Improving Healthcare for ALL Colorados Children

1
Improving Healthcare for ALL Colorados Children

• James K. Todd, MD
• Disclosures
• 1. Advisor to Procter Gamble (tampon safety)
• 2. Participated in the ups and downs of 40 years
  of pediatric health care
  improvement

2
Of the forty-five pediatricians in the city,
only two would accept a new Medicaid patient at
their office. Their reason is one of economic
survival. . So although all of the pediatric
practices in the city have some Medicaid
patients, virtually none can afford to accept
many more. Fortunately, we do have a Community
Health Center in Colorado Springs, at which
nearly half of the patients are children on
Medicaid. But this facility cannot and should not
be asked to care for all such children in the
city. All of this has caused predictable results.
Children on Medicaid with chronic conditions such
as asthma or diabetes often cannot find a
physician. Without regular care, they appear in
hospital emergency rooms critically ill. They are
then admitted to intensive care units such as
mine, where they often require many days of very
expensive therapies. The irony is, although
Medicaid is willing to pay my hospital thousands
of dollars for intensive care, it is unwilling to
pay an office pediatrician to provide care that
could have prevented the intensive care admission
in the first place.
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Childrens Hospital Collaborators for quality
healthcare for All Colorado children partial
list

• Business Colorado Forum, Metro Denver Chamber
  of Commerce
• Foundations
• The Piton Foundation
• Colorado Trust
• The Community Child Health Foundation
• The Colorado Health Foundation
• Rose Community Foundation
• Caring For Colorado
• The Denver Foundation
• University of Colorado School of Medicine
• Hospitals University Hospital, Denver Health
• FQHCs Neighbor Health Centers
• Professional Organizations - American Academy of
  Pediatrics, Colorado Academy of Family
  Physicians, Colorado Medical Society
• Advocacy Groups Colorado Coalition for the
  Medically Underserved, Colorado Childrens
  Campaign
• Colorado Legislators Administration
• CDPHE
• HCPF
• And many others..

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History of Advocacy Leadership

• Child Health Plan, 1990
• SB 25 (S. Berman)
• Uninsured children not covered by Medicaid
• After-hours phone triage system (B. Schmidt, S.
  Poole),1993
• Poole SR, Schmitt BD, Carruth T, Peterson-Smith
  A, Slusarski M. After-hours telephone coverage
  the application of an area-wide telephone triage
  and advice system for pediatric practices.
  Pediatrics. 199392670-679
• Colorado Childrens Immunization Coalition,
  1991-present
• Sponsored by The Childrens Hospital and included
  a wide variety of participants, including
  physicians, insurance providers, parents and
  state officials
• Child Health Plan , 1997
• Response to initial SCHIP legislation (S.
  Berman)
• Colorado Rural Immunization Project (CRISP),
  1996-2001
• Federal Demonstration Grant (S. Berman)
• Colorado Immunization Information System (CIIS),
  1996-present
• Federal Demonstration Grant (S. Berman)
• Transitioned to CDPHE

TCH principal collaborators
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History of Advocacy Leadership

• State of the Health of Colorados Children
  Program (SHCC), 2003 (J. Todd)
• On-going Annual Measurement of
• Vaccine-preventable Diseases
• Hospitalization Rates for privately-insured and
  children with Public or No health insurance
• Mason-Dixon Colorado Survey Results, September
  2006
• Voters take the problem of uninsured children
  very seriously
• Medical Home Bill SB 07-130, 2007
• Medical Home Standards for Publicly-insured (J.
  Todd)
• Improvement to Healthcare for Children SB
  07-211, 2007
• Annual Outcomes Measurement and Reporting (J.
  Todd)
• Implementation Committees for SB-130 SB-211 (J.
  Todd, S. Poole, L. Bajaj, and others)
• Colorado Childrens Healthcare Access Program (S.
  Poole)

TCH principal collaborators
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Pioneers in population-based measurement - the
critical engine of improvement
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TCH Working to reduce vaccine preventable
diseases (CCIC, VACC. Purchasing Cooperative
Initiative)
SHCC Volume VI, Number 1 February 8, 2009
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1/3 of Colorados children dont have private
insurance
SHCC Volume VI Number 2 February 8, 2009
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.. and almost 45 of newborns
SHCC Volume VI Number 2 February 8, 2009
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Measuring Outcomes Most disparities are
increasing

