Medicine Dish: Medicaid and Medicare Data for American Indians and Alaska Natives

[Kitty Marx]
Welcome to Medicine Dish. I'm Kitty Marx, Director of the CMS Tribal Affairs
Group and your host of today's Medicine Dish. This broadcast will feature
experts providing the highlights of an exciting event that took place in July
2010 at the Museum of the American Indian in Washington D.C. to stimulate the
development of Medicaid and Medicare data for American Indians, Alaska Natives,
and the providers on whom they rely for health care. All this, and more, on
today's installment, of Medicine Dish.
[music playing]
Again, welcome to Medicine Dish. As I mentioned earlier, today's topic is Data.
But first, let's take just a minute to review what the Medicine Dish is and how
you can use the information.
The Medicine Dish introduces you to various topics pertinent to health care
programs operated by the Indian Health Service, tribes, tribal organizations and
Urban Indian Health Programs.
Medicine Dish is now broadcast on the third Wednesday of every other month at
1:30 Eastern Time and can be seen over the Web through a partnership with the
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access if you can't watch at the regularly scheduled time or want to review the
information. You can also find us on YouTube. Just do a search for Medicine
Dish.
And now let's turn to the topic for today's Medicine Dish broadcast -- Data.
We're being joined by experts from the California Rural Indian Health Board and
the Centers for American Indian and Alaska Native Research at the University of
Colorado, Denver to share information on how Medicaid and Medicare data is
becoming a valuable new tool for improving the funding and use of health care by
American Indians and Alaska Natives.
I'm going to turn the show over to David Nolley, our moderator for today's show,
to introduce our experts. David?
[David Nolley]
Thanks Kitty. In the summer of 2010, representatives of tribal communities,
their health care providers and federal health care funding agencies got
together with health policy researchers in a symposium to look at the health
care data of American Indians and Alaska Natives. The objective of the group was
to integrate their thinking about how to use data to make health and health care
better as new legislation changed the role of Medicare and Medicaid in the lives
of community members and providers alike.
We've brought together a panel of participants from that day. I'm pleased to
welcome Jim Crouch, from the California Rural Indian Health Board, Carol
Korenbrot also from the California Rural Indian Health Board and Joan O'Connell
from the University of Colorado, Denver, Centers for American Indian and Alaska
Native Research. Thank you all for joining us today. We have a lot of
information to cover so let's try to get started as quickly as we can, and I'd
like to start off with you Jim. Before we get into details, can you give us some
background information on the Data Symposium?
[Jim Crouch]
The Data Symposium was sponsored by the Tribal Affairs Group at CMS, and the CMS
TTAG, or Tribal Technical Advisory Group, which is a group of tribal health
leaders and tribal leaders who are really interested in CMS/IHS interface. One
of the reasons this Symposium was important is that CMS is organized by state.
Essentially, we're mostly interested in Medicaid money and Medicaid programming
issues, and the IHS is organized by twelve regional areas, they're called. So
some of them are multiple state, some of them are single state, so organizing
the data in a way that makes sense for Indian policymakers is a critical thing
that we're trying to achieve, and the Symposium was a, really, a showcase for
some work that we've done over the last couple of years.
[David Nolley]
Now, not everyone in our Medicine Dish audience is a researcher. So can you
reassure us that we're going to get practical use out of today's show?
[Jim Crouch]
I can reassure you that because, really, data is the basis upon which decisions
are made. The community is looking at a lot of issues around health reform and
also around the operations of the Indian Health Service itself and the CMS
program, and really we use the data to help understand how those systems
interact. So I'm pretty sure today there will be things that will be useful to
administrators and other people who are responsible for the IHS and CMS delivery
systems.
[David Nolley]
Hey Jim, why is it important to have Medicare and Medicaid data for American
Indians and Alaska Natives?
