Children and Access to High Quality Care: Future Directions

1
Children and Access to High Quality CareFuture
Directions

• Karen Davis
• Family Voices National Conference
• May 24, 2007
• kd_at_cmwf.org
• www.commonwealthfund.org

2
What Does it Take to Have a High Performance
Health System for All Children?

• Health insurance for all children that ensures
  access to effective care
• A health care system organized to meet the needs
  of patients and families that ensures accessible
  and coordinated care
• Effective strategies for enhancing value and
  aligning incentives for providers and patients
• Benchmarks for safe, effective, efficient care
  that are pursued by all providers and continually
  raised, and a health system that has the capacity
  to innovate and improve
• A coherent set of health care policies achieved
  through national leadership, public/private
  collaboration, and patient/family involvement

3
U.S. Health System Performance Where Do We
Stand?
4
What Are the Problems?
Uninsured Rates
Costs of Care
Fragmented care and insurance system
Quality of Care Chasm
5
Percent of Uninsured Children Declined Since
Implementation of SCHIP but Gaps Remain
ACCESS UNIVERSAL PARTICIPATION
Data Two-year averages 19992000 and 20042005
from the Census Bureaus March 2000, 2001 and
2005, 2006 Current Population Surveys. Estimates
by the Employee Benefit Research Institute.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
6
What Does it Take to Have Insurance You Can Count
On?

• Expansion of coverage to all children
• Incremental steps that would help
• Expansion of SCHIP to children in families with
  incomes up to 300 of federal poverty level
• Raising age of eligibility for Medicaid/SCHIP to
  25 or 29
• Covering parents of all eligible children
• Retaining coverage under parents health
  insurance to age 25 or 29
• Enacted to age 30 in New Jersey 5 other states
  have raised beyond age 18
• Proposal to raise age to 30 and mandate coverage
  of college students in Pennsylvania
• Eliminating two-year waiting period for coverage
  of disabled under Medicare
• Letting Medicaid/SCHIP beneficiaries retain
  coverage when otherwise become ineligible by
  paying an income-related premium through the tax
  system

7
Strong Support for Eligibility Expansions under
SCHIP
What is your opinion about who SCHIP should
cover going forward?"
Percent
88
91
82
80
73
51
14
Source Commonwealth Fund Health Care Opinion
Leaders Survey, April 2007.
8
What Does it Take to Have Accessible and
Coordinated Care?

• Every child enrolled in a medical home
• Medical home required to meet standards of
• Accessibility during the day, nights and
  weekends, by e-mail
• Care coordination, including specialty care
• Comprehensive services
• Clear communication
• Treating family with respect
• Preventive and developmental services
• Information for patients and families
• Example NCQA Physician Practice Connection tied
  to patient surveys about care experience

9
Children with a Medical Home, by Top and Bottom
States, Race/Ethnicity, Family Income, and
Insurance, 2003
QUALITY COORDINATED CARE
Percent of children who have a personal doctor or
nurse and receive care that is accessible,
comprehensive, culturally sensitive, and
coordinated
Child had 1 preventive visit in past year
access to specialty care personal doctor/nurse
who usually/always spent enough time and
communicated clearly, provided telephone advice
or urgent care and followed up after the childs
specialty care visits. Data 2003 National Survey
of Childrens Health (HRSA 2005 retrieved from
Data Resource Center for Child and Adolescent
Health database at http//www.nschdata.org).
10
At Least Half of Children and Youth with Special
Health Care Needs without a Medical Home
Percent of CYSHCN without coordinated, ongoing,
comprehensive care within a medical home
Source The Commonwealth Fund, calculated from
the National Survey of children with Special
Health Care Needs, 2001.
11
How Should Payment be Designed to Enhance Value?

• Medicaid payment to managed care plans and
  providers that rewards high quality and
  accessible care
• Monthly care coordination fee to medical home in
  Medicare, Medicaid/SCHIP, and commercial plans
• Adequate Medicaid payment for dental and mental
  health care to ensure provider participation and
  accessibility

12
Building Quality Into RIte CareHigher Quality
and Improved Cost Trends
Cumulative Health Insurance Cost Trend Comparison

• Quality targets and incentives
• Improved access, medical home
• One third reduction in hospital and ER
• Tripled primary care doctors
• Doubled clinic visits
• Significant improvements in prenatal care, birth
  spacing, lead paint, infant mortality, preventive
  care

Percent
Source Silow-Carroll, Building Quality into
RIte Care, Commonwealth Fund, 2003. Tricia Leddy,
Outcome Update, Presentation at Princeton
Conference, May 20, 2005.
13
What Does it Take for All Children to Have the
Best Care?

