Data to Enhance Public Health Outreach in Response to the Flint - PowerPoint PPT Presentation

1 The Role of Medical Claims Data to Enhance Public Health Outreach in Response to the Flint Water Crisis Krutika Jariwala, PhD, MS Min Tao, PhD Elizabeth Wasilevich, PhD, MPH Blue Cross Blue Shield of Michigan

1 Introduction 2 How it all started? • In April 2014, Flint, MI changed its water supply source from the treated Detroit Water and Sewage Department to the Flint River which has no corrosive inhibitor water treatment. This decision resulted in lead leaking from pipes into the drinking water. Picture credit: http://www.democracynow.org/2015/12/17/how_flint_michigan_saved_money_and. Retrieved on 6/6/2016

2 Introduction 3 Why are we concerned? And who is affected the most? • Consuming lead contaminated water can cause significant lifelong health effects, especially for exposed young children and fetuses of pregnant women. • Symptoms can range from constipation, vomiting and anemia to some serious health effects such as irreversible cognitive defects and attention-related Picture credit: problems among children (Mayo Clinic website, http://www.democracynow.org/2015/12/17/how_flint_michigan_saved_money_and. Retrieved on 6/6/2016 2016; National Toxicology Program report, 2012). Mayo Clinic website: http://www.mayoclinic.org/diseases-conditions/lead-poisoning/basics/symptoms/con-20035487. Accessed on 6/6/2016 NTP report: https://ntp.niehs.nih.gov/ntp/ohat/lead/final/monographhealtheffectslowlevellead_newissn_508.pdf. Accessed on 6/6/2016

3 Introduction 4 Recent research in this area • Expert estimates indicate ~6,000-12,000 children in Flint are potentially at risk for lead exposure due to this contamination (United Way of Genesee County, MI). • In Flint, MI, kids (≤5 years) with elevated blood lead level (≥5 µg/ dL) significantly increased from 2.4% (in 2013) to 4.9% (in 2015) with ~6.6% (4.0% to 10.6%) increase in selected neighborhoods (Hanna-Attisha et al., 2016). • Another study in Flint, MI shows an initial declining elevated blood lead trend from third-quarter (Q3)2010 (7.5%) to Q32013 (~3.6%; before the Picture credit: http://www.mlive.com/news/index.ssf/page/flint_water_crisis.html water system was changed) but an increase again in Q32014 (7%) and Retrieved on 6/6/2016 Q32015 (6%) among children (Laidlaw et al., 2016). Hanna-Attisha, Mona, et al. "Elevated blood lead levels in children associated with the Flint drinking water crisis: a spatial analysis of risk and public health response." American journal of public health 0 (2016): e1-e8. Laidlaw, Mark AS, et al. "Children’s blood lead seasonality in Flint, michigan (USA), and soil-Sourced lead hazard risks." International journal of environmental research and public health 13.4 (2016): 358. United Way of Genesee County, MI. http://www.wnem.com/story/30995770/united-way-estimates-cost-of-helping-children-100m. Accessed on 6/6/2016

4 Our Effort 5 • Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network are reaching out to help the Flint community and our members who may be affected by lead exposure in drinking water. • The primary short-term goal of the outreach program is to ensure all young children (aged 0-6 years) and pregnant women in Flint are tested for lead exposure. • The long term goal is to ensure children’s long term health services needs are met.

5 Objectives 6 • To demonstrate how medical claims data can be used to assist with provider-driven and health plan-implemented outreach programs by identifying potentially affected members who should be screened for high blood lead levels. • To demonstrate how medical claims can be used as a surveillance tool.

6 Outreach Program 7 Identify BCBSM Ongoing Members Outreach Surveillance • Letters to the • Short term • Young children (0-6 children’s (0 -6 years) • Tracking lead testing years) and women of childbearing age (15-44 families and primary care years) • Physician organizations utilization • BCBSM nurses direct • Case management if outreach lead level is high • Long term • Behavior health services needs

7 Methods 8 • Design: A longitudinal, descriptive study was conducted using Blue Cross Blue Shield of Michigan commercial data. • Identification of potentially affected children (0- 6 years) and women of childbearing age (15-44 years). • Time period: April 2014 through December 2015 • Zip codes: seven Flint zip codes • Current and relocated members since April 2014 were included