[Jim Crouch]
Well, there are a number of reasons. Probably the most important is that the
Indian Health Service system is jointly funded by the Indian Health Service in a
direct appropriation, and also then the reimbursements from both Medicare and
Medicaid. So it's really important that we understand the flow of those funds,
the extent of which services are being provided. More importantly, we can learn
a lot from what we're actually doing by looking at those reimbursement data. So
it really is important for both planning and for policy reasons, and also for
improving ultimately the health status of the Indian community.
[David Nolley]
Okay. Jim, why is American Indian Medicare and Medicaid data going to be
important, as recently passed health legislation, such as the Affordable Care
Act, Indian Health Care Improvement Act, and the Recovery Act are implemented?
[Jim Crouch]
Well, there are a number of reasons. First and foremost is there's going to be a
great expansion in Medicaid coverages, and that's a major provider of resources
for Indian health care. It's going to expand from, in various states at
different levels, but it will expand uniformly to 133 percent of the Federal
Poverty Level for Medicaid, and that population -- we don't know a lot about
them from our normal data systems, and we're seeking to learn more about the
number of Indians and where they're located that will be covered by these new
expanded Medicaid coverages.
There's a second Indian population that's even more broadly distributed that's
not necessarily getting care now through the IHS system that will be eligible
for the subsidized private insurance coverages that'll be available through the
exchange. So those will be the Indians from 133 percent of poverty or up to
about 400 percent, and we're seeking to learn more about those populations so we
can make sure they're outreached and know of the advantages. There's some really
specific Indian benefits in the Indian Health Care Improvement Act and in the
Affordable Care Act. First and foremost is to the Indian community has issues
around waivers of premiums and copayments, so we need to be able to identify the
Indians so that they can take advantage of those benefits. And then the last
part about the health reform bill is that we're interested in Indian
participation as being providers of services to our clients and how managed care
and insurance coverage would include tribal health and IHS facilities in their
care provider networks.
[Carol Korenbrot]
Another thing about managed care is people were automatically enrolled into
managed care whether they wanted to or not, and that managed care may not
provide them a provider but for hundreds of miles away. And so it's very
important that people now, as American Indians, will not be automatically
enrolled in managed care, should not be automatically enrolled in managed care.
They will be able to defer managed care at all from the beginning when things
are all implemented.
[David Nolley]
Well, thanks for the input, and for a moment I want to pick a little bit from
your brain, Joan. How can data from the claims of IHS-funded health care
providers be used to improve IHS-funded health care and the health status of
American Indians and Alaska Natives who use IHS system providers?
[Joan O'Connell]
Okay. Well, data extracted from clinical reporting systems, the Resource Patient
Management System, and claims data from Medicaid on inpatient, outpatient, and
pharmacy services, are being used to more fully understand how more preventive
and medically necessary care can be provided to American Indians and Alaska
Natives while we do see hospitalizations and other treatments for complications
of diseases that could be avoided.
This slide describes three types of care; preventive, primary, and inpatient
care. Studies by Dr. Korenbrot and others have shown that a significant
percentage of hospitalizations are avoidable through the provision of preventive
and primary care. It is important to conduct studies to understand how best to
improve the provision of these services to reduce the need for hospital care.
For example, we did a study of American Indians with diabetes in the Phoenix
Indian Medical Center Service Unit that relied on data that is present in
Medicaid and Medicare claims. We compared medical complications of the disease
comorbidities for American Indians with diabetes to those without diabetes. We
established the proportions of Indians that were affected by the conditions that
develop alongside diabetes but are desirable to prevent entirely or to keep
under control.
In this first row you can see the percent of persons with diabetes who have
hypertension is much higher than those without diabetes. Similarly, persons with
diabetes are more likely to have cardiovascular disease, and this trend persists
across the other conditions on the slide. We then compared the disparities in
the presence of these complicating conditions and their severity in American
Indians with persons with diabetes who were commercially insured. To do this, we
used a scoring system developed by clinical experts that measures severity of
medical risk across different clinical conditions. The American Indians with
diabetes had a medical risk of 5.4. The score for the U.S. commercially insured
adults was 3.6. The risk among the American Indians was about 50 percent higher.
On the right side, you see a similar pattern for American Indians with both
diabetes and cardiovascular disease. Due to the presence of comorbidities,
American Indians are at much higher risk.
