The results are in for FY23 Montgomery Cares Clinical Quality, but what do they mean in context? How does the care provided compare — both within the program over time, and to broader populations? To provide a better frame, we’re expanding on the report’s discussion section with additional explanatory graphs and figures.
For comparison to broader populations, Montgomery Cares utilizes the national averages of HEDIS measures customized for Medicaid HMOs as benchmarks for performance (HEDIS Mean). HEDIS refers to the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS), a tool used by more than 90 percent of U.S. health insurance plans to measure performance on important dimensions of clinical care and service. Medicaid HMO averages are chosen as the patient population aligning most similarly with the MCares community.
1. We have largely bounced back from pandemic declines:
Many quality indicators had declined from pre-pandemic (FY19) to mid-pandemic (FY21), a pattern that was true for HEDIS Mean results as well. But by the end of FY23, we’ve seen a recovery in most indicators and even progress against FY19 results. While cervical cancer screening rates remain a concern, MCares partners showed more consistent progress on indicator results overall versus the HEDIS Mean. The trajectories looked something like this:
For comparison to broader populations, Montgomery Cares utilizes the national averages of HEDIS measures customized for Medicaid HMOs as benchmarks for performance (HEDIS Mean). HEDIS refers to the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS), a tool used by more than 90 percent of U.S. health insurance plans to measure performance on important dimensions of clinical care and service. Medicaid HMO averages are chosen as the patient population aligning most similarly with the MCares community.
1. We have largely bounced back from pandemic declines:
Many quality indicators had declined from pre-pandemic (FY19) to mid-pandemic (FY21), a pattern that was true for HEDIS Mean results as well. But by the end of FY23, we’ve seen a recovery in most indicators and even progress against FY19 results. While cervical cancer screening rates remain a concern, MCares partners showed more consistent progress on indicator results overall versus the HEDIS Mean. The trajectories looked something like this:
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2. But we need to continue working on hypertension and blood sugar control:
However, chronic disease management is a key consideration for the health of our patient population, particularly given that the MCares patients most likely to remain in the program year-over-year are those with at least one chronic condition. While the MCares patient population is above the HEDIS Medicaid average for both hypertension control and HbA1c control, there is room for improvement in conditions that endure among our patient population and that have severe (and expensive) potential complications.
In FY2020, Social Capital Valuations, LLC used available literature to estimate the savings (in both health care costs and economic productivity) associated with treating MCares patients for select conditions between January 2018 and June 2019. This is what they found:
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Note that these results are based on the total cost of treatment. Because MCares operates as a public-private partnership, the estimated ROI on county dollars for these conditions was approximately double.
3. Data disaggregation remains complicated and incomplete:
Race and ethnicity are often difficult to quantify effectively. For example, a recent analysis of race/ethnicity reporting in Michigan emergency department visit records showed substantial discrepancies between the race or ethnicity reported for a patient in their initial visit and the race or ethnicity reported for the same patient in subsequent visits to the same hospital system. Those discrepancies were highest for patients initially classified as Black and other.[1]
A CNN piece offers a deeper dive on some of the reasons behind these inconsistencies, including who documents a patient’s race/ethnicity—is it self-reported or based on a staff member’s perception[2] —as well as the cultural specificity around the ways we define race/ethnicity. The article notes that ethnicity identification can be challenged not only by varying national contexts but by political changes over time and variations in the degree of an individual’s affinity with ethnic characteristics.[3] It also discusses the pros and cons of merging current census race and identity questions.
Our MCares demographic categories separate race and ethnicity; however, many patients may identify as Latinos and not as specific racial categories. Consider racial identification over multiple fiscal years, particularly the proportion of patients with an identified versus unknown or other race:
A CNN piece offers a deeper dive on some of the reasons behind these inconsistencies, including who documents a patient’s race/ethnicity—is it self-reported or based on a staff member’s perception[2] —as well as the cultural specificity around the ways we define race/ethnicity. The article notes that ethnicity identification can be challenged not only by varying national contexts but by political changes over time and variations in the degree of an individual’s affinity with ethnic characteristics.[3] It also discusses the pros and cons of merging current census race and identity questions.
Our MCares demographic categories separate race and ethnicity; however, many patients may identify as Latinos and not as specific racial categories. Consider racial identification over multiple fiscal years, particularly the proportion of patients with an identified versus unknown or other race:
Compared to ethnicity identification over the same period:
4. Our network structure rewards screening for depression and anxiety:
The FY 23 Montgomery Cares Clinical Quality Measures Report notes that the PCC collaborative care model, which integrates behavioral health services within primary care, likely drives the high screening rates we see. Providers and medical staff may put greater emphasis on these screenings when they have a warm handoff process and are confident there are tools to manage any concerns the screening uncovers.
The evidence appears to support this conclusion: A study estimating national depression screening rates in adult ambulatory care resulted in very low numbers, ranging from 0.64% to 3% annually on analysis of data from the 2005 – 2015 National Ambulatory Medical Care Survey. The study excluded patients with an existing depression diagnosis as well as psychiatry visits. Authors noted that while the US Preventive Services Task Force had recommended primary care depression screening in 2009, it specifically excluded screenings when there were no available treatment resources. Another study exploring NAMCS data for 2012 and 2013 narrowed its field to include only adult visits that appeared to be routine primary care – providers in fields associated with primary care, no existing diagnosis or presenting symptoms of depression, and no referral to more acute care or other circumstances that would impact screening viability. Those narrower parameters raised the screening rate to an estimated 4.2%.
The MCares system’s ability to screen more than two-thirds of patients annually and connect them with treatment resources also has important cost implications. Social Capital Valuations, LLC also considered the return on investment for MCares anxiety and depression treatment between January 2018 and June 2019. They found:
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The Montgomery Cares program, the clinical providers, and PCC can be very proud of these results. As always—and for all of us—there is room for continuous improvement. That is why we produce Clinical Quality Measure Reports year after year and why we convene quarterly meetings with all primary care health center medical directors: to discuss the data and work on approaches to improvement.
ROI analyses were performed by an independent consultant engaged by PCC. This document has not been reviewed or approved by the Montgomery Department of Health and Human Services.
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