State-Level Impact of Health Reform: What Can Existing Data Sources Tell Us?

1. State-Level Impact of Health Reform: What Can Existing Data Sources Tell Us? State Health Research and Policy Interest Group AcademyHealth Annual Research Meeting June 11, 2011 Julie Sonier, Deputy Director State Health Access Data Assistance Center University of Minnesota SHADAC is supported by a grant from the Robert Wood Johnson Foundation.

2. Goals • How can state-level data be used to inform planning, implementation, and evaluation of the ACA? • Focus on four types of data: • Population surveys • Medicaid administrative data • All-payer claims databases • Health plan data reported to insurance regulators

3. Overview • Background on data and how they are collected • Opportunities and challenges for using existing data • What changes would make the data more useful for policymakers and/or researchers? • What important gaps need to be filled?

4. Panelists • Sharon Long, Ph.D., University of Minnesota • Chris Peterson, MPP, Medicaid and CHIP Payment and Access Commission (MACPAC) • Sean Kolmer, MPH, Office of Oregon Governor John Kitzhaber • Deborah Chollet, Ph.D., Mathematica Policy Research

5. Using Federal and State Survey Data to Inform State Health Reform Sharon K. Long University of Minnesota State Health Research Policy Interest Group AcademyHealth Annual Research Meeting Seattle, WA June 11, 2011

6. Key Federal Surveys • General household survey • ACS: American Community Survey • Employment/Income surveys • CPS: Current Population Survey • SIPP: Survey of Income and Program Participation • Health surveys • NHIS: National Health Interview Survey • MEPS-HC: Medical Expenditure Panel Survey-Household Component • BRFSS: Behavioral Risk Factor Surveillance System

7. Feasibility of State-Level Estimates from Federal Surveys • * Two-year averages recommended.

8. Potential Outcomes of Interest • Health insurance coverage • Affordability and scope of insurance coverage • Access to care/barriers to care • Health care use • Affordability of care • Quality of care

9. Availability of Outcome Measures in Federal Surveys

10. Timeliness of Data Release for Federal Surveys • Data files available now: • ACS 2009 • SIPP 2008 • CPS 2010 (data for 2009) • NHIS 2010 • MEPS-HC 2008 • BRFSS 2010

11. Strategies to Increase the Value of Federal Surveys for State Studies • Expand state-level estimates • Increase state sample sizes • Expand use of small area estimation methods • Expand survey content • Improve data availability • More timely data release • Make state identifiers available outside of Research Data Center settings

12. Changes in NHIS and BRFSS to Address Needs Under Health Reform • NHIS • State-level estimates: Added sample size & exploring use of small area estimation methods • Content: • Added questions • Expanding links with administrative data • Availability: More timely release of data • BRFSS • State-level estimates: States can add sample size • Content: • Core questions include emerging issues • States can add their own questions

13. The Bottom Line on Federal Surveys for State-Level Analyses of Health Reform • No single data source is “best” • CPS, ACS, and BRFSS have accessible 50-state estimates but are limited in scope • NHIS and MEPS-HC have greater scope but can’t provide estimates for all states and access to state identifiers is restricted • MEPS-HC on slow track for data release • No good alternatives available for some states and for some outcome measures

14. State Survey: One Strategy for Addressing Gaps in Federal Surveys • Larger state sample sizes • Potential to oversample key subgroups • Information on state-specific insurance and health care programs • More outcomes: health care access & use, costs, quality, barriers to care, awareness of reform, attitudes toward reform • More timely access to data to inform policy and program design 14

15. State Surveys Addressing Health Insurance Coverage and Other Issues

16. Federal and State surveys will play an important role under health reform, but… • Sample sizes often can’t support analyses of important subgroups, including Medicaid/CHIP enrollees • Surveys rely on self-reported information, including type of insurance coverage • Some outcomes are difficult to capture in surveys—such as costs, diagnoses, quality of care

17. References • SHADAC. 2011. “Monitoring the Impacts of Health Reform at the State Level: Using Federal Survey Data.” Brief #24. Minneapolis, MN: University of Minnesota. • Sonier, J. and E. Lukanen. Forthcoming. “A Framework for Tracking the Impacts of the Affordable Care Act in California.” Minneapolis, MN: University of Minnesota.