• Public/No vs Private
• Increased severity of illness
• Increased chronic illness
• Increased Death Rate
• Increased admits via ER
• Increased cost of care

SHCC Volume VI Number 2 February 8, 2009
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No private insurance increases excess charges
SHCC Volume VI Number 2 February 8, 2009
12
US Hospitalization Disparities 2000-2006
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Widening disparities in US hospitalization rates
for children with Public/No health insurance
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Excess US charges if Public Private Outcomes
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Reasons why Colorado pediatricians in 2003
limited or did not accept Medicaid patients
Berman S, Armon C, Todd J. Impact of a decline
in Colorado Medicaid managed care enrollment on
access and quality of preventive primary care
services Pediatrics 2005116(6)1474-9.
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85 of Colorado pediatricians surveyed would
provide care to more Medicaid/CHP children if
barriers were addressed.
Berman S, Armon C, Todd J. Impact of a decline
in Colorado Medicaid managed care enrollment on
access and quality of preventive primary care
services Pediatrics 2005116(6)1474-9.
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(No Transcript)
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Engaging the Voters Mason-Dixon Colorado Survey
Results, September 2006

• On the issue of health care and children, voters
  take the problem of uninsured children very
  seriously 73 believe that every child in
  Colorado should be covered by a
  government-supported health care program if their
  parents are unable to afford it.

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A Sequential, Three-Phase Process to Improve the
Health Care System for Colorado Children

• Phase 1 Ensure that Medicaid and the Child
  Health Plan and their contracted providers
  provide measurable, high quality clinical care
  that is patient-centered, safe, effective,
  timely, and efficient.
• Phase 2 Enroll more uninsured children who are
  eligible for Medicaid and the Child Health Plan
• Phase 3 Expand eligibility for the Colorado
  Child Health Plan to reduce the number of
  uninsured children

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SB 07-130 Medical Home

• "MEDICAL HOME" MEANS AN APPROPRIATELY QUALIFIED
  MEDICAL SPECIALTY, DEVELOPMENTAL, THERAPEUTIC, OR
  MENTAL HEALTH CARE PRACTICE THAT VERIFIABLY
  ENSURES CONTINUOUS, ACCESSIBLE, AND COMPREHENSIVE
  ACCESS TO AND COORDINATION OF COMMUNITY-BASED
  MEDICAL CARE, MENTAL HEALTH CARE, ORAL HEALTH
  CARE, AND RELATED SERVICES FOR A CHILD.
• IF A CHILD'S MEDICAL HOME IS NOT A PRIMARY
  MEDICAL CARE PROVIDER, THE CHILD MUST HAVE A
  PRIMARY MEDICAL CARE PROVIDER TO ENSURE THAT A
  CHILD'S PRIMARY MEDICAL CARE NEEDS ARE
  APPROPRIATELY ADDRESSED.
• ALL MEDICAL HOMES SHALL ENSURE, AT AMINIMUM, THE
  FOLLOWING
• HEALTH MAINTENANCE AND PREVENTATIVE CARE
• ANTICIPATORY GUIDANCE AND HEALTH EDUCATION
• ACUTE AND CHRONIC ILLNESS CARE
• COORDINATION OF MEDICATIONS, SPECIALISTS, AND
  THERAPIES
• PROVIDER PARTICIPATION IN HOSPITAL CARE
• TWENTY-FOUR-HOUR TELEPHONE CARE.
• Instructs the state department of health care
  policy and financing ("department") to develop
  systems and standards to maximize the number of
  children who are enrolled in the medical
  assistance program or the children's basic health
  plan who have a medical home.
• Requires the department to report annually their
  progress toward maximizing the number of children
  who have a medical home

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SB 07-211 Measurement Outcomes

