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Infertility Prevention Project Infertility Prevention Project Region I Advisory Board MeetingRegion I Advisory Board Meeting

Lessons Learned In MichiganLessons Learned In Michigan

Amy Peterson, MPHAmy Peterson, MPHMichigan Department of Community HealthMichigan Department of Community Health

June 1, 2009June 1, 2009

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Presentation TopicsPresentation Topics

o Michigan Background Michigan Background

o Quick and Dirty Cost Savings AnalysisQuick and Dirty Cost Savings Analysis

o Use of Cost Saving InformationUse of Cost Saving Information

o Michigan IPP Program ManagementMichigan IPP Program Management

o Targeted ExpansionTargeted Expansion

o Gonorrhea/Chlamydia Reduction PlanGonorrhea/Chlamydia Reduction Plan

o Program Expansion and Contraction Program Expansion and Contraction

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Michigan BackgroundMichigan Background

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Gonorrhea and Chlamydia Gonorrhea and Chlamydia Burden in Michigan Burden in Michigan

o 46,555 reported cases of chlamydia 46,555 reported cases of chlamydia o 77% age 77% age ≤≤ 24 24

o 17,905 reported cases of gonorrhea 17,905 reported cases of gonorrhea o 66% age 66% age ≤≤ 24 24

o * All numbers reflect CY 2008* All numbers reflect CY 2008

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66

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Michigan IPP Tie-DyeMichigan IPP Tie-Dye

o Quarterly Alliance Quarterly Alliance MeetingsMeetingso STDSTDo FPFPo Bureau of LabsBureau of Labso Adolescent HealthAdolescent Healtho Oakland CountyOakland Countyo Juvenile DetentionJuvenile Detention

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IPP Screening ActivityIPP Screening Activity

o Calendar Year 2008Calendar Year 2008o ~ 105,000~ 105,000 ( (104,621104,621) screened for chlamydia) screened for chlamydia

o Over 10.3% (Over 10.3% (10,78910,789) found positive) found positiveo 75% of positives are 15-24 yrs/age (75% of positives are 15-24 yrs/age (63% of tests63% of tests))

o ~ 90,000~ 90,000 ( (91,83591,835) screened for gonorrhea) screened for gonorrheao 4.2% (4.2% (3,8403,840) found positive) found positiveo 61% of all positives are 15-24 yrs/age (61% of all positives are 15-24 yrs/age (58% of tests)58% of tests)

o Diagnose ~23% of the State’s morbidityDiagnose ~23% of the State’s morbidity

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Quick and Dirty Cost Savings Quick and Dirty Cost Savings AnalysisAnalysis

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Funding for IPP ActivityFunding for IPP Activity

o STDSTDo Federal IPP (tests/administration)Federal IPP (tests/administration)o State General Fund/Michigan Health Initiative State General Fund/Michigan Health Initiative

(tests/administration)(tests/administration)o Local Public Health Operating funds (staff)Local Public Health Operating funds (staff)o Local health jurisdiction funding (staff)Local health jurisdiction funding (staff)

o Family PlanningFamily Planningo Tests and Plan First!/MedicaidTests and Plan First!/Medicaid

o Adolescent and School Health Program Adolescent and School Health Program o Tests/coordinating consultantTests/coordinating consultant

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Cost Savings AnalysisCost Savings Analysis

o Began as a way to avoid cuts during 2007 Began as a way to avoid cuts during 2007 budget crisisbudget crisis

o Good PR tool for all stakeholdersGood PR tool for all stakeholderso Local Health Jurisdiction – IPP analysisLocal Health Jurisdiction – IPP analysiso Medicaid cost analysisMedicaid cost analysis

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Steps in Michigan’s Unscientific FormulaSteps in Michigan’s Unscientific Formula

o Identify number of FEMALES diagnosed with Identify number of FEMALES diagnosed with CT and/or GC in population of choice (IPP, CT and/or GC in population of choice (IPP, total morbidity, persons on Medicaid, etc)total morbidity, persons on Medicaid, etc)

o Apply CDC statement – undiagnosed 30-40% Apply CDC statement – undiagnosed 30-40% may progress to PIDmay progress to PID

o Multiply # positives times .40, times cost of Multiply # positives times .40, times cost of treating a case of PID (multiple reference treating a case of PID (multiple reference articles available).articles available).

o Add disclaimers and footnotesAdd disclaimers and footnoteso Use terms like “estimated” and “expected” Use terms like “estimated” and “expected”

frequentlyfrequently

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Medicaid Cost Savings AnalysisMedicaid Cost Savings Analysis

o Two calculations:Two calculations:1.1. Estimated amount saved based on avoided Estimated amount saved based on avoided

PID at current screening levelPID at current screening level

2.2. Cost to treat cases of PID which could have Cost to treat cases of PID which could have been avoided with 100% screening of been avoided with 100% screening of eligible patientseligible patients

