Center for

Health Care

Research &

Policy

AHRQ 2009 Annual ConferenceResearch to Reform

Improving Care and Outcomes

in Uninsured Populations:

The Invisible Disparity

Randall D. Cebul, M.D.

rdc@case.edu

Overview: Quality of Care Among the Uninsured

1. Without claims or EMRs, the quality of care and outcomes of the uninsured are largely invisible.

– Yet we know they fare more poorly

2. 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

http://www.census.gov/ accessed 9-12-09

We know how many uninsured there are. 15.4% (46M), growing: 26% if publicly insured are

excluded

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

“Poor Glycemic Control” Among Diabetics: The Uninsured do Worst

• 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

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

Aligning Forces for Quality - 2008

OUR MISSIONBetter 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.

AF4Q in NortheastOhio

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

Diabetes - 2008

19% Increase in Uninsured,2007 to 2008

Vs. HEDIS. Uninsured do ok – compared to Medicaid

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

Measure Group Medicare Commercial Medicaid Uninsured Overall

HbA1c testingRegionNational

95.088.1

93.188.1

91.777.3

90.8NA

93.4--

Poor HbA1c Control (>9)*

RegionNational

12.329.0

18.829.4

26.347.9

35.8NA

19.3--

Eye ExamsRegionNational

69.662.7

62.055.1

44.249.9

48.5NA

61.5--

LDL-C ScreeningRegionNational

89.985.7

89.483.9

75.070.8

77.4NA

86.8--

LDL-C Control (<100)

RegionNational

61.346.8

53.843.8

38.331.3

36.7NA

53.0--

MonitoringNephropathy

RegionNational

91.885.7

89.480.6

86.674.4

87.0NA

89.7--

Blood PressureControl (<130/80)

RegionNational

38.531.7

38.632.1

36.129.5

31.7NA

37.5--

Blood PressureControl (<140/90)

RegionNational

66.158.9

71.363.9

59.755.5

62.6NA

67.3--

*Lower rates are better for this measure.

Overall, we’re improving on our composite measures

And most practices have betteroutcomes and better care processes

But our Uninsured are not Improving

Thank you

Visit our website:

http://www.betterhealthcleveland.org