18. Federal Medicaid Administrative Datafor State Use Chris L. Peterson Director—Eligibility, Enrollment & Benefits June 11, 2011 Seattle, WA

19. Presentation Overview • Brief MACPAC background • A few key sources of federal Medicaid administrative data and how to use them • Form CMS-64 and Form CMS-21 • MSIS • Form CMS-416 • Policy issues regarding federal Medicaid/CHIP administrative data

20. MACPAC Statutory Charge Legislative History • Established in February 2009 (Children’s Health Insurance Program Reauthorization Act, CHIPRA) • Expanded and funded in March 2010 (Patient Protection and Affordable Care Act, PPACA) Commission • Appointed by the Comptroller General of the United States to 3-year terms • 17 Commissioners represent broad spectrum of interests and expertise on Medicaid and CHIP Goals • Serve as a federal non-partisan and analytic resource on Medicaid and CHIP policy for the Congress • Review federal and state Medicaid and CHIP policies and data sources • Regularly consult with states

21. MACPAC Duties • Review Medicaid and CHIP policy issues listed in statute: • Payment policies and payment methodologies • Access • Eligibility and enrollment • Quality • Interactions between Medicaid and Medicare • Data for policy analysis and program accountability • Review and comment on Secretarial reports and regulations that relate to policies under Medicaid and CHIP • Submit two annual reports to the Congress—March 15 and June 15 • March 2011 report Chapter 6 on federal administrative data • June 2011 report on managed care • MACStats in every report

22. MACStats • State-level and national data on Medicaid and CHIP • March 2011 MACStats state-by-state tables include: • Medicaid enrollment by eligibility group • CHIP enrollment by FPL (e.g., 90% of CHIP kids <200% FPL) • Medicaid and CHIP income eligibility levels • Medicaid spending by service, federal and state dollars • Medicaid as a share of states budgets (total and state-funded) • Preview of MACStats in June 2011 Report • Trends in Medicaid enrollment and spending • Health characteristics, enrollment and spending among Medicaid and CHIP populations • State-by-state info on Medicaid managed care enrollment & spending

23. Key Sources of Federal Medicaid Administrative Data

24. Form CMS-64 & Form-CMS 21 • Overview/purpose • Form used by states to report actual Medicaid and CHIP spending • Basis of federal payment • Available on CMS website as Excel file thru FY09 • Policy application—Examine each state’s Medicaid and CHIP aggregate spending • Medicaid services: 40+ categories, $360B • Medicaid administration: 30+ categories, $18B • Medicaid-expansion CHIP: 30+ service and premium-collection categories, $2.8B • Separate CHIP: 30+ service, premium-collection, and administration categories: $7.9B • §2105(g) spending in up to 11 states, $0.02B

25. Form CMS-64 and CMS-21, cont. • Limitations • “As submitted by states” • States may report spending in different places • A line of spending may not actually include everything • Only about spending; no enrollment numbers • Availability and usage tips • Annual summary spreadsheets: https://www.cms.gov/MedicaidBudgetExpendSystem/Downloads/FY1998throughFY2009MedicaidCHIPTotals.zip • Detailed Financial Management Report (FMR) spreadsheets from CMS-64 and CMS-21 data: https://www.cms.gov/MedicaidBudgetExpendSystem/Downloads/NetExpendituresFY2002throughFY2009a.zip

26. Medicaid Statistical Information System (MSIS) • Overview/purpose of MSIS: Provide person-level eligibility and claims info on every Medicaid enrollee in every state • Available in a variety of forms, including: • Online state summary “Datamart” (FY) • Annual person summary file (FY) • MAX (cleaned up, by CY, but long lag) • Policy application—Examine each state’s Medicaid enrollment and spending by individuals’ characteristics (basis of eligibility, BOE)

