Patient-Centered Medical Homes
and the Health of Ohio’s Adults and Children
Thomas Wickizer, Kenneth Steinman, Abigail Shoben, Deena Chisolm, Jeff Biehl, Lauren Phelps
#OMAS2015
1
Please note: This study examines survey respondents’ perceptions of
their health care and whether they reflect
“care consistent with a patient-centered medical home”
(CC-PCMH).
It does not assess whether individuals actually received
care from a certified or accredited PCMH.
WWW.GRC.OSU.EDU/OMAS 2
OUTLINE
• Highlights
• Background
• Methods
• Findings
• Conclusions / Implications
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KEY HIGHLIGHTS • Lower income adults, whether on Medicaid or employer-sponsored
insurance (ESI) have similar access to CC-PCMH
• Lower income adults and children with CC-PCMH are less likely to have: – unmet health needs
– frequent emergency department visits
– misused prescription painkillers
• CC-PCMH is less common for African-Americans vs. whites
• CC-PCMH equally benefits African-Americans and whites – Less benefit for pregnant women
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What is a PCMH?
• Patient-Centered Medical Home (PCMH):
a model of coordinated, comprehensive
primary care
– improve outcomes
– reduce costs
– increase patient/provider satisfaction
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PCMH in Ohio • PCMH Education Pilot Project led 42 primary care
practices through a 2-year transformation process.
• Comprehensive Primary Care Initiative, with 61
practices in southwest Ohio (sponsored by CMS)
• $75 million State Innovation Model grant from CMS to
develop payment systems that will facilitate PCMH
development and practice.
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PCMH in OMAS
• Respondents’ perspective
– Not assessing certified PCMH locations
– Care consistent with a PCMH – “CC-PCMH”
• Broad statewide perspective
– Across all health systems; include the uninsured
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Research Questions
• Does Medicaid facilitate access to CC-PCMH?
• Is CC-PCMH associated with better health care?
• Does CC-PCMH reduce health disparities?
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Sample • 2015 Ohio Medicaid Assessment Survey (OMAS)
– 42,876 adults
– 10,122 proxy interviews of children
• Focus on Medicaid-covered and potentially Medicaid-eligible
• ≤138% FPL for adults
• ≤200% FPL for children
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(1) Has an appropriate, usual source of care (e.g., doctor’s office);
(2) Has a personal care provider (PCP; i.e., “a health professional who knows you well and is familiar with your health history”);
(3) Has seen this PCP in the past 12 months;
(4) PCP communicates well;
(5) Got urgent care (if needed) on the same/next day;
(6) Got after hours care (if needed) without a problem;
(7) Got specialist care (if needed) without a problem.
Defining CC-PCMH
12
Does not have
CC-PCMH
CC-PCMH
“yes” to all
“no” to any
Analyses • Multivariable logistic regression
– Adjust for demographic characteristics and health status (special health care needs; history of chronic conditions)
• Survey estimates, represent all Ohio
• Statistical significance, p<0.05
• Predicted probabilities: – predicted (not observed) values from statistical models
– “the estimated percentage of a hypothetical subpopulation predicted to have the outcome, assuming they have otherwise average characteristics”
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Findings
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Who has CC-PCMH?
Does Medicaid facilitate access to CC-PCMH?
Is CC-PCMH associated with better health care?
Does CC-PCMH reduce health disparities?
Adults
Children
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CC-PCMH varies by income, age and gender
22.9% 26.6%
31.8% 35.2% 35.7%
40.4% 39.9%
45.6%
50.8%
0%
25%
50%
75%
100%
unad
just
ed %
adults
with C
C-P
CM
H
Household income (%FPL)
17.7% 20.9%
29.6%
38.9%
46.8%
52.6%
28.0% 31.4%
39.6%
45.0%
51.1%
56.4%
19-24 25-34 35-44 45-54 55-64 65+
Adult age group
male female
State mean = 40.0%
“lower income”
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CC-PCMH is similarly common in different regions
23.1%
27.4% 25.8%
29.2% 26.2%
24.0% 25.2%
0%
10%
20%
30%
40%
50%
1 2 3 4 5 6 7
%*
adults
≤138%
FPL w
ith C
C-P
CM
H
Medicaid Managed Care Region
*Predicted probabilities based on statistical models that adjust for demographic and other characteristics
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CC-PCMH is similarly common in different types of counties
26.1% 25.7% 25.3% 27.8%
0%
10%
20%
30%
40%
50%
urban suburban rural Applachian rural non-
Applachian
%*
adults
≤138%
FPL w
ith C
C-P
CM
H
*Predicted probabilities based on statistical models that adjust for demographic and other characteristics.