We next characterize the use of hospital care and excess treatment costs
associated with excess morbidity for American Indians. The American Indians with
diabetes represented approximately 11 percent of the adults in our service
population, yet nearly half of all hospitalizations, excluding those for
obstetrical care. Furthermore, the same percentage of people with diabetes, 11
percent, accounted for over a third of treatment costs, much of which was for
inpatient stays and, as we noted earlier, a significant percentage of these may
be prevented or avoided.
What is needed is to track claims data to follow health status, health care use,
and treatment costs so that we can improve preventive and medically necessary
care, like control of blood sugar and regular foot exams and avoid emergency
room visits and hospitalizations for complications such as coma and amputations.
The reduction in disparities in health status should follow from such efforts
and be documented by reductions in medical risk scores otherwise, improvements
in health status.
[Carol Korenbrot]
And that's why we asked Joan to come and talk at the Data Symposium because she
showed the power of using this data and to actually get at the health status of
American Indians to measure it and show how data can be used over time to follow
whether health care is being used properly and whether health status is
improving and, if not, to see that funding and payments go to reinforce that
kind of funding that would improve that health care use and the health status.
And this is why we invited her to come speak and why we wanted her on the panel
today, too. It shows what we can do with the data, but we're not ready to do
that right now.
[David Nolley]
Well, thank you so much Carol and Joan. But now another question for you, Carol.
What Medicaid and Medicare data is being analyzed for American Indian and Alaska
Native beneficiaries who utilize the Indian health system providers?
[Carol Korenbrot]
We basically have access to eligibility data and to claims data. The eligibility
data has enrollment information, and that tells us about the characteristics of
the services that the American Indian is eligible for. We also can tell from
that demographic information about their age, their sex, and things like that
that are important to group the information. From the claims data -- oh, we also
most importantly can distinguish American Indians and Alaska Natives by racial
definition, a self-declared definition, from those who are in the Indian Health
System of providers and have been determined to either use an IHS, a tribal, or
an urban provider, and therefore are in a special category. From the claims
data, we can determine what health care services they are using, and we can also
determine characteristics of their health status. Finally, and as you have seen
from what Jim has been talking to you about, we get information about the
payments that have been made to the providers for their services.
[David Nolley]
Well, thank you Carol. Can you give us an example or two of that?
[Carol Korenbrot]
Glad to. In this next slide, we see that there's data, similar data to exactly
what Jim provided earlier. This is IHS system provider payment data, and this
includes the IHS and the tribal providers. There's no data here for the urban
populations. This then shows that American Indian beneficiaries on the Medicaid
data -- what they're receiving in payments from their IHS providers in the
bottom part of the bars, and in the top part of the bars you see what the
payments amount is for the other providers that they have. This is a beginning.
We can look across each of the 12 IHS areas and compare the kinds of services
they're getting from the different kinds of providers, and we can find out the
whole range of providers that those American Indians are using. Medicaid and
Medicare are about the only sources of data where one can find the whole range
of providers that the American Indians and Alaska Natives are using.
We also have data for IHS-eligible American Indians and Alaska Natives, and
those American Indians who are racially American Indians by self-declaration but
are not necessarily eligible for -- to use the IHS system providers. We can see
in the slides and the data that we use that we can compare the range of services
that each type of American Indian group gets, and we can try to see that both
groups get a balanced and equitable amount of services. We can look at the
amount of services that they're getting and the types of care that they get.
[David Nolley]
Okay. Thank you, Carol. I would like to, at this point, throw out a question to
all of you, so anyone please feel free to just step up and answer this question
as you feel comfortable. What were some of the challenges that you faced?
[Jim Crouch]
Well, Dave, the first real challenge in any of this work is getting permission
to have access to the data, to have the ability to do that in a way that's
compliant with the Federal regulations and statutes. And Carol's worked hard to
make this access available to us, and that was probably the first issue. I think
the second issue is, again, that the two data sets are so very different. The
IHS is organized by its 12 provider areas, and each local provider has a very
different mix of services. So, getting a handle on what's available through the
IHS system by looking at Medicaid data helped us get beyond that problem.