27. MSIS, cont. • Limitations • 9% of records have “unknown” BOE—usually prior-year enrollees with a claim paid this year • MSIS spending does not align with CMS-64 • MSIS 13% lower nationally • By state, ranges from 40% lower to 19% higher • About 25% of spending is for managed care payments, but little is known about enrollees’ encounters • Availability and usage tips • State summary Datamart available (Internet Explorer): http://msis.cms.hhs.gov/

28. MSIS Datamart Cheat Sheet • For “annual,” click on “quarterly” (FY08=all states; FY09=80%) • 3rd icon at bottom: Get data later • Take out CHIP enrollees • Drag CHIP folder onto line under “2009 annual” • Right-click to “insert calculation” to create a new No-CHIP variable, based on adding: NON-CHIP, CHIP UNKNOWN • Right click to “Hide/show” and hide everything but new No-CHIP • Break by Basis of Eligibility (BOE) • Drag BOE folder onto line under “UniqElgblsCnt” • Right-click to “insert calculation” to create a new NondisabKids variable, based on adding: CHILDREN, CHILDREN (UNEMPLOYED PARENT), FOSTER CARE CHILDREN • Right-click to “insert calculation” to create a new NondisabAdults (under 65) variable, based on adding: ADULTS, UNEMPLOYED ADULTS, BCCA WOMEN • Right click to “Hide/show” and hide everything used to build new variables (i.e., capped names in last two bullets) • Click “Get Data” • Once numbers are shown, click penultimate button to “export to CSV”

29. Form CMS-416 • Overview/purpose of Form CMS-416 • State Medicaid programs must provide children <21 with early and periodic screening, diagnostic, and treatment services (EPSDT) • CMS-416 is the 2-page state-required report on EPSDT, by state, age group, and categorically needy (CN) vs. medically needy (MN) • Reports available online as pdfs • Policy application: Assess Medicaid children’s utilization of a handful of services (screenings, whether referred for treatment, dental services, blood lead test)

30. CMS Form-416, cont. • Limitations • Many concerns about accuracy of data (see GAO and OIG reports) • However, may be better than MSIS because of broader inclusion of managed care • Availability and usage tips • https://www.cms.gov/MedicaidEarlyPeriodicScrn/03_StateAgencyResponsibilities.asp

31. Policy issues regarding Medicaid/CHIP administrative data

32. Selected Policy Issues on Data • Competing desires on data quality • If data aren’t being used by policymakers and researchers, states won’t (can’t) make data quality a priority • If data quality isn’t a state priority, policymakers and researchers won’t use the data • Use the data • Competing needs—states and federal government • Example 1: Voluntary initial core quality measures for Medicaid/CHIP children could inform policymakers about what works • Example 2: Encounter data in MSIS could be used to reduce federal reporting redundancies • Requires state and federal investment

33. Selected Data Issues, cont. • Federal Medicaid and CHIP administrative data only tell you so much about Medicaid and CHIP. Other sources of data: • Survey data • Surveys of households • Surveys of providers • States’ own Medicaid and CHIP administrative data, state all-payer claims databases (APCDs) • All are being used in MACPAC analyses

34. Health reform in OregonUsing data to drive reform Sean Kolmer, MPH Deputy Health Policy Advisor Office of Governor Kitzhaber

35. The challenge before us • Health care has become increasingly unaffordable for businesses large and small, families and individuals and state and local governments, due in large part to inefficiencies in the system that waste dollars and drive people to more expensive care.   • Public and private dollars are being spent in an inefficient system at a time when there is no public dollar to spare. • Inefficiencies in care drive people to getting care in the most expensive settings such as hospitalization and institutionalization. • Between 30-40 percent of health care costs are attributed to inefficiencies and waste.

36. The challenge before Oregon • There are too many uninsured in Oregon: 16.5 percent uninsured, or approximately 614,000 Oregonians, are without health insurance. • Costs are unsustainable for individuals and families in Oregon: • Average family health insurance premiums in Oregon increased by 44 percent between 2003 and 2009. • Average premiums accounted for 19 percent of the median income in Oregon in 2009. • The average deductible for family coverage increased by 94 percent between 2003 and 2009. Source: Uninsured: 2008 American Community Survey. Premium data: The Commonwealth Fund, December 2010.

