SCHIP: Reauthorization, Increased Cost Sharing, and Quality Initiatives

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SCHIP Reauthorization, Increased Cost Sharing,
and Quality Initiatives

• Betsy Shenkman
• Institute for Child Health Policy
• Department of Epidemiology and
• Health Policy Research
• University of Florida
• June 2006

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Key Issues

• State policy changes and increased cost sharing
• Quality initiatives Whats required? Whats
  novel?

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• Illustration of Policy Changes in Two States

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(No Transcript)
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Florida Title XXI Enrollment and Major Program
Changes
336,689

• Fall 2004
• Premium non-payment penalty reverts to 60 days
• Reinstatements allowed if in the data system
  before 3/12/04
• Hurricane Relief Provisions No disenrollments
  for failure to provide renewal documents or
  failure to pay premiums, credits for those who
  did pay (3 months)
• December 04
• Open enrollment announced
• Disenrollments for renewal non-compliance and
  unpaid premiums implemented
• Legislature reduced income documentation
  requirements

331,281
326,755
323,262
Apr. 04 Begin enrolling Title XXI Wait List
322,997
315,222

• July 03
• No Growthbudget enacted
• Program over-enrolled, wait list started
• No Title XIX toTitle XXI transfers
• Federal and state funding for Florida KidCare
  Outreach eliminated

• Dec. 03
• 6-month cancellation for premium non-payment
• No reinstatements for breaks in coverage
• Jan. 04 Only CMSN accepts Medicaid to Title XXI
  transfers (ended Mar. 04)
• Mar. 04 Legislation enacted wait list funded,
  other program changes

• July 04
• New income documentation access to employer
  health insurance requirements (delayed due to
  hurricanes)
• New enrollees accepted only during open
  enrollment
• Loss of Medicaid for over-income eligible to
  apply outside of open enrollment, 7/1/04
• FY 04-05 Appropriated Avr. Monthly Caseload
  389,515

264,278
252,209
July 05 Year-round open enrollment
reinstituted application valid for 120 days FY
05-06 Appropriated Avr. Monthly Caseload 388,862
220,533
Aug. 05 Back-to-School campaign, post cards
Jan. 05 Open enrollment Jan. 1-30, 2005
applications processed, children enrolled
(ongoing)
202,433
202,615
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Cost Sharing

• Increased cost sharing in the form of increased
  premiums a large portion of the changes
• Important issue because of Deficit Reduction Act
  of 2005 so lessons to be learned for SCHIP and
  Medicaid

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Florida Premium Changes
Family Income PFPM Premium Amount PFPM Premium Amount PFPM Premium Amount
Family Income Prior to July 2003 July 2003 September 2003 October 2003 Forward
101-150 FPL 15 20 15
151-200 FPL 15 20 20
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Cost Sharing

• Using Florida data, accelerated failure time
  model (AFT) enrollment length
• Opportunity to examine potential changes in
  behavior across time and with shifting premiums
• Followed 153,768 Title XXI children from July 1,
  2002 to June 30, 2004
• Included age, gender, and health status in our
  analyses

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Enrollment Length Ratios By Income and Premium
Amount
Time Ratio
Premium 15
Premium 20 for 151-200 FPLPremium 15 for
101-150 FPL
Premium 20
3
2
1
101-150 FPL
151-200 FPL
Time
Jul-02
Jul-03
Oct-03
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Interaction of Premium Change and Health Status

• Children were classified into health status
  categories using the Clinical Risk Groups
• Interaction between premium and health status not
  significant for children with moderate chronic or
  major chronic conditions
• In the short-term enrollment duration decreased
  for children who were healthy, had significant
  acute or minor chronic conditions and were above
  150 FPL and then increased but not back to
  baseline levels.

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Quality of Care in SCHIP

• Annual CMS Report - Core quality measures
• Well child visits first 15 months of life
• Well child visits 3rd, 4th, 5th, and 6th years
• Appropriate medications for children with asthma
• Access to primary care practitioners

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Quality of Care in SCHIP -Mathematica Study

• 2005 report based on SFY 2003 Reporting
• Core Measures reported
• 8 states use 4 measures
• 18 states use 3 measures
• 7 states use 2 measures
• 3 states use 1 measure
• 14 states use no measures

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Quality of Care in SCHIP -Mathematica Study

• Most frequent well child in 3rd, 4th, 5th, 6th
  years 33 states (13 to 73 compliance)
• Least frequent asthma medications 15 states
  (52 to 70 compliance)
• Goal Re Quality
• Improve consistency of reporting
• Report something
• Use performance data for quality improvement

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Published Reports Quality of Care in SCHIP

• Primary focus on access to care usual source of
  care
• Continuity of care continuity with usual
  provider
• Utilization of specific health services
• Usually parent report
• See increase in those with USC, greater
  continuity, increased reports of preventive care
  visits

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Illustration Texas Value-Based Purchasing
Initiative

• Concept - buyers should hold providers of health
  care accountable for both cost and quality of
  care
• HEDIS core measures and Consumer Assessment of
  Health Plan Survey (CAHPS) results reported
• Additional adult measures used
• Reported in a quarterly chart book by plan,
  service delivery area, and overall
• Annual encounter data certification and
  validation performed

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Illustration Texas Value-Based Purchasing
Initiative

• Established standards usually average of
  Medicaid plans reporting to NCQA
• Validated calculations with the health plans
• Three year process to reach validation stage
• Plans submit goals to state health plan managers
  and report on strategies to improve performance
• SFY 2007 3 goals and measures increase to 5-7
  per year

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Examples - Chart 17. HEDIS Well-Child Visits in
the 3rd, 4th, 5th, And 6th Years of Life-TANF
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Illustration Texas Value-Based Purchasing
Initiative

• Health plan meetings and workgroups
• Meet with state plan managers on status
• Financial incentive
• 1 of premium at risk
• Unearned funds available to those plans that
  excel on selected measures
• Exceptional performance additional 0.5 of
  available funds
• Liquidated damages and remedies

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Outcomes?

• Even prior to implementation of value-based
  purchasing seeing indicator improvement
• Some studies modest to no performance increases

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Pay for Performance

• CMS/Premier P4P demonstration
• Mostly private sector interest
• Interest in Medicare
• Some states P4P in Medicaid
• New York, Michigan, California, RI, NC, PA
• New York 1 of premium and may increase to 3
  of premium

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Potential Obstacles

• Credibility of information
• Lack of dissemination
• Information not being used to initiate change
• Time, effort, and expertise
• No requirement

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Summary

• Cost sharing changes, among others, have an
  impact on enrollment and access
• Little required in terms of quality measurement
  and little is known
• Some innovations with financial incentives but
  outcome uncertain