Say Ahhh!

Charlie Homer
President and CEO, National Initiative for Children's Healthcare Quality

In this time of agonizing about broad health care reform, I take solace in celebrating the passage of CHIPRA (the Child Health Insurance Program Reauthorization Act) just over a year ago, and focusing on its productive implementation. CHIPRA not only expanded access to health insurance for children, but--as the regular readers of this blog know--included groundbreaking activities to strengthen the QUALITY of care that children who are insured through CHIP or Medicaid receive.  These activities included substantial grants to states for demonstration projects (announced just yesterday) funding for an electronic health record that meets the specific needs of children, and two sequential activities around the measurement of quality of children's health care.

The first measurement activity mandated by the CHIPRA legislation was the creation of a "core" measurement set. The legislation called for a tight deadline, mandated the scope of the measures, and specified an inclusive process for selecting the measures. Last summer, the Agency for Healthcare Research and Quality (AHRQ) conducted a thoughtful, broadly inclusive process to create that core measurement set.

The process that AHRQ used is well described on their website. The panel included leaders of state Medicaid and CHIP programs, consumers, pediatricians and family physicians, dentists, and public health professionals. AHRQ contracted with experts to produce background information, too. The committee used a formal consensus process, voting on the validity, feasibility and importance of the measures. It then prioritized measures to make sure the set was balanced (e.g., acute, preventive and chronic care, inpatient and outpatient, and oral health). They recommended 25 measures that were subsequently reviewed by AHRQ's National Advisory Committee and ultimately the Secretary of Health and Human Services. This recommended measurement set is now out for public comment, with responses due by March 1st.

This set includes 13 measures of preventive care, 5 for management of children with acute conditions, 9 of care for children with chronic conditions, 1 of patient experience and 1 of availability. 

• Most of the preventive measures are relatively simple, emphasizing counting encounters (e.g., number of well child visits, frequency of prenatal care, and number receiving preventive dental care) rather than focusing on the content of the preventive care itself. Preventive content is addressed in assuring documentation of BMI (happily consistent with the current emphasis by the White House on obesity prevention), using standard tools for developmental screening, immunizations, and Chlamydia screening. 

• Acute care measures address appropriate use of antibiotics, catheter associated blood stream infections in intensive care inpatient settings (the only inpatient measure), counts of those EPSDT eligible children who receive dental treatment and counts of emergency departments visits in a population (presumably an outcome measure assessing prevention and integration of care more than quality of acute care itself). 

• The most common chronic conditions in childhood are addressed through a simple outcome measure for asthma (number of children over one year old with one or more asthma related emergency room visits), follow up for children on a medication for ADHD, follow up after mental illness hospitalization, and assessment of hemoglobin A1C for children with diabetes. 

• Rounding out the set, the list includes the CAHPS Health Plan survey including supplemental items for Medicaid and Children with Chronic Conditions and an indicator of access to primary care practitioners.

One can quibble with some of the measures (e.g., the inclusion of children under two in the asthma measure given the difficulty of diagnosis, the accuracy of coding, and effectiveness of treatment in that age group) and lament the generally low bar the measures establish (e.g., counts of visits receiving more emphasis than content). I also believe the committee could have recommended the measurement of the "medical home" through the use of the CAHPS survey rather than defer this measurement to the future.  

Congress recognized that any initial measurement set would be inadequate and specified that CMS create a program to develop new measures to address gaps in the core measurement set. Indeed, this week, AHRQ is convening a panel to recommend criteria for the measures under this new program. The committee highlighted gaps in their measurement set, specifically highlighting the need for better measures of mental health and substance abuse service, inpatient and specialty care, duration of enrollment and coverage, medical home, and other means of care integration, and availability of services. We at the National Initiative for Children's Healthcare Quality--working with the National Quality Forum--recently convened an expert group that identified additional gap areas such as care coordination, broader indicators of population health, and special topics such as pediatric palliative care. We anticipate the Secretary will be seeking public comment on which topics the new program should address.