37. The imperative and the opportunity • Medicaid is eating up an increasing portion of Oregon’s budget – unnecessary health care costs that are depleting dollars that could be used for education and other important public services. T • The state can no longer afford to throw dollars into an inefficient system that drives people to the most expensive care and services. • Today, the state’s fiscal reality gives Oregon an opportunity to remake the Medicaid service and health delivery system to help address the immediate shortfall and reap savings in the years to come. • If we don’t take action now, we will pay the price later.

38. The imperative and the opportunity

39. Health system transformation principles • Local coordination and accountability of all benefits, including physical health, mental health and addiction services, oral health and long-term care services. • Coordination of social supports that promote health and keep people out of high cost medical care. • Oregonians who are qualified for both Medicaid and Medicare should be included in improvements. Blend funding to create more efficient use of resources, care management, aligned incentives. • Set global budgets at levels that are sustainable, affordable, and sufficient for best-practices, incentives for prevention efforts, and lower costs. • Build on best practices in local communities where health entities partner with each other and consumers and are accountable for improved health.

40. Coordination Care Organization Principles • An organization that serves as a single-point of accountability for the cost of health care within a global budget and for access to and quality of a coordinated system of physical health, behavioral health and oral health care services delivered to the specific population of patients enrolled with the organization. • Global budget should be configured to hold CCOs accountable for outcomes. • Responsible for the full integration of physical, behavioral and oral health care services for the Medicaid enrollees, including their members who are dually eligible for Medicaid and Medicare. • Governance reflect the responsibility for risk, the major components of the health care delivery system, and the community at large.

42. We don’t know, what we don’t know • Oregonians pay for health care without comparable information about cost and quality across the health care system settings. • Currently, Oregon has fragmented, inconsistent and incomplete information about how our health care system is performing • An all payer, all claims data database is a tool for better understanding of cost, quality, and utilization across Oregon’s health care system.

43. What is all payer, all claims (APAC) data? • Data includes • Claims (medical, pharmacy, and/or dental) • Health plan member demographic information • Health plan provider information • Pharmacy, and/or dental files from: • Data from • Commercial health insurers • Third party administrators • Public payers (Medicaid, Medicare) • Pharmacy benefit managers

44. APAC data includes • Plan payments • Member financial responsibility (co-pay, coinsurance, deductible) • Patient demographics (date of birth, gender, geography, race/ethnicity) • Diagnoses • Procedures performed • Type of bill (i.e. inpatient, outpatient, emergency department)

45. Statutory framework • Oregon Law Chapter 595, Section 1200-1202 • OHA has authority to: • Require collection • Commercial insurers (all lines of business) • Third party administrators • Medicaid managed care organizations • Pharmacy benefit managers • Write administrative rules • Penalties for non-compliance 45

46. Statutory framework of uses • Determining the maximum capacity and distribution of existing resources allocated to health care. • Identifying the demands for health care. • Allowing health care policymakers to make informed choices. • Evaluating the effectiveness of intervention programs in improving health outcomes. • Comparing the costs and effectiveness of various treatment settings and approaches. 46

47. Statutory framework of uses • Providing information to consumers and purchasers of health care. • Improving the quality and affordability of health care and health care coverage. • Assisting the administrator in furthering the health policies expressed by the Legislative Assembly in ORS 442.025. • Evaluating health disparities, including but not limited to disparities related to race and ethnicity. 47

48. APAC data value • APAC data provides information necessary to describe health care utilization, patterns of care, disease prevalence, and cost of care. • Bringing in all payers eliminates biases created when assessing only Medicare, commercial or Medicaid in isolation—much greater precision. • Community level assessment and comparisons • Comparison of the current world • Comparison of a future world (i.e. accountable care organizations)

50. Variation in payments by geography State A average rate = $4,614 If State A avg Pmt = State B avg pmt: Potential Payment savings = $1.5M State B average rate = $4,064