CHIPRA Strengthening Quality of Children’s Health Care – Say Ahhh! A Children’s Health Policy Blog

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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

  • 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.

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