[David Nolley]
Okay. Now, this question I'm directing to you since you responded, but again
this is for anyone -- can you point to any situations where you've used their
data that's become available as a result of this project?
[Jim Crouch]
Well, I guess that I can't think of a specific one. What are you thinking,
Carol?
[Carol Korenbrot]
Well, I've always been impressed that the Portland Area, who when we first
presented the data and they received it, they were shocked by, actually what
they found were lower enrollment numbers for Medicaid than they had ever
expected. And so their immediate -- took action right away to redo what they had
done several years prior, which was to enroll as many of the American Indians
that were using their system providers and get them enrolled again in Medicaid.
They found that they were getting off the rolls in Medicaid and it was too much
trouble to get back on. They needed the same kinds of, like, maintenance work to
keep Medicaid enrollment intact. And the Portland Area has done a lot to use
this data for their -- to improve their system and capture more payments. What
is difficult about using the data is making sure and keeping the data
confidential. The reason that is it's hard to get access to the data is it's
medical information, and we have a lot of precautions that are taken from
beginning to end to see that the data is stripped of confidential information,
and it's de-identified so that when we're looking at the information, it's
absolutely -- we would have no idea who these records belong to and could not
possibly figure that out, nor could anyone else.
We also find that that it's very difficult to get all the information. In other
words, we find that claims are missing. And most importantly, the fact that that
the user who was entitled to the Medicaid services is not recorded as an
American Indian. We call it a misclassification of racially Indians, but it's
even more damaging when the IHS-eligible American Indians are not recorded as
Indians at all on the claims, because this data tends to get lost, and what
we're looking at is very incomplete data because the states who work with the
IHS system providers don't know that they've actually got a record from an IHS
system provider for one of these -- for this data.
[Jim Crouch]
One of the things that we know about the data is that the IHS is really quite
clear and truly the expert on identifying who are the Indians that are using
their system. But they don't have really good data on the types of services that
they're providing and the cost of those data -- of those services, whereas the
exact opposite is true with the Medicaid data sets. Who's an Indian is often
misclassified, but they're very precise on the type of service that was provided
and the dollar value that -- or the cost of that service. So bringing those two
together we get not only a more complete view of what's happening to the
individual Indian's care but also know for sure that we're looking at exactly
the right population and we're able to better understand their unique health
status. So again it's in the joining of these two data sets--the weaknesses and
the strengths happen to match up, and Carol can do the work, and we've been very
lucky with all of this.
[David Nolley]
Great, great.
[Carol Korenbrot]
And I think it's--in addition to ensuring the data's accurate, and it's
important to work with providers and health policymakers and the different IHS
areas and service units to ensure that the analyses that are being done are very
useful for their planning and for their purposes to improve clinical care and
the health status to the people they serve.
[Jim Crouch]
I think it's also true, Dave, that we're hoping that they will themselves try to
address the data. We've got a number of studies that we've done that are
available on the CRIHB Web page that have been a part of this CMS-funded,
TTAG-directed activity, and there's no doubt secondary uses of this information
that we can't even dream of at this point, once more people essentially address
the data and think about how it impacts what they're doing and what it tells
them about what's going on in their local health care program.
[David Nolley]
Oh, well thanks again, Jim. So here's another question for the group again, and
I guess maybe I'll target you this time, but feel free anyone to jump in. How
can our viewers and the IHS tribal and urban Indian health programs use this
data in their everyday work?
[Joan O'Connell]
Well, I think from this data, as Carol pointed out, they can look at the types
of reimbursements for American Indians and Alaska Natives being served in their
region to understand how there's variability between the regions with regard to
the amount of funding coming in. Then I'd say the second thing would be is for
the Indian Health Service, tribal and urban providers to work with their local
Medicaid agencies to understand and assess opportunities for billing for
services that would really enhance care for people with certain conditions, such
as diabetes, heart disease, or perhaps adolescents with mental health needs.