But, overall, for now, rather than critique the current set, it is far more important to commend the committee, AHRQ, CMS, and the Secretary for moving quickly, transparently and yet rigorously to assemble a thoughtful and credible measurement set. We should also urge HHS to move on to establishing effective mechanisms for collecting and reporting these data across all types of care provided in Medicaid and CHIP programs (e.g., fee-for-service and primary care case management as well as managed care), for encouraging universal, standardized reporting (not required under CHIPRA), and for assisting states and delivery organizations in using these data to improve care.

The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

Just as Washington is finally thawing out from under all the snow, it seems that health reform was dug out too with the release today of President Obama's health reform proposal.  The President's plan sets the stage for the bipartisan health reform summit that the White House is convening on Thursday. In an effort to add more transparency to the legislative process, the meeting will be streamed live.  For those of you unable to watch, we'll fill you in via this blog.

In his proposal, the President lays out a clear roadmap of policies that he wants included in a comprehensive health reform bill. The basic framework is the same as leading bills developed in Congress over the past year of debate: insurance market reforms, new health insurance Exchanges and subsidies for those who need help purchasing coverage, an individual mandate to obtain coverage (with exceptions for those at lower incomes and those paying too much in premiums), and a number of health care delivery and access initiatives. 

But, the new proposal adds improvements aimed at addressing concerns with the earlier congressional proposals, including provisions to strengthen the affordability of coverage, changes to the structure of the excise tax on high-cost plans, and new authority for the Secretary of HHS to monitor and, if appropriate, address sharp increases in health insurance premiums.

The President's proposal does not include legislative language so we don't have all the "nitty-gritty" details that some of us are eager for.  But, here is a quick read on where it lands on the key issues affecting children and families (CCF has also released a fact sheet on the proposal):

• Expands Medicaid up to 133% FPL and addresses some of the controversy over the financing of this coverage. The so-called "Cornhusker" fix, which gave Nebraska special help in coping with the new Medicaid costs, was eliminated. Instead, borrowing from both the House and Senate bills, all states would be eligible for a Medicaid matching rate (for those newly-eligible) of 100% for 2014 through 2017, 95% for 2018 and 2019, and 90% in subsequent years.
• States that have already expanded Medicaid to adults (up to 100% FPL) would receive a matching rate increase of eight percentage points "on certain health care services".
• CHIP would be continued through fiscal year (FY) 2019, with funding through FY 2015. States would receive a 23-percentage point increase in their CHIP match beginning in FY 2016.
• Stronger affordability protections (relative to the Senate bill) would be in place so that individuals and families purchasing coverage through the Exchange at 100% FPL would pay no more than 2% of their income and those at 300% up to 400% FPL would pay no more than 9.5%. Cost-sharing assistance would also be provided to families up to 250% of the FPL.
• Simplification measures for Medicaid, CHIP, and subsidies including using modified adjusted gross income (as in the House bill), a 5% income disregard for Medicaid eligibility to ensure coordination between the programs, and "seamless enrollment". Medicaid and CHIP individuals would enroll through "streamlined, easy to use, State-by-State websites".

With the release of the President's proposal, health care reform once again takes center stage. Stay tuned as we explore the implications for children and families. 

In this often-called "unprecedented" economic recession, it is easy to become jaded by the dire statistics thrown our way. This week however, the Kaiser Commission on Medicaid and the Uninsured (KCMU), gave us a positive number to consider:  over the last year, 3.3 million more uninsured people (2 million who were children) were able to rely on Medicaid for health coverage. According to KCMU, this was the largest one-year increase in terms of numbers of people in the history of the program.  When you think about it, it should come as no surprise.  Since most people receive their health coverage through their jobs, the current high unemployment rate equates to millions of families also losing health coverage. Fortunately for these families, they were eligible for Medicaid (or CHIP) and did not have to forgo doctor's visits for themselves or their children. 

