Snapshot of Determinants for an Enhanced Primary care Home Initiative: Current Status of Primary Care and Policy Considerations
Lisa Raiz, William Hayes, Keith Kilty, Tom Gregoire,Christopher Holloman
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Ohio Employer and Ohio Family Health Research Conference
July 29, 2011
Agenda
Project Aims
Defining Primary Care
Expanded Focus
Aim 1
Aim 2
Policy Considerations
Next Steps
Project Aims
1. To estimate the proportion of Ohioanswho have, or do not have, primary care
2. To examine the association betweenhaving, or not having, primary care andunmet health needs, health status andhealth outcomes
3. To develop an operational definition ofEnhanced Primary care Home specificto Ohio policy, rules and laws
Defining Primary Care
1.Usual source of care
a.yes/no
2.Place care is received
a.Clinic or health center
b.Doctor’s office or HMO
c.Hospital emergency room
d.Other
3.Levels of care use
a.Enhanced use
b.Limited use
c.No use
Three Levels of Primary Care Use
1.Enhanced use
Received a routine check-up duringprevious year
2.Limited use
No routine check-up; visited a doctor duringprevious year
3.No use
No routine check up; did not visit a doctorduring previous year
Sociodemographic Variables
Chronic Conditions
Not chronic
Chronic mental health
Other chronic
Insurance
Medicare
Medicaid
Dual eligibles
Private ESI
Other private
Uninsured
Region
Appalachia
Rural, non-Appalachia
Suburban
Metropolitan
Race/Ethnicity
Asian
Black
Hispanic
White
Age
18-24
25-34
35-44
45-54
55-64
Sex
Female
Male
SES
<100%FPL
101-138%FPL
139-150%FPL
151-200%FPL
201-250%FPL
>300%FPL
Logic Model
Expanded Focus
INDIVIDUALS WITHCHRONICCONDITIONS
Patient Protection and AffordableCare Act
Title II: Role of Public Programs
Subtitle I: Improving the Quality of Medicaidfor Patients and Providers
○Section 2703: State Option to Provide HealthHomes for Enrollees with Chronic Conditions
○Eligible individuals:
Eligible for State assistance
Has at least:
-2 chronic conditions
-1 chronic condition and is at risk of having asecond chronic condition; or
-1 serious and persistent metal health condition
Chronic Conditions
Populations with chronic conditions
Not chronic
Chronic mental health
Other chronic
Risk Factors:
○Currently smokes cigarettes
○Positive response to any episodes of bingedrinking
Chronic Groups
Group Variable
Total
0-100%FPL
101-138%FPL
Chronic Groups
2008
Not chronic
Chronic mental health
Other chronic
2010
Not chronic
Chronic mental health
Other chronic
71.3%
  6.4%22.3%
71.4%
  8.2%
20.4%
62.0%
14.0%
24.0%
63.1%
14.2%
22.7%
67.4%
  9.3%
23.3%
67.3%
12.0%
20.7%
Aim 1
What is the proportion of Ohioans whohave primary care?
What is the proportion of Ohioans whohave primary care, based onsociodemographic variables?
What variables are associated with anincreased likelihood of having primarycare?
Usual Source of Care:
Chronic Conditions
% witha usualsourceof care
Usual Source of Care:Insurance Type
% witha usualsourceof care
Usual Source of Care:Region of Residence
% witha usualsourceof care
Usual Source of Care:
Age
% witha usualsourceof care
Usual Source of Care:
Race and Ethnicity
% witha usualsourceof care
Usual Source of Care:
Socioeconomic Status
% witha usualsourceof care
Place Care is Received
11 response categories (if usual source of care)
Clinic or health center
Doctor’s office or HMO
Hospital emergency room
Hospital outpatient department
Military hospitals
Does not go to one place most often
Books/internet/hotline
Hospital
Urgent care
Family member or friend
Some other place
Place Care is Received - 2008Doctor’s Office or HMO: 73.6% all Ohioans
>73.6%>73.6%
MedicareMedicare
Private ESIPrivate ESI
Not chronicNot chronic
Rural – Non AppRural – Non App
SuburbanSuburban
35-4435-44
45-5445-54
55-6455-64
WhiteWhite
FemaleFemale
201-250%FPL201-250%FPL
251-300%FPL251-300%FPL
>300%FPL>300%FPL
60%-73.5%60%-73.5%
Other privateOther private
Other chronicOther chronic
AppalachiaAppalachia
MetroMetro
