CHIP Quality and Performance Monitoring

1
CHIP Quality and Performance Monitoring

• Wendy J. Wolf, MD, MPH
• Senior Policy Fellow
• Health Resources and Services Administration
• Agency for Health Care Policy and Research

2
Objectives

• Who are the CHIP kids?
• Quality Issues
• What is it?
• Why is it important?
• Attributes of quality medical care
• Review the quality/performance measures proposed
  for CHIP
• Problems in quality monitoring for child health
• Strategies to promote quality care

3
Who are CHIP children?What do we know about
their health needs and utilization?
4
Who are the uninsured?

• Uninsured children are more likely to
• Be teenagers (ages 13-17)
• Be Hispanic
• Live in single-parent families
• Have parents with little education
• Live without employed parents
• Live outside of metropolitan service areas

RM Weinick
5
What Does Providing Insurance Do for Uninsured
Children?

• Study of western PA CHIP program
• Insurance enrollment improved access
• Regular source of care increased (89 to 99)
• Regular dentist (60 to 85)
• children having unmet need or delayed care
  decreased from 57 to 16
• children seeing MD increased (59 to 64),
  while ER visits fell (22 to 17)

6
What Constitutes Quality of Health Care?

• Quality of care is the degree to which health
  services for individuals and populations increase
  the likelihood of desired health outcomes, and
  are consistent with current professional
  knowledge.
• - Institute of Medicine/Lohr, 1990
• Quality of care is doing the right thing for the
  right person at the right time.
• - John Eisenberg, M.D., 1997

7
(No Transcript)
8
Nine Key Elements Defining Quality Medical Care
for Children

• Accessible
• Convenient
• Practical
• Affordable
• Continuous
• Comprehensive
• Coordinated
• ACCOUNTABLE

• Clinically Effective
• Up to date, appropriate diagnostics treatments
• Child-centered
• Includes families in decision-making
• Community-oriented
• Culturally competent

9
Quality / Performance Assessment in the new Title
XXI (CHIP) programs
10
Types of CHIP programs (2/22/99)Yellow
Medicaid Expansion Red Separate PlanBlue
Combination Program Gray Not submitted
11
In their CHIP proposals, States will

• assure the quality and appropriateness of care,
  and
• Describe how performance under the plan will be
  measured through objective, independently
  verifiable means and compared against performance
  goals in order to determine the states
  performance..

12
SUGGESTED PERFORMANCE INDICATORS LISTED ON
TITLE XXI APPLICATION

• 9.3.4. The extent to which outcome measures show
  progress on one or more of the health problems
  identified by the state.
• 9.3.5 HEDIS measurement Set relevant to children
  and adolescents younger than 19.
• 9.3.6. Other child appropriate measurement set.
  List or describe the set used.
• 9.3.7. If not utilizing the entire HEDIS set,
  specify which measures will be collected, such
  as
• Immunizations Well child care
• Adolescent well visits Satisfaction with care
• Mental Health Dental care

13
48 (States DC) CHIP PLANSQUALITY/PERFORMANCE
MEASURES

• Complete HEDIS 3.0 measures selected by 17 States
  (35)
• Selective HEDIS 3.0 measures selected by 26
  states (54)
• No HEDIS measures selected by 5 states (10)

14
Consumer Satisfaction

• Measure of States
• HEDIS 3.0 survey 18
• CAHPS survey 11
• (as part of HEDIS or separate)
• Other survey (unspecified) 21
• No assessment 8
• Consumer education materials 22
• Cultural competency focus 3

15
Problems with CHIP Quality/Performance Evaluation

• Lack of good baseline data
• Inadequate data information systems for baseline,
  tracking, comparisons
• Lack of measurement uniformity
• No mechanism for risk adjustment
• Changing insurance status
• No accepted national standards

16
Other Problems with CHIP

• Little information about provider and health care
  system capacity.
• Mental and behavioral health care system needs of
  CHIP kids have probably been underestimated.
• Access to dental care is the first problem to
  solve before we focus on performance.

17
Quality Issues for Childrens Health Care
Requires a Special Focus

• Children are not just little adults.
• Children are dependent.
• Care is rendered within a family context.
• Optimal health care for children goes beyond
  traditional medical care.

18
Other Challenges in Quality Assessment for
Children

• Children are healthy with a low incidence and
  prevalence of disease
• Large part of care is preventive
• Hard to assess long term outcomes
• Limited research base
• Indicators have to be age-appropriate and
  developmentally appropriate
• Family focus

19
QUALITY ISSUES

• What gets measured, gets done,
• However, measurement alone
• does not insure quality.

20
Quality Varies Variations in Immunization Rates
Selected Regions
Selected Plans
SOURCE NCQA, HEDIS data, 1996
21
Assessing the national impact of CHIP

• State-specific measures
• Aggregate State measures
• National data sets

22
State-specific measures

• Know whats in your States quality/performance
  plan
• Monitor performance in conjunction with other
  State-specific measurement sets
• Title V performance measures
• State National Immunization Survey
• Vital Statistics
• Urban Institute Study in 13 States

23
Aggregate State Measures

• Aggregate State reporting data can
• be used to assess the national
• impact of CHIP for those aspects
• of care that have been
• comparably measured

24
National data sets that can provide information
about CHIP/Medicaid

• CPS (Census) - assess changes in
  insurance/uninsured status but is not a health
  care questionnaire.
• NHIS (NCHS/CDC) and MEPS (AHCPR) - assess income,
  insurance status, usual source of care, type of
  health care contact, health status, immunizations
• NIS (CDC) - can assess immunization status for
  different income groups but does not have
  insurance information

25
What role can MCHB States play in improving
quality?

• Know what services are
• being purchased in contracts.
• Encourage high quality through purchasing
  strategies
• Provide high quality services
• Measure the quality of care
• Inform consumers
• Protect consumers