But unfortunately, at the same time that many more families are seeking a safety valve to help them through these insecure times, states are facing their own economic uncertainties. Decreased revenues coupled with increased demand for services have put a strain on states, with a number considering Medicaid cuts just when families need it the most. A number of states have been able to hold the line due to a temporary increase in their Medicaid matching rate that was included in the stimulus bill. Since a condition of receiving the enhanced match was that states not cut Medicaid eligibility (referred to as a maintenance-of-effort requirement), the funding was critical in ensuring that the growing ranks of families needing Medicaid could obtain that care.

The KCMU report shows however that with the FMAP increase ending December 31, 2010, states are again looking at dramatic enrollment increases that they cannot sustain. As I previously described on this blog, the President's proposed budget includes a six-month expansion of the FMAP increase. There are also legislative proposals to do the same, including the House's inclusion of an extension in its "job's bill".  Families USA released a report this week that explains the positive impact the FMAP increase and the maintenance-of-effort requirement has had for families, and what they could lose if it is not extended.

Let's think about that number again: Medicaid enrollment increased by over 3 million individuals. That is a lot of families who are struggling, and it is wonderful that this help is available to them (and hopefully will continue to be). But lets also not forget the millions more who became uninsured but were not eligible for Medicaid or CHIP. We will report next week on the President's health care summit for solutions put forth to address the growing ranks of the uninsured.

By Gary Brunk

President & CEO, Kansas Action for Children

"I just couldn't believe the state would cut personnel on a program that's for kids," commented Harold Stultz to a reporter from the CBS affiliate in Wichita, Kansas. 

According to a local television news report, Harold's 12-year-old son Keenan had injured his knee during a wrestling match.  Harold believed that Keenan was covered under HealthWave, the state's Medicaid and CHIP program, but was surprised to learn that the application had never been processed because of a backlog. 

In fact, Keenan is one of many children in Kansas waiting for health care coverage because the state has not been able to process their applications.

The need for health coverage has been growing as the number of uninsured children in Kansas climbed from 51,000 to 72,000 in just three years.  The pool of potential applicants was further expanded on January 1 of this year, when income eligibility for HealthWave increased from 200 to 250 percent of the federal poverty level.

Cuts in funding that reduce the state's ability to process applications, on top of the increase in demand, add up to a large backlog of unprocessed applications, now at around 20,000.  The state is taking steps to simplify the application and renewal process that should result in long-term improvements, but the ongoing recession and a projected state deficit of around $400 million for the next fiscal year mean that reducing the backlog in the short-term will be extremely difficult.

The situation in Kansas underscores the pressing need for further fiscal relief for the states, and in particular for the FMAP extension proposed by Senators Rockefeller and Reid.

For self-employed Harold Stultz, the backlog means his family has $6,000 in medical bills they need to cover.  But Harold knows he is not the only one affected.  "It...upsets me even more that there are more people in my situation," he says.  

How will Congress respond to the predicament of Harold's family - and the predicament that so many other families find themselves in during these tough economic times?

The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

Express Lane Eligibility (ELE) is a relatively simple concept. There are millions of uninsured children eligible for Medicaid and enrolled in other public programs, like school lunch or food stamps. Since they serve the same populations and families have already submitted relevant information, we can create connections between the programs in order help more children access affordable health coverage. Such a commonsense approach doesn't sound like it should be too heavy of a lift, but once you get below the surface you'll find many layers that have to be peeled back.

As in many things in life, public programs have a tendency to operate within silos, each having its own applications, staff, rules, and computer systems. I witnessed this first hand when working for The Children's Partnership (the first group to use the term Express Lane Eligibility) in California to link free school lunch with Medicaid/CHIP (Medi-Cal and Healthy Families in the state). From legislation to implementation, it was really rewarding but tough: it hadn't been done before, the culture of working across programs wasn't there, and the different federal rules governing the programs were a mine field. We had mixed results, which you can read more about here.