25-3425-34
AsianAsian
MaleMale
101-138%FPL101-138%FPL
139-150%FPL139-150%FPL
151-200%FPL151-200%FPL
50-59.9%50-59.9%
MedicaidMedicaid
Dual eligibleDual eligible
Chronic mentalChronic mental
   health   health
18-2418-24
<100%FPL<100%FPL
40-49.9%40-49.9%
UninsuredUninsured
BlackBlack
HispanicHispanic
Place Care is Received - 2010Doctor’s Office or HMO: 72.5% all Ohioans
>72.5%>72.5%
MedicareMedicare
Private ESIPrivate ESI
Other privateOther private
Not chronicNot chronic
Rural – NonAppRural – NonApp
SuburbanSuburban
45-5445-54
55-6455-64
WhiteWhite
FemaleFemale
201-250%FPL201-250%FPL
251-300%FPL251-300%FPL
>300%FPL>300%FPL
60%-72.4%60%-72.4%
Other chronicOther chronic
AppalachiaAppalachia
MetroMetro
25-3425-34
35-4435-44
MaleMale
101-138%FPL101-138%FPL
139-150%FPL139-150%FPL
151-200%FPL151-200%FPL
50-59.9%50-59.9%
MedicaidMedicaid
Dual eligibleDual eligible
Chronic mentalChronic mental
   health   health
18-2418-24
AsianAsian
HispanicHispanic
<100%FPL<100%FPL
40-49.9%40-49.9%
UninsuredUninsured
BlackBlack
Increased by >4%
Decreased by >4%
Place Care is Received - 2008Clinic: 13.1% all Ohioans
 >20% >20%
MedicaidMedicaid
Dual eligibleDual eligible
UninsuredUninsured
Chronic mentalChronic mental
   health   health
BlackBlack
AsianAsian
Hispanic (>30%)Hispanic (>30%)
<100%FPL<100%FPL
13.2-19.9%13.2-19.9%
Other privateOther private
Other chronicOther chronic
AppalachiaAppalachia
MetroMetro
18-2418-24
25-3425-34
MaleMale
101-138%FPL101-138%FPL
139-150%FPL139-150%FPL
151-200%FPL151-200%FPL
201-250%FPL201-250%FPL
<13.1%<13.1%
MedicareMedicare
Private ESIPrivate ESI
Not chronicNot chronic
Rural non-AppRural non-App
SuburbanSuburban
35-4435-44
45-5445-54
55-6455-64
WhiteWhite
FemaleFemale
251-300%FPL251-300%FPL
>300%FPL>300%FPL
Place Care is Received - 2010Clinic: 14% all Ohioans
 >20% >20%
MedicaidMedicaid
UninsuredUninsured
Chronic mentalChronic mental
   health   health
BlackBlack
Hispanic (>30%)Hispanic (>30%)
<100%FPL<100%FPL
14.1-19.9%14.1-19.9%
Dual eligibleDual eligible
Other privateOther private
Other chronicOther chronic
AppalachiaAppalachia
MetroMetro
18-2418-24
25-3425-34
45-5445-54
AsianAsian
MaleMale
101-138%FPL101-138%FPL
139-150%FPL139-150%FPL
151-200%FPL151-200%FPL
<14%<14%
MedicareMedicare
Private ESIPrivate ESI
Not chronicNot chronic
Rural non-AppRural non-App
SuburbanSuburban
35-4435-44
55-6455-64
WhiteWhite
FemaleFemale
201-250%FPL201-250%FPL
251-300%FPL251-300%FPL
>300%FPL>300%FPL
Increased by >4%
Decreased by >4%
Place Care is Received - 2008Emergency Room: 5.8% all Ohioans
<5.8%<5.8%
MedicareMedicare
Private ESIPrivate ESI
Other privateOther private
Not chronicNot chronic
Rural – NonAppRural – NonApp
SuburbanSuburban
45-5445-54
55-6455-64
WhiteWhite
AsianAsian
FemaleFemale
201-250%FPL201-250%FPL
251-300%FPL251-300%FPL
>300%FPL>300%FPL
5.8-9.9%5.8-9.9%
Other chronicOther chronic
AppalachiaAppalachia
MetroMetro
25-3425-34
35-4435-44
HispanicHispanic
MaleMale
139-150%FPL139-150%FPL
151-200%FPL151-200%FPL
10-14.9%10-14.9%
Dual eligibleDual eligible
Chronic mentalChronic mental
   health   health
18-2418-24
BlackBlack
101-138%FPL101-138%FPL
>15%>15%
MedicaidMedicaid
UninsuredUninsured
<100%FPL<100%FPL
Place Care is Received - 2010Emergency Room: 5.2% all Ohioans
<5.2%<5.2%
MedicareMedicare
Private ESIPrivate ESI
Other privateOther private
Not chronicNot chronic
AppalachiaAppalachia
Rural – NonAppRural – NonApp
SuburbanSuburban
45-5445-54
55-6455-64
WhiteWhite
FemaleFemale
151-200%FPL151-200%FPL
201-250%FPL201-250%FPL
251-300%FPL251-300%FPL
>300%FPL>300%FPL
5.2-9.9%5.2-9.9%
Other chronicOther chronic
Chronic mentalChronic mental
   health   health
MetroMetro
18-2418-24
25-3425-34
35-4435-44
HispanicHispanic
MaleMale
101-138%FPL101-138%FPL
10-14.9%10-14.9%
MedicaidMedicaid
Dual eligibleDual eligible
BlackBlack
<100%FPL<100%FPL
139-150%FPL139-150%FPL
>15%>15%
UninsuredUninsured
Increased by >4%
Decreased by >4%
Place Care is Received:
Chronic Conditions - 2008
%with
% withplaceforcare