• Providing quality health care coverage for all
  children in Colorado, regardless of economic
  status or geographic location, is of vital
  importance to the state.
• Authorizing the appointment of a chief medical
  officer for the department of health care policy
  and financing
• THERE IS HEREBY CREATED IN THE STATE DEPARTMENT
  THE ADVISORY COMMITTEE ON COVERING ALL CHILDREN
  IN COLORADO TO PLAN AND OVERSEE THE
  IMPLEMENTATION OF A PLAN TO PROVIDE HEALTH
  COVERAGE FOR ALL LOW-INCOME CHILDREN IN OLORADO
  BY THE END OF 2010.
• THE STATE DEPARTMENT, FOLLOWING CONSULTATION WITH
  EXTERNAL CLINICAL ADVISORS, SHALL DEVELOP
  CLINICAL STANDARDS AND METHODS FOR COLLECTING,
  ANALYZING, AND DISCLOSING INFORMATION REGARDING
  CLINICAL PERFORMANCE, INCLUDING BUT NOT LIMITED
  TO IMMUNIZATION RATES, MEDICAL HOME STANDARDS,
  CLINICAL CARE GUIDELINES, CARE COORDINATION, CASE
  MANAGEMENT, DISEASE MANAGEMENT, AND COORDINATION
  AND INTEGRATION OF MENTAL HEALTH SERVICES.

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Childrens Hospital Finding solutions..
http//communitypeds.squarespace.com/cchap/
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CCHAP Services Provided

• Administrative Supports
• Enhanced Provider Reimbursement
• Enrollment Specialist And Help With Enrollment
  And Eligibility.
• Help To Streamline Administrative Processes
• Practice Administrators Network
• Family Supports
• Social Services Support
• Improved Mental Health Services
• Case Management/Care Coordination
• Asthma education
• No-shows
• ED utilization
• Immunization Registry And Reminder Recall
• Transportation
• Diversity Training For Practices
• Medical Spanish Interpretation Courses
• After-hours telephone care
• Quality Improvement Coaching
• Provider Hotline to identify all available
  services for chronically ill children

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TCH Telephone Triage Pioneers - A Fundamental
Tool of the Medical Home - Keeping Children out
of the ED Hospital
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CCHAP Providing resources for the Medical Home

• 90 pediatric offices
• Nearly 85 of pediatric practices along the front
  range
• A three year grant to recruit and support family
  practices to provide a medical home for children
• Preliminary results of CCHAP program
• ? Emergency Department Visits
• ? Pharmaceutical Utilization
• ? Home Health Utilization
• ? Net savings (Savings - Cost of services)

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ED Focus Home Care Rather than Hospitalization
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Keeping children out of the hospital
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Problems/Solutions for (Colorado) Childrens
Healthcare

• 34 Public or No Insurance
• Many eligible are not enrolled
• Many enrolled have no PCP
• Insufficient clinic capacity
• For loss reimbursement reduces access
• Medical Home not always provided
• Not all settings/PCPs provide a MH
• Not all parents take advantage of services
• Outcomes not routinely measured
• Higher morbidity
• Higher mortality
• Increased ED and Hospitalization
• Unnecessary costs ( gt 100 million)
• Cost-shifting to payers and providers
• Higher premiums
• Failed practices

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Colorado Medical Home Standards
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Pediatric Measure Advisory Group Recommendations

• The PMAG recommended a total of twenty-five
  pediatric measures, using the following
  guidelines for measure development
• 1. Align with national quality measures when
  feasible measures exist.
• 2. Review sample measures from other states.
• 3. Reach consensus on definitions of each of the
  domains in the legislation.
• 4. Utilize the following parameters to assess
  potential measures
• a. The availability and reliability of data
• b. The availability of valid measurement tools
• c. The cost of data collection and analysis
• d. The burden of data collection
• e. The potential of each measure to improve
  health outcomes
• f. The potential of a measure to improve
  efficiency and costs of care.

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Improving Primary Care Reimbursement
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Colorado Eligibility Increasing 2007-2009
? Hosp Fee
225
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Accomplishments 2008

• Increased the number of insured Coloradans by
  covering over 30,000 more children and 10,000
  more parents in the Medicaid and Child Health
  Plan Plus (CHP) programs since January 2007.
• Provided comprehensive health care, including
  linkages to community social programs (food,
  clothing, shelter), by enrolling over 60,000
  children in a Medical Home.
• Sixty-eight certified provider practices provided
  accessible, continuous, family-centered,
  coordinated and culturally sensitive care.
• Improved reimbursement rates (especially for
  preventive services)
• Jan 2009 medical home enrollment (NICHQ medical
  home index)
• 62,000 CHP
• 80,000 Medicaid (CCHAP and others)

