-based Center for Health Care Strategies (CHCS) started a five-year initiative to identify and pilot best practices to improve the delivery of preventive care services for children within their own health plans.
Literature on clinical preventive practice supports the idea that every visit to a doctor should be a preventive visit. According to the report, most health plan leaders agree that it is important to develop programs supporting preventive practices because: (1) children represent 50% of Medicaid beneficiaries, making them the largest demographic Medicaid group; (2) nearly all SCHIP enrollees are children; (3) only about 50% of 2-year-olds on Medicaid receive the full regimen of immunizations; (4) while preventive care service delivery is a problem in both private and public settings, poor children tend to receive less preventive care; (5) state and federal Medicaid officials often target preventive care services for children as a quality improvement project; (6) child prevention measures often are used as performance measures in report cards and other consumer materials; and (7) it is seen as the right thing to do.
Margaret Oehlmann, a program officer who directed the initiative for CHCS, tells State Health Watch the best practices toolbox is needed because it often is difficult to do even basic things under Medicaid. "Outreach is particularly challenging," she says. "People on Medicaid move frequently, and typical outreach activities such as outbound phone calls and mail don’t work."
Best practices vary
Ms. Oehlmann says it’s not possible to identify preventive care techniques that will work in every circumstance.
"As in much of Medicaid, if you’ve seen one successful program, you’ve seen one successful program," she says. "What works for one health plan doesn’t necessarily work for others. We looked at the barriers to care and brainstormed a number of approaches that work. It’s hard to give a blanket statement that something will always work."
The typology used by the workgroup includes strategies for identifying children in need of preventive care services, stratifying their risks, conducting outreach, and finally making appropriate health interventions. Strategies employed by health plans in the workgroup included analyzing missed opportunities to deliver immunizations and well-child services and developing methods to reverse those situations; designing automatic reminder systems to patients and providers, based on variables such as member age or immunization status; developing regional, cross-company, or corporatewide registries to track immunizations; and redesigning and supporting health plan operations to make every visit a preventive visit.
The workgroup report includes a process improvement strategy that covers a Plan-Do-Study-Act cycle that provides a systematic analysis to the improvement process. (See cycle, below.)
For example, Hawaii’s AlohaCare has implemented a unique approach to building a foundation for well-child care even before a baby is born. An analysis of the plan’s data showed that although 1,200 births had taken place among its 30,000 members in 2000, only 40% of those babies had received the full range of well-child care. Plan officials contended that affiliation with a provider was the most important predictor of well-child care. To foster development of a relationship before delivery, they created a program to engage prenatal providers as advocates of well-baby care. Thus, during prenatal visits, doctors encourage mothers to select pediatricians and meet them even before their baby is born. The plan tracks the information and follows up with providers if a pediatrician is not selected.
While the idea made sense, tracking the information was more complicated than originally thought. AlohaCare ended up modifying its information system to better capture newborn information and developed an outreach initiative with prenatal mothers to identify high-risk mothers and promote well-baby care.
As part of the new program, the prenatal authorization form was expanded to identify maternal risk factors such as substance abuse and teen pregnancy, expected delivery date, and the pediatrician selected by the mother. A major objective of the revised form was to identify pregnant women and assign a temporary identification number to their unborn babies. That information went into the database, allowing an early screening detection and treatment coordinator to monitor babies after birth and provide outreach to families whose babies are not receiving well-baby care.
Before the program’s implementation, 10% of mothers had named a pediatrician prior to delivery, and approximately 18% named a pediatrician within one month following delivery. Six months into the project, those numbers had increased to 14% and 21%. To further increase the number of new mothers who choose a pediatrician prior to delivering their newborns, the plan will send study results to prenatal providers to reinforce the link between what they do and the program outcomes.
With new babies being identified and tracked, outreach coordinators can work to reach babies who are not receiving necessary care, often partnering with community health centers to identify families in need of services. The plan’s goal is to reduce the number of infants who are not receiving well-child care by 50% or more. The plan also wants to provide two Early Periodic Screening, Diagnosis, and Treatment visits to 100% of infants by the fifth month of life.
Reaching out to teens
Targeting another specific demographic group, Neighborhood Health Plan of Rhode Island worked with a community health partner to improve adolescent health. Their goal was to increase the number of students who complete physical examinations at school-based health centers in the town’s middle schools and high schools from 19% to 50%.
Reneé Rulin, MD, the plan’s medical director, tells State Health Watch that children typically are not a focus of health plans because they are not those on whom much money is spent. The intention of the program, she says, is to provide incentives to teens to make use of preventive services at the school-based centers. The incentive was $10 gift coupons for a music store, Blockbuster, and Pizza Hut.
The plan began by initiating a letter campaign to students who were not enrolled in the school-based health centers but were patients of Thundermist Health Associates. The letter advised of the availability of the incentives to those who enrolled in the school-based centers and completed a physical exam. A separate mailing and incentive offer went to students who were enrolled in the centers but were overdue for a complete physical exam. The plan also encouraged students to promote the program to their peers to take advantage of the incentive gifts.
In the project’s first year, the number of plan members who enrolled in school-based health centers increased by 22%. Among the new members, 37% completed a physical examination during the project period. Of members who were enrolled in the school centers but had not received a physical, 74% had a complete physical exam during the project period. Overall, the number of eligible students who received a physical during the project increased from 19% to 50%. "To us, that’s pretty successful," Ms. Rulin says. The program, which started in Woonsocket, is being expanded to the rest of the school-based health centers next year.
An emphasis on immunizations was the focus of efforts by The Wellness Plan, a nonprofit health plan in Michigan with 110,000 Medicaid members who wanted to increase the immunization rate for 2-year-olds from 43% in 2000 to 80% by 2004.
To achieve the increase, the plan modified existing data systems to identify 100% of the members ages 12 months to 18 months and stratify them by immunization status. A cross-referencing system was developed to determine the accuracy of health plan data by verifying immunization status with parents and providers.
The new cross-referencing system evaluates whether a child has been assigned to more than one primary care provider while enrolled in the health plan, has more than one member identification number, and has duplicate insurance and no encounters with The Wellness Plan. The system also is able to determine whether the member’s assigned pediatrician has more than one practice location and/or more than one medical record documenting the child’s medical history.
Once members were cross-referenced, letters were sent to providers with lists of their members and their immunization status. Providers were asked to submit revised documentation if the immunization status listed was incorrect. Letters also were sent to members asking parents to review their child’s immunization records and contact the child’s provider for an appointment if immunizations were missing.
The cross-referencing system allowed the plan to increase the number of 2-year-olds with complete immunization records captured by the health plan’s administrative database from 0.44% to 17%. The plan then identified remaining children with incomplete immunizations and contacted the child’s parent and/or primary care provider. A significant response was received from providers and parents, who submitted updated immunization information and/or scheduled well-child visits. Overall, the plan achieved a 9% increase in its Health Plan Employer Data and Information Set immunization rates between 2000 and 2001, from 43% to 52%.
[Contact Ms. Oehlmann at (609) 895-8101 and Ms. Rulin at (401) 459-6130.]