Place Care is Received:Insurance Type - 2008
% withplaceforcare
Place Care is Received:Insurance Type - 2010
% withplaceforcare
Place Care is Received:Region of Residence - 2008
% withplaceforcare
Place Care is Received:Region of Residence - 2010
% withplaceforcare
Place Care is Received:
Race and Ethnicity - 2008
%withplaceforcare
Place Care is Received:
Race and Ethnicity - 2010
% withplaceforcare
Place Care is Received:
Socioeconomic Status - 2008
% withplaceforcare
Place Care is Received:
Socioeconomic Status - 2010
% withplaceforcare
Logic Model
Logic Model
Logic Model
Aim 2
What is the relationship between havingprimary care and ER use?
What is the relationship between havingprimary care and access to care from aspecialist?
What is the relationship between havingprimary care and health status?
What is the relationship between havingprimary care and health outcomes?
Aim 2
ER use: number of ER visits
Access to a specialist: degree of difficultyseeing a specialist
Health status: general health
Health outcomes: number of hospitalizations;BMI; smoking status, Diabetes control
Unmet needs: not filled a prescription due tocost; not get other health care needed,frequency of getting needed help coordinatingcare
Rating of health care
Having a Usual Source ofCare is associated with:
More
ER visits *
Hospital admissions *
Control of diabetes *
Satisfaction withhealth care *
Less
Difficulty seeing aspecialist *+
Worse general health*
Likely to smoke +
Likely to report notgetting other neededcare
Outcomes by Place Careis Received
Clinic v. ER
Clinic v. Doctor
ER v. Doctor
ER Visits
2008
more
more
more
2010
more
ns
more
Hospital admissions
2008
more
ns
more
Difficulty seeing aspecialist
2008
more
more
more
2010
more
ns
more
Unmet Needs by Place Careis Received
Clinic v. ER
Clinic v. Doctor
ER v. Doctor
Not filled a prescriptiondue to cost
2008
more
ns
more
2010
more
ns
more
Not get other healthcare needed
2008
more
ns
more
2010
ns
ns
more
Select Variables by Place Careis Received
Clinic v. ER
Clinic v. Doctor
ER v. Doctor
General Health
2008
ns
better
better
2010
ns
ns
better
Health care rating
2008
better
better
better
2010
ns
ns
better
Smoking status
2008
more
ns
more
2010
more
ns
more
Policy Considerations
Additional questions/revision of currentquestions would promote betterpopulation level data on primary careand its association with outcomes
Policy Considerations
Although the Hispanic populationcontinues to lag behind other racial andethnic groups in having a usual sourceof care, they experienced a 6% increasebetween 2008 and 2010.
Factors associated with this increase shouldbe investigated.
Reduction in use of ER as a usual source of caremust address the primary factors associatedwith high ER utilization among Ohioans:
Uninsured (>15%in 2008 and 2010)
<100%FPL
Medicaid
Dual eligible
African American
Chronic mentalhealth
18-24
101-138%FPL
139-150%FPL
Policy Considerations
Policy Considerations
As income increases, a largerpercentage of Ohioans have a doctor astheir usual source of care while smallerpercentages have either a clinic or theER
Policy Considerations
For select unmet needs (not filling aprescription due to cost; not gettingother needed health care), having ausual source of care was critical in both2008 and 2010.
However, whether that usual source of carewas a clinic or a doctor did not matter.
Next Steps
Development of multivariate models topredict the likelihood of having primarycare
Continued examination of therelationship between primary care andhealth outcomes and unmet needs
Comparison of findings to MEPS data
Appendix
Usual Source of Care:
Gender
% witha usualsourceof care
Place Care is Received:
Age - 2008
% withplaceforcare
Place Care is Received:
Age - 2010
% withplaceforcare
Place Care is Received:
Gender - 2008
% withplaceforcare
Place Care is Received:
Gender - 2010
% withplaceforcare
Level of Care Use:Insurance Type - 2008
%levelofcareuse
Level of Care Use:Region of Residence
% witha usualsourceof care