[Carol Korenbrot]
It's very important that all the IHS system providers -- the administrators know
who their state Medicaid tribal liaison or IHS liaison -- they're named
differently in different states -- but who that person is, and if that person
changes, who it's changing to because they have to work closely so that state
Medicaid programs learn better how to capture and identify this data and enrich
the databases that they provide to the federal system. This is especially true
because there are many system providers who have to deal with more than one
state, so they have to deal with more than one Medicaid program, more than one
liaison, and more than one system of capturing data. That's very important, and
we're asking that burden to be shared, now.
[Joan O'Connell]
And it's an ongoing process. The regulations are always changing and evolving.
New opportunities exist, such as under health care reform. So having that
ongoing relationship to understand opportunities to improve care will be -- is
really important, especially in the coming years.
[David Nolley]
Okay. Well Jim, if I may, I want to target you with this one because they both
touched on something that maybe you can expand on. Now that our viewers know
this data is available, what advice would you give them about accessing and
using the data?
[Jim Crouch]
Well, the simplest thing would be to get on their Web browser and search out
"California Rural Indian Health Board." Our Web address is www.crihb.org, and
you can find under the research tab a whole series of publications that we've
put together at the direction of the CMS TTAG.
[Carol Korenbrot]
On the slide, it shows that you have to go into the "Policy In Action" part,
which is how we view data -- not to just collect data and archive it, but to put
policy into action, and you'll find the "Research" tab under that, and national
documents under that particular part as well.
[David Nolley]
Well, this question again is for the group. What's the future of the project? Do
you see any further developments on the horizon?
[Jim Crouch]
Oh, we're doing some really exciting work right now, and it particularly
pertains to how the mix of resources -- CMS and IHS resources differ by IHS
area. You might think that the Indian Health Service has a uniform sort of
resource allocation process, but actually it's an alluvial thing that's grown up
over time, and so that when the Medicaid program became available for billing in
'76, the IHS really never took advantage of it, and over time they've learned to
coordinate better with it.
So we're doing some research on how much reimbursement is coming in per IHS
client through all their providers, not just the IHS provider site, and we hope
that it will help inform the IHS and their allocation of the Indian Health Care
Improvement Fund monies -- that's a special pot of funds that Congress set aside
to improve funding equity. The IHS is not a defined benefit system. It's sort of
like discretionary. What happens depends on funding availability, the local
leadership of the tribe or the IHS system. It's a real mix, and this next
research we're going to do is, I think, going to be very informative to how the
agency can affirmatively make sure that there's equal access across all of
Indian country.
[David Nolley]
Okay. And where can our audience find more information about this project?
[Jim Crouch]
Well, I think the IHS Web page is a good place go under "Non-Medical Programs."
They have a whole section on the Indian Health Care Improvement Fund, and of
course as our work gets done we'll be reporting out to the Centers for Medicare
& Medicaid Services Tribal Advisory Group, and the TTAG. So attending those
meetings is another good way to stay informed of how this research is evolving
over time.
[David Nolley]
Thanks Jim. I'd like to thank all of our panelists for their contribution to
this discussion and for joining us today. Kitty?
[Kitty Marx]
We've covered a lot of information today. I'd like to thank Jim Crouch, Carol
Korenbrot, and Joan O'Connell for sharing their insight on the impact of
Medicare and Medicaid data on Indian Country. We're at the end of our Medicine
Dish show, and I want to thank you for your participation in our broadcast. Our
next broadcast will be on the third Wednesday of June. That's June 15th, at 1:30
p.m. Eastern Time. You can access previous Medicine Dish programs at a new
location on the NIH Website, videocast.nih.gov. Go to "Past Events." Select
"Trainings and Meetings," and then select "CMS Centers for Medicare and Medicaid
Services," or find us on YouTube under Medicine Dish.
Thank you, and I hope you enjoyed and benefited from today's Medicine Dish show.
I'm Kitty Marx, host of Medicine Dish, wishing you a very productive day.
[music playing]
[end of transcript]
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