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Medicaid Analysis Data SourcesMedicaid Analysis Data Sourceso Requested data from Michigan Medical Requested data from Michigan Medical

Services Administration, Data Analysis and Services Administration, Data Analysis and Quality Assurance Section (MSA)Quality Assurance Section (MSA)

o Number screened was gathered from the Number screened was gathered from the Medicare Managed Care Annual Report Medicare Managed Care Annual Report

o Received number diagnosed with PID by Received number diagnosed with PID by race from MSA – based on diagnosis code race from MSA – based on diagnosis code

o MSA system does not collect number of MSA system does not collect number of positives, only number of tests. Received positives, only number of tests. Received aggregate count by age and race; # of aggregate count by age and race; # of positives were estimated based on Michigan positives were estimated based on Michigan case rates.case rates.

o See handout for detailsSee handout for details

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Missed Screening Opportunities Missed Screening Opportunities Cost Michigan MoneyCost Michigan Money

o Amount spent by Medicaid to screen Amount spent by Medicaid to screen female female members age 16-25 in 2006 – members age 16-25 in 2006 –

o ~ $2.2 million ~ $2.2 million

o Cost to screen and treatCost to screen and treat 100% of eligible Medicaid 100% of eligible Medicaid female members age 16-25 in 2006 - female members age 16-25 in 2006 -

o ~ $4 million~ $4 million

o Cost to treat chlamydia related PIDCost to treat chlamydia related PID in 2006 – in 2006 –

o ~ $~ $5.5 million5.5 million

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Projected cost/savings in 2012Projected cost/savings in 2012 (shown in millions)(shown in millions)

$0

$1

$2

$3

$4

$5

$6

$7Cost ofInitiative

HealthSystemSavings

Screening for CT is a good investment

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Cost Savings Analysis as Cost Savings Analysis as Advocacy ToolAdvocacy Tool

o Garnering good will with screening partners Garnering good will with screening partners and their upper level administratorsand their upper level administrators

o Build case for additional funding from State; Build case for additional funding from State; proven cost savings for Medicaidproven cost savings for Medicaid

o Advocate to keep resources based on Advocate to keep resources based on “Evidence Based”, “Cost-Effective Public “Evidence Based”, “Cost-Effective Public Health Strategy”Health Strategy”

o $ adds power to sound bites$ adds power to sound bites

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Michigan’s IPP Program Michigan’s IPP Program ManagementManagement

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Program ManagementProgram Management

o Pre-Paid FormsPre-Paid Forms

o CT-only Testing AlgorithmCT-only Testing Algorithm

o Constant Monitoring of Usage Constant Monitoring of Usage

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Pre-Paid FormsPre-Paid Forms

o See handoutSee handout

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CT-only Testing Algorithm: CT-only Testing Algorithm: Targeted Use of ResourcesTargeted Use of Resources

o See HandoutSee Handout

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Constant Monitoring of UtilizationConstant Monitoring of Utilization

o Monitored semi-annuallyMonitored semi-annually

o Robin Hood approach to test re-allocationRobin Hood approach to test re-allocation

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Targeted ExpansionTargeted Expansion

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Juvenile Detention/Juvenile Detention/Adolescent Health ExpansionAdolescent Health Expansion

o 2002 – RVIPP Mini-grant to target juvenile 2002 – RVIPP Mini-grant to target juvenile detentiondetentiono Children’s Village/ Children’s Village/ Lynda ByerLynda Byero JD sites in high morbidity counties JD sites in high morbidity counties

approachedapproachedo School based health centers – OaklandSchool based health centers – Oaklando Statewide expansion with Carrie TarryStatewide expansion with Carrie Tarry

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Wayne County Juvenile DetentionWayne County Juvenile Detention

o Over two years of trying, asking, Over two years of trying, asking, beggingbegging

o Multiple staff and attemptsMultiple staff and attemptso New Medical Director – Dr. Carla New Medical Director – Dr. Carla

Scott Scott o Full implementation July 2006Full implementation July 2006o 01/08 – 12/08 (paid for ½ of tests 01/08 – 12/08 (paid for ½ of tests

themselves)themselves)o 3,771 tested 770 F; 3001 M3,771 tested 770 F; 3001 Mo 424 + CT (22% F, 9% M)424 + CT (22% F, 9% M)o 87 + GC (6% F, 1.3% M)87 + GC (6% F, 1.3% M)

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Expansion and ContractionExpansion and Contraction

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Dream Big…Dream Big…

o Focus on mission of programFocus on mission of programo Acknowledge uncomfortable Acknowledge uncomfortable

decisions that come with limited decisions that come with limited resourcesresources

o Challenge politics as usualChallenge politics as usualo Target non-traditional partnersTarget non-traditional partnerso Target services to address health Target services to address health

disparities (not just racial)disparities (not just racial)o Look for yield from every test Look for yield from every test

supportedsupported

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Gonorrhea/Chlamydia Gonorrhea/Chlamydia Reduction PlanReduction Plan

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52,673* casesper year

144 new infections per day

removing 144 infections per day

Status Quo:gonorrhea and chlamydia in

Michigan

* Average 2002-2007

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Goal of InitiativeGoal of Initiative

To decrease overall prevalence of To decrease overall prevalence of gonorrhea and chlamydia by identifying gonorrhea and chlamydia by identifying and treating infected individuals at a faster and treating infected individuals at a faster rate than new infections occur.rate than new infections occur.