28.5% 32.5%
35.3% 36.6% 38.9%
35.8%
42.5% 41.8%
49.1%
0%
25%
50%
75%
100%
unad
just
ed %
child
ren w
ith C
C-P
CM
H
Household income (as %FPL)
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CC-PCMH varies by income and age
“lower income”
52.2%
41.9% 38.5%
35.8%
<1 1-5 6-12 13-18
Child age group
State mean = 39.2%
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CC-PCMH is similarly common in different regions
34.3%
39.5%
35.6%
31.4% 31.7%
35.9% 34.5%
0%
10%
20%
30%
40%
50%
1 2 3 4 5 6 7
%*
child
ren ≤
200%
FPL
with C
C-P
CM
H
Medicaid Managed Care Region
*Predicted probabilities based on statistical models that adjust for demographic and other characteristics
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CC-PCMH is less common in rural non-Appalachian counties
vs. those in rural Appalachian counties
34.4% 37.9% 38.8%
32.6%
0%
10%
20%
30%
40%
50%
urban suburban rural
Appalachian
rural non-
Appalachian
%*
child
ren ≤
200%
FPL
with C
C-P
CM
H
*Predicted probabilities based on statistical models that adjust for demographic and other characteristics.
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CC-PCMH is similarly common for lower income adults
covered by Medicaid or other types of insurance
29.4% 31.3%
29.4% 27.7%
9.0%
0%
10%
20%
30%
40%
50%
Medicaid Medicare & other govt Employer-Sponsored Private/Other Uninsured
%*
adults
≤138%
FPL
with C
C-P
CM
H
*Predicted probabilities based on statistical models that adjust for demographic and other characteristics
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Medicaid, 298,000
Medicare, 176,000
employer-sponsored,
96,000
private/other, 47,000
uninsured, 20,000
Estimated number of lower income adults with
CC-PCMH, by insurance type/status
Nearly half of lower income adults with CC-PCMH have Medicaid
Findings
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Which adults have CC-PCMH?
Does Medicaid facilitate access to CC-PCMH
among children?
Is CC-PCMH associated with better health care?
Does CC-PCMH reduce health disparities?
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CC-PCMH is less common among lower income children
with Medicaid versus those with employer-sponsored insurance
*Predicted probabilities based on statistical models that adjust for demographic and other characteristics
34.7%
42.0%
31.8%
20.8%
0%
10%
20%
30%
40%
50%
Medicaid Employer-Sponsored Private/Other Uninsured
%*
child
ren ≤
200%
FPL
who
hav
e C
C-P
CM
H
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Most components of CC-PCMH are equally common
among lower income children with Medicaid versus ESI
*Predicted probabilities based on statistical models that adjust for demographic and other characteristics
95% 91% 95% 90%
80%
96% 92% 95% 92% 85%
0%
25%
50%
75%
100%
Has an appropriate usualsource of care
Has a personal careprovider (PCP; of those
who have an appropriateusual source of care)
Has seen PCP in the past12 months (of those who
have a PCP)
Has good communicationwith PCP (of those who
have seen PCP in past 12months)
Got specialist carewithout a problem
(of those who needed it)
%*
child
ren ≤
200%
FPL
with o
utc
om
e
Medicaid Employer-Sponsored
difference
not
significant
difference
not
significant
difference
not
significant
difference
not
significant
difference
not
significant
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Lower income children with Medicaid are less likely than those with ESI
to get needed urgent care or after hours care without a problem
*Predicted probabilities based on statistical models that adjust for demographic and other characteristics
78%
57%
83%
64%
0%
25%
50%
75%
100%
Got urgent care same or next day
(of those who needed it)
Got after hours care without a problem
(of those who needed it)
%*
child
ren ≤
200%
FPL
with o
utc
om
e
Medicaid Employer-Sponsored
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Medicaid, 323,000
employer-sponsored,
98,000
private/other, 19,000
uninsured, 7,000
Estimated # of lower income children with
CC-PCMH, by insurance type/status
Nearly ¾ of lower income children with CC-PCMH have Medicaid
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Lower income Medicaid adults with CC-PCMH
are less likely to have unmet health needs
19.2%
31.0%
0%
25%
50%
%*
adults
≤138%
FPL
with u
nm
et
heal
th n
eeds
Has CC-PCMH Does not have CC-PCMH
*Predicted probabilities based on statistical models
that adjust for demographic and other characteristics.