• Information on provider quality and patient
  outcomes
• Payment system that rewards quality
• Quality measures specific to childrens health
  needs and benchmarks on top performance
• Spread of best practices
• Research on comparative effectiveness

14
Quality of Adult and Child Health Care
Percent receiving recommended care
Source McGlynn et al, NEJM 2003, 348 26 2635-45
15
Practices Can Improve Quality Utah Collaborative
Percent of children receiving
Source Young PC et al. Pediatrics
20061171469-76
16
What Policies are States Implementing to Achieve
High Performance Health System for Children?
17
Selected State InnovationsImproving Access and
Qualityfor Children

• Illinois All Kids insurance initiative
• Illinois Assuring Better Child Health and
  Development Healthy Beginnings -- Screening for
  Maternal Depression
• North Carolina Assuring Better Child Health and
  Development Developmental Screening
• Minnesota P4P to Promote Developmental and
  Socio-Emotional Screening
• Vermont Child Health Improvement Project
  Improvement Partnerships
• Connecticut Help Me Grow
• North Carolina Fluoride Varnish By Pediatricians

18
Moving ForwardAddressing Access, Quality, and
Healthy Lives
19
A High Performance Health System for Children

• Coverage
• Universal health insurance coverage for children
  is key
• Quality
• Need better quality measures and transparency in
  reporting on quality of care for children
• Need to build quality standards into coverage
  programs
• Payment
• Need payment systems for childrens health care
  that rewards quality and efficiency, medical
  homes
• Organized Care
• Need new models of care that ensure
  family-centered, accessible and coordinated care
• Adoption of health information technology and
  accessibility of information and care by Internet
  and e-mail
• Investment in high performance pediatric care
  workforce team approach to care
• National goals and priorities public-private
  collaboration

20
A Policy Agenda for Childrens Health

• Reauthorization of SCHIP
• Expansion to more uninsured children
• Quality standards
• Issues Funding levels? Source of funding?
• Medical home demonstrations that are tied to
  payment, involve public and private payers, and
  test the model for all children
• Public reporting of access, quality, and
  childrens health outcomes
• Pay for performance
• Rewarding childrens health service quality in
  Medicaid/SCHIP
• Improving accessibility of dental and mental
  health services for children including special
  needs children
• IT and health information networks/exchanges
• Supporting state innovations
• Insurance coverage for all children
• Quality and child development innovations

21
Thank You!
Melinda Abrams, Senior Program Office, Child
Development and Preventive Care, Patient-centered
Primary Care, mka_at_cmwf.org
Ed Schor, M.D., Vice President, Child Development
and Preventive Care, els_at_cmwf.org
Anne Gauthier, Senior Policy Director, Commission
on a High Performance Health System, ag_at_cmwf.org
Rachel Nuzum, Senior Program Officer, State
Innovations, rn_at_cmwf.org
Stephen C. Schoenbaum, M.D., Executive Vice
President and Executive Director, Commission on a
High Performance Health System, scs_at_cmwf.org
Katie Shea, Research Associate. ks_at_cmwf.org
Visit our website www.commonweathfund.org
22
AppendixSelected State Innovations
23
Illinois All-Kids

• Effective July 1, 2006
• Available to any child uninsured for 6 months or
  more
• Cost to family determined on a sliding scale
• Linked to other public programs (FamilyCare
  KidCare)
• Federal and state funds
• Children lt200 of FPL covered by federal funds
• Children 200 of FPL funded by state savings
  from Medicaid Primary Care Case Management
  Program
• All-Kids Training Tour
• Public outreach program to highlight new and
  expanded healthcare programs

24
Illinois ABCD Project Healthy Beginnings
Screening for Maternal Depression
IL

• Broad-based coalition (84 members)
• New Medicaid policy
• Edinburgh Depression Scale
• Increased reimbursement for physicians (14.60)
• Training of physicians and all public health
  officials
• 1-800 consultation line for providers (funded by
  HRSA)
• Excellent relationship with EI
• Policy committee

25
North Carolina ABCD Initiative Successfully
Increased Developmental Screening
Percent of children screened with a standard
developmental screening tool
Percent Screened
Source The North Carolina ABCD Project A New
Approach for Providing Development Services in
Primary Care Practice. August 2002.
26
Minnesota to Implement P4P to Promote
Developmental and Socio-Emotional Screening

• Medicaid will pay a financial incentive to
  contracted health plans in 2007 for increasing
  use of objective developmental screening tools.
  Plans will receive
• 20.00 for each developmental screen above
  previous years rate for children 0 to 6
• 25.00 for each mental health screening of a
  child age 0 to 21

Source N. Kaye, J. May, and M. Abrams, State
Policy Options to Improve Delivery of Child
Development Services Strategies from the Eight
ABCD States, National Academy for State Health
Policy and The Commonwealth Fund, December 2006.
27
Improvement Partnerships
Practices in NC and VT improve developmental
services

• A durable, public-private regional QI
  partnership improving systems of care
• Broad participation
• 85 of pediatric practices (n33)
• 23 of family practices (n24)
• 27 of OB practices (n7)
• 100 of hospitals (n11)

28
Improving CoordinationHelp Me Grow Program

• Statewide, toll-free telephone number for
  referral
• Connect to Care Coordinators
• Child Development Community Liaisons
• Replication potential New Mexico, Hawaii, Iowa
  and Orange County, CA
• Web-based toolkit for providers

Children Identified
Source The Commonwealth Fund. Data from Dworkin,
P. Help Me Grow Project. Hartford, CT 2005.
29
North Carolina Fluoride Varnish By Pediatricians

• Reform
• Targets high-risk infants/toddlers under 3
• Varnishing done in well-child care setting
• Up to 6 fluoride applications, anticipatory
  guidance
• Payment to MEDICAL providers
• Impact
• 212,000 procedures in 3 years
• 40 of children under 3 treated
• Evaluation underway, simulated cost savings
• National Trend Awaiting evaluation, high interest

Source The Commonwealth Fund, from Edelstein, B.
Improving Early Childhood Oral Health, March
2006.