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Steps to a State-wide Healthcare Solution

• Start with children.
• Use data to drive decisions
• Define the problem
• Measure both costs and outcomes.
• Engage with Business Government
• Make the Ethical Case.
• Make the Business Case.
• Demonstrate the solution
• Focus on a medical home (continuity, preventive
  care personal responsibility).
• Keep children out of the Emergency Departments
  Hospital
• Continually measure and improve emphasize care
  that is both effective and efficient.
• Implement an ongoing measurement system

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PMAG Measures

• 1. The percentage of children who turned two
  years old during the measurement year who had 4
  DTaP/DT, 3 IPV, 1 MMR, 3 H influenza type B, 3
  Hep B, and 1 VZV by the time period specified and
  by the childs second birthday (431331)
• 2. The percentage of eligible adolescents who
  have received recommended MMR and Tdap boosters
  by the 15th birthday
• 3. Evidence of developmental screening using a
  standardized, validated instrument at 9, 18, and
  24 (or 30) month visits or three times by age 3
  years. (Recommended tools ASQ, PEDS)
• 4. The percentage of children, 2-18 years of
  age, whose weight is classified based on BMI
  percentile for age and gender (provisional
  measure)
• 5. The percentage of infants with an oral health
  evaluation by a dentist or primary health care
  provider before age 1 (between ages 6-12 months)
• 6. The percentage of children seen for routine
  preventive dental care every six months once a
  dental home is established (beginning at age 1
  year)
• 7. The percentage of children who have received
  protective sealants on the first permanent molars
  by age 6 (or when adequately erupted)
• 8. The percentage of children who have received
  protective sealants on the second permanent
  molars by age 12 (or when adequately erupted)
• 9. The percentage of clients who were given a
  diagnosis of upper respiratory infection (URI)
  and were not dispensed an antibiotic prescription
  on or 3 days after episode date

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PMAG Measures

• 10. The percentage of clients who were diagnosed
  with pharyngitis, prescribed an antibiotic, and
  who received a group A streptococcus test for the
  episode
• 11. Child with asthma has received influenza
  immunization (done yearly)
• 12. Child with persistent asthma is on an
  inhaled corticosteroid or controller medication
  (reviewed for compliance yearly)
• 13. Child with persistent asthma has an action
  plan (reviewed yearly)
• 14. Evidence of use of a standardized, validated
  ADHD screening tool to aid in diagnosis
  (Vanderbilt, Conners)
• 15. Initiation Phase Percentage of children
  6-12 years of age as of the Index Prescription
  Episode Start Date with an ambulatory
  prescription dispensed for an ADHD medication and
  who had one follow-up visit with a practitioner
  with prescribing authority during the 30-Day
  Initiation Phase
• 16. Of the children who remained on an
  ambulatory prescribed ADHD medication for at
  least 210 days, the percentage of children 6-12
  years of age as of the Index Prescription Episode
  Start Date who, in addition to the visit in the
  Initiation Phase, had at least two additional
  follow-up visits with a practitioner within 270
  days (9 months) after the Initiation Phase Ends
• 17. Percentage of recipients who receive
  age-appropriate well-child checks, including
  vision, hearing, developmental, behavioral/mental
  health, oral health, newborn screening,
  immunizations (based on EPSDT or HEDIS well child
  schedule)

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PMAG Measures

• 18. The rates at which children with specified
  chronic, disabling, or ambulatory care sensitive
  conditions are hospitalized
• 19. Length of time on Medicaid
• 20. Identify the subgroup of children with
  Severe Emotional Disturbance (SED) and assess
  care quality in that group using the Department
  performance measures
• 21. The percentage of children with a diagnosed
  mental health condition based on the DSM IV or
  the ICD 9 who received mental/behavioral health
  services in the past six months
• 22. Evidence of psychosocial screening in all
  ages using a standardized, validated tool (e.g.,
  PSC, GAPS)
• 23. Depression management (effective acute phase
  treatment) Of adolescents started on medication,
  length of treatment with medication and
  percentage that were referred to a mental health
  provider
• 24. Adolescent suicide attempt and completion
  rates Track this measure if suicide attempt data
  is available (e.g., through Medicaid claims)
• 25. Assess specific injury rates (specify
  ICD-9/10 and E-codes)