WWW.GRC.OSU.EDU/OMAS 34
Lower income Medicaid adults with CC-PCMH
are less likely to have frequent emergency department visits
13.2%
4.3%
23.0%
9.5%
0%
10%
20%
lower income Medicaid adults
with special health care needs
lower income Medicaid adults
without special health care needs
%*
Medic
aid a
dults
≤138%
FPL
with fre
quent
(3+
) ED
vis
its
in t
he p
ast
year
Has CC-PCMH Does not have CC-PCMH
*Predicted probabilities based on
statistical models that adjust for
demographic and other characteristics.
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Lower income Medicaid adults with CC-PCMH (and who have special health care needs)
are less likely to misuse prescription painkillers
*Predicted probabilities based on
statistical models that adjust for
demographic and other characteristics.
2.1%
1.0%
5.2%
1.6%
0%
5%
10%
lower income Medicaid adults
with special health care needs
lower income Medicaid adults
without special health care needs
%*
Medic
aid a
dults
≤138%
FPL
mis
usi
ng
pre
scri
ption p
ainkill
ers
in t
he p
ast
year
Has CC-PCMH Does not have CC-PCMH
difference not significant
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Lower income Medicaid adults with CC-PCMH (and who have a history of chronic conditions)
are less likely to have an overnight hospital stay
*Predicted probabilities based on
statistical models that adjust for
demographic and other characteristics.
23.8%
11.1%
30.3%
12.6%
0%
25%
50%
lower income Medicaid adults
with a history of chronic conditions
lower income Medicaid adults
without a history of chronic conditions
%*
Medic
aid a
dults
≤138%
FPL
who h
ave b
een h
osp
ital
ized
in t
he p
ast
year
Has CC-PCMH Does not have CC-PCMH
difference
not
significant
WWW.GRC.OSU.EDU/OMAS 38
Lower income children with CC-PCMH
are less likely to have unmet health needs
*Predicted probabilities based on
statistical models that adjust for
demographic and other characteristics.
4.5%
8.9% 8.0%
15.2%
0%
10%
20%
all lower income Medicaid children lower income Medicaid children with special health care
needs
%*
child
ren ≤
200%
FPL
with u
nm
et
heal
th n
eeds
Has CC-PCMH Does not have CC-PCMH
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Lower income Medicaid children with CC-PCMH
are less likely to have frequent emergency department visits
3.7%
10.9%
6.7%
18.4%
0%
10%
20%
all low income Medicaid children low income Medicaid children with special health care needs
%*
Medic
aid c
hild
ren ≤
200%
FPL
with fre
quent
(3+
) ED
vis
its
in t
he p
ast
year
Has CC-PCMH Does not have CC-PCMH
*Predicted probabilities based on
statistical models that adjust for
demographic and other characteristics.
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CC-PCMH is not associated with having an overnight hospital stay
*Predicted probabilities based on
statistical models that adjust for
demographic and other characteristics.