8 Methods 9 • Key information for outreach using medical claims data • Demographic (age as of 12/31/2015 and sex) • Contact information (address, phone number, etc.) • Member’s Primary Care Physician (PCP) attribution and practitioner information • Member’s group and subscriber information

9 Methods 10 • Ongoing surveillance for lead assay test • Surveillance data for lead assay test (after 04/2014) was obtained from three different sources: • Medical claims (identified using the codes below for children and women) • CPT: 83655 • LOINC_CD: '10368-9', '10912-4', '14807-2', '17052-2', '25459-9', '27129-6', '32325-3', '5671-3', '5674-7', '77307-7' • Reports from Wellness Care Management (WCM) using Michigan Care Improvement Registry (MCIR) data for children • Reports from Physician Organization (PO) for children and women

10 Methods 11 • Ongoing surveillance for primary care physician utilization • PCP visit after first lead test and April 2014 by using medical claims data for children • Any visit with professional rendering physician as PCP • No CPT code/s restrictions • Any preventive E&M Service visit with professional rendering physician as PCP • CPT: 99381-99387, 99391-99397, 99401-99429

11 Results – Demographic Distribution 12 Initial Results Female members of Total Flint BCBSM Pediatric members childbearing age Members (0-6 years) (15-44 years) Members 16,463 946 (6%) 3,455 (21%) Male 8,049 (49%) 462 (49%) - Female 8,414 (51%) 484 (51%) 3,455 (100%) Location* Moved to Flint 1,115 (7%) 84 (9%) 294 (9%) Moved out of Flint 1,729 (11%) 132 (14%) 418 (12%) Always in Flint 13,619 (83%) 730 (77%) 2743 (79%) * Both current and relocated members after 04/2014 were included.

12 Results – Lead Testing 13 Pediatric members (0-6 years) 2016 data Jan_16 Feb_16 Mar_16* April_16* May_16* Jun_16* Total number (percent) with ≥1 lead assay test since 4/1/2014 verified by claims, MCIR 336 (36%) 353 (37%) 459 (55%) 489 (70%) 495 (75%) 504 (77%) or physician organization # identified by claims 222 257 286 329 329 394 # identified by PO - - 187 257 264 289 # identified by WCM/MCIR 314 314 431 451 452 461 Lead level documented (5 µg/dL or higher) since 4/1/2014 # with high level (≥5 µg/ dL ) at least once 4 5 6 6 6 6** # with high level (≥5 µg/ dL ) based on the 4 3 3 2 2 2** most recent test performed *Members who are not exposed to Flint water crisis are excluded from the denominator and numerator over time. **So far six members had lead levels ≥5 µg/ dL since 04/2014. Four of these members were re-tested for lead and had lead levels <5µg/dL. PO = Physician Organization; WCM = Wellness Care Management; MCIR = Michigan Care Improvement Registry

13 Results – Primary Care Utilization 14 Pediatric members (0-6 years) 2016 data 3/28/2016* 4/25/2016** 05/16/2016* 06/10/2016* Total number (%) of members who had a PCP visit 249 (54%) 261 (54%) 294 (59%) 311 (62%) after 4/1/2014 and after their first lead test (Out of 459) (out of 489) (out of 495) (out of 504) Total number (%) of members who had a PCP visit 177 (39%) 179 (37%) 205 (41%) 219 (44%) for preventive service after 4/1/2014 and after (Out of 459) (out of 489) (out of 495) (out of 504) their first lead test *Members who are not exposed to Flint water are excluded from the denominator and numerator over time.

14 Results 15 First lead assay test performed (after April 2014) for pediatric members (0-6 years) 90 82 80 66 70 Members Tested 60 50 39 40 29 30 22 24 19 21 19 18 20 14 12 12 14 13 12 8 10 12 8 10 12 6 11 6 10 4 1 0 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 First Lead Assay Date

15 Conclusion 16 • ~77% (504) of children and ~12%(415) of women are now tested for lead. • Six children (0.9%) have been identified with high lead levels. • Four of them got retested and have current lead levels below 5 µg/dL (normal). • A steady number of children got their first lead assay test between April 2014 to August 2015. We see an increasing trend with more children who got their first lead test in the last six months. • ~62% of members had a PCP visit and ~44% had a PCP visit for preventive service after 4/1/2014 and after their first lead test based on the most current medical claims data. • 241 (25%) of members were later excluded (on monthly basis) because they self-reported not being affected by the Flint water crisis (most of them indicated that they have well water or other types of water systems).