How…How…

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Evidence Based Components Evidence Based Components of the Planof the Plan

1.1. IncreaseIncrease school-based school-based screening screening

2.2. Implement universal Implement universal screening of screening of malesmales in STD sites in STD sites

3.3. Increase Increase private sector screeningprivate sector screening

4.4. Support Support alternative site high-riskalternative site high-risk screeningscreening

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Evidence Based Components Evidence Based Components of the Planof the Plan

5.5. Implement Implement CDC re-testing guidelineCDC re-testing guideline

6.6. UtilizeUtilize electronic medium electronic medium to notify to notify partners partners

7.7. Encourage Encourage field-delivered therapyfield-delivered therapy for for identified casesidentified cases

8.8. Improve Improve partner managementpartner management in public in public and private sectorand private sector

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Targeted Expansion – Targeted Expansion – 2009 Pilot Projects in High 2009 Pilot Projects in High

Morbidity AreasMorbidity Areaso School Blitz School Blitz (8.3/11.9)(8.3/11.9)o Teen Health Centers Teen Health Centers (19 CT, 5.2 GC)(19 CT, 5.2 GC)o Wayne County Jail Wayne County Jail (10 CT, 3 GC)(10 CT, 3 GC)o Pregnancy Test Only (10.2 vs. 7.5)Pregnancy Test Only (10.2 vs. 7.5)o University Dorms University Dorms (15 CT, 3.3 GC)(15 CT, 3.3 GC)o Federally Qualified Health Center – STD Federally Qualified Health Center – STD

Overflow Overflow (11 CT, 4 GC)(11 CT, 4 GC)o Expanded Screening Initiative (ESI) GrantsExpanded Screening Initiative (ESI) Grantso RetestingRetestingo Universal male screening in STD ClinicsUniversal male screening in STD Clinics

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Likely Targeted Contraction - 2010Likely Targeted Contraction - 2010

o Maintaining screening criteria age limit Maintaining screening criteria age limit at 24 years oldat 24 years old

o State support of health center State support of health center screening at Oakland University – likely screening at Oakland University – likely discontinued (6 / 9 CT)discontinued (6 / 9 CT)

o ESI Grants – support for testing onlyESI Grants – support for testing only

o Discontinue universal male screening Discontinue universal male screening in STD clinics in STD clinics

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Targeted Contraction - 2010Targeted Contraction - 2010

o Reviewing Adolescent Health and Reviewing Adolescent Health and Family Planning sites Family Planning sites o cutting low prevalence sites to minimumcutting low prevalence sites to minimumo encouraging billing Medicaid and “Plan encouraging billing Medicaid and “Plan

First!” when possible (50% estimated) First!” when possible (50% estimated) o drill down analysis to ID who is testing drill down analysis to ID who is testing

positive and providing guidance positive and providing guidance

o Shifting resources to high prevalence Shifting resources to high prevalence sitessites

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Calling on Our Partners in 2010Calling on Our Partners in 2010

o Adolescent health picking-up larger portion of Adolescent health picking-up larger portion of costscosts

o Targeted expansion to two new screening Targeted expansion to two new screening sites in high prevalence sitessites in high prevalence sites

o Family Planning willing to make hard calls Family Planning willing to make hard calls with low positivity siteswith low positivity sites

o Increase attention to private sector (Nancy). Increase attention to private sector (Nancy). Using LPH partners to increase knowledge Using LPH partners to increase knowledge and action among local providersand action among local providers

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No/ low cost program No/ low cost program improvementsimprovements

o School blitz guidanceSchool blitz guidanceo Messages to private sector through managed Messages to private sector through managed

care organizations to increase attention to care organizations to increase attention to HEDIS measureHEDIS measure

o Re-test in current sitesRe-test in current siteso Field delivered therapy guidanceField delivered therapy guidanceo Work with IPP providers to increase partner Work with IPP providers to increase partner

management capacity and intentionsmanagement capacity and intentions

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Questions…ContactQuestions…Contact

Amy PetersonAmy Peterson

IPP CoordinatorIPP Coordinator

Michigan Department of Community HealthMichigan Department of Community Health

STD ProgramSTD Program

313/456-4425313/456-4425

petersonam@michigan.govpetersonam@michigan.gov