3.7%
13.1%
4.0%
14.1%
0%
10%
20%
all low income Medicaid children low income Medicaid children with special health care needs
%*
child
ren ≤
200%
FPL
who h
ave b
een h
osp
ital
ized
in t
he p
ast
year
Has CC-PCMH Does not have CC-PCMH
difference
not
significant
difference
not significant
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Lower income Medicaid children with CC-PCMH
are more likely to have a well-child visit
*Predicted probabilities based on
statistical models that adjust for
demographic and other characteristics.
90.9% 92.1%
74.9%
83.9%
0%
25%
50%
75%
100%
low income Medicaid children
WITHOUT special health care needs
low income Medicaid children
with special health care needs
%*
Medic
aid c
hild
ren ≤
200%
FPL
hav
ing
a w
ell-
child
vis
it
in t
he p
ast
year
Has CC-PCMH Does not have CC-PCMH
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White adults are more likely to have CC-PCMH
*Predicted probabilities based on
statistical models that adjust for
demographic and other characteristics.
42.1% 39.6%
44.7%
36.1%
28.4%
42.4%
36.6%
32.3%
37.5%
0%
10%
20%
30%
40%
50%
overall Medicaid ESI
%*
adults
who h
ave C
C-P
CM
H
White African-American Hispanic
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For both white and African-American lower income adults,
those with CC-PCMH are less likely to have unmet health needs
*Predicted probabilities based on
statistical models that adjust for
demographic and other characteristics.
20.4%
24.4%
32.6%
37.9%
0%
10%
20%
30%
40%
50%
White African-American
%*
adults
with u
nm
et
heal
th n
eeds
Has CC-PCMH Does not have CC-PCMH
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CC-PCMH is not associated with health care outcomes
among lower income pregnant women
*Predicted probabilities based on
statistical models that adjust for
demographic and other characteristics.
17.7%
12.9%
43.2%
27.7%
9.9%
44.4%
0%
10%
20%
30%
40%
50%
has unmet health needs frequent (3+/year) emergency
department visits
overnight hospital stay
%*
pre
gnan
t w
om
en ≤
200%
FPL
with o
utc
om
e
Has CC-PCMH Does not have CC-PCMH
difference
not
significant
difference
not
significant
difference
not
significant
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White children are more likely than African-American children
to have CC-PCMH
*Predicted probabilities based on
statistical models that adjust for
demographic and other characteristics.
42.6% 39.8%
46.4%
37.6% 34.8%
41.3%
0%
10%
20%
30%
40%
50%
overall Medicaid ESI
%*
child
ren
who h
ave C
C-P
CM
H
White African-American
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For infants from lower income homes, those with CC-PCMH
are less likely to have frequent emergency department visits,
but are just as likely to have an overnight hospital stay
*Predicted probabilities based on
statistical models that adjust for
demographic and other characteristics.
3.7%
24.3%
6.8%
20.9%
0%
10%
20%
30%
40%
50%
frequent (3+/year) emergency department visits overnight hospital stay
%*
infa
nts
≤200%
FPL
with o
utc
om
e
Has CC-PCMH Does not have CC-PCMH
difference
not
significant
Summary of Findings
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Adults Children
Who has CC-PCMH? older, female,
higher income
younger,
higher income
Does Medicaid facilitate access
to CC-PCMH? = ESI; > uninsured < ESI; > uninsured
Is CC-PCMH associated with better
health care?
strong, consistent
associations
strong, consistent
associations
Does CC-PCMH reduce racial/ethnic
disparities?
White > Afr-Am;
CC-PCMH helps both;
weak/no effect for
pregnant women
White > Afr-Am;
CC-PCMH helps both;
weak effect for infants
Conclusions
• Medicaid is facilitating access to CC-PCMH
• CC-PCMH has robust associations with
favorable health care outcomes
• CC-PCMH may reduce certain health disparities
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Policy Considerations • Medicaid expansion may have increased access to
CC-PCMH
• Improving access to urgent and after hours care may help facilitate Medicaid children’s access to CC-PCMH
• Care delivery models that promote CC-PCMH may improve health care outcomes
• Promoting CC-PCMH may help reduce health disparities
• OMAS can help monitor CC-PCMH
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