As Maryland health officials prepare for nationwide health reform, the goal is clear: enrolling the state's estimated 800,000 uninsured residents. But finding them is a challenge.
There is no master list or map of the uninsured, who make up 14 percent of the state's population. And though census data can identify concentrations, including those in Baltimore City, Price George's County and the rural Eastern Shore, it doesn't provide detailed information about neighborhoods that should be targeted.
To close that gap, officials are using upgraded electronic health records to develop maps highlighting where Marylanders overuse emergency rooms for care — one indicator of the uninsured — or where pockets of disease develop. New surveys could break health demographics down to the community level. And community health groups and state health leaders plan to flood pharmacies, grocery stores and street festivals this fall to find those who need care but are unaware of their options.
"Understanding where health care problems are and how they can be prevented is a critical need," state Health Secretary Joshua M. Sharfstein said, adding that the new maps "will help the state both reduce suffering and disease and control costs."
The data is important because boosting enrollment in Medicaid and in coverage sold in a new state insurance marketplace could make or break the federal reforms. With the opening of the state insurance marketplace, Maryland Health Connection, just a few weeks away, the urgency is heightened.
Those such as Nobbie Coleman, a 53-year-old East Baltimore resident, stand to gain — or miss out.
She receives some assistance under a limited state health care program, enough to cover monthly visits to a psychiatrist and quarterly visits to a doctor at Health Care for the Homeless. She has an application pending for more comprehensive Medicaid coverage.
Could she benefit from health reform's expansion of Medicaid eligibility? "I didn't hear anything about that," she said last week after picking up a prescription to treat bronchitis at the Mount Vernon Pharmacy at Fallsway.
Unknown to Coleman, state health officials say the 81,000 enrollees in her program, Maryland Primary Adult Care, are the largest group to benefit from health reform's Medicaid expansion. The program will be folded into Medicaid come Jan. 1, as long as members don't let their enrollment expire before then. MPAC, as the program is known, covers only doctor visits, prescriptions, mental health and addiction treatment and some hospital costs, while Medicaid's more comprehensive coverage includes hospice care, eyeglasses and podiatry.
A large number and mix of people enrolling in plans offered on Maryland Health Connection is a key factor in keeping prices affordable and insurance plans viable, health and insurance officials say.
The U.S. Census Bureau estimates that about 21 percent of Maryland's uninsured lived in Prince George's County and 14 percent lived in Baltimore as of 2011, with the rest scattered around the state. While their numbers are smaller, counties on the Eastern Shore have some of the highest proportions of uninsured residents, according to estimates compiled using data from federal tax returns, Medicaid and Children's Health Insurance Program participation and census forms.
Obtaining more detailed data is difficult. Officials can make some assumptions about which neighborhoods might have higher concentrations of the uninsured, based on income levels or demographics, for example. But that data can be difficult to employ practically, said Nicolette Highsmith Vernick, CEO of the Horizon Foundation in Howard County.
"It's really hard at a community level to use that to target your outreach efforts," she said.
To clear that hurdle, Horizon and Howard health officials are going further. They are following a model pioneered in Camden, N.J., to use hospital data to detect heavy users of emergency rooms and other medical care.
Partnering with the Columbia Association and Howard County General Hospital, Horizon and the county are also conducting a telephone survey modeled after a national Centers for Disease Control collection of data on health factors such as obesity, smoking and flu vaccinations. The last was conducted a year ago, with another planned for next summer.
The result is data specific to county planning areas such as Columbia, Ellicott City and Laurel — not exactly a block-by-block mapping of health disparities, but enough to give an idea where pockets of the uninsured are.
Across the state, more of that so-called "hotspotting" detection of emergency room overuse could become possible under a health information exchange that has sprouted in the past several years. Electronic records are being shared among hospitals through the Chesapeake Regional Information System for our Patients, allowing primary-care doctors to be alerted when a patient of theirs visits an emergency room, for example.
The system isn't effective at tracking insurance status, however, said David Horrocks, executive director of the information exchange known as CRISP. In many cases, insurance information included in reports at the time of a hospital admission, or even a discharge, is out of date or incorrect until later revised.
CRISP leaders plan to use the real-time data they collect on admissions to focus on improving care. Hospitals are given incentives to prevent readmissions — when a patient is discharged only to return soon with more or the same problems — but they don't necessarily know if the patient has been discharged recently from a different hospital. The information exchange will alert them, Horrocks said.
CRISP can generate maps that show where patients are overusing emergency room care, down to the ZIP code level, Horrocks said. But health officials aren't putting the data to use yet because they are still figuring out how and where to apply it.
On a larger scale, state health officials are building a collection of dozens of health indicators that show county-by-county changes in statistics such as obesity rates, infant mortality, life expectancy and access to health care. The effort started in 2011, pulling together various sources of health data that were already available, said Laura Herrera, Maryland's deputy secretary for public health services.
Given only a three-year window before health reform became effective, officials went for the "low-hanging fruit" of readily measurable and available indicators, she said. The aim is to develop more detailed maps of the indicators.
For now, Health Care Access Maryland and other groups are employing the same strategies they have used for years to reach the uninsured.
Health Care Access Maryland, which is responsible for outreach and recruitment for Maryland Health Connections and Medicaid in Baltimore City and Baltimore and Anne Arundel counties under a contract with the state health department, helped lead the state's last major recruitment for expanded Medicaid coverage in 2007.
Executive director Kathleen Westcoat said the group's strategy, based on past lessons, is to hit events where the largest number of people can be reached — events such as the coming African American Heritage Festival in Towson or Latino Fest in Anne Arundel County. The group also sent information home with schoolchildren across the region and is working with churches to get the word out.
But Westcoat acknowledged that if enrollment in new health plans is low after a few months, the group will change gears. She has found over the years that the hardest-to-reach people are found through word of mouth.
"Some people who are vulnerable are not linked to anything, and those are the trickiest people to find," Westcoat said. "Nothing beats that personal interaction. Being where people go is really critical."
For more information
To learn more about Medicaid expansion and the health insurance marketplace:
Go to: Maryland Health Connection's website at MarylandHealthConnection.gov