Key Issues
SCHIP: Reauthorization, Increased
Cost Sharing, and Quality Initiatives
State policy changes and increased cost
sharing
Quality initiatives – What’s required?
What’s novel?
„
Betsy Shenkman
Institute for Child Health Policy
Department of Epidemiology and
Health Policy Research
University of Florida
June 2006
„
Texas Title XXI Enrollment and Major Program Changes
600,000
Se pt , 2 00 3
( E nr ol l ment 5 0 7 , 25 9 ) :
• Benef its el iminated f or hospi ce, skil led nur si ng, dental, tobacco cessati on, vi si on &
chir opr acti c ser vi ces
• Benef its r educed f or i npati ent &outpatient mental heal th
507,259
488,690
500,000
Oc t , 2 0 0 3
( E nr ol l me nt 4 8 8, 6 9 0 ) :
• Continuous el igibil ity r educed f r om12 to 6 months
• 90 day wai ti ng per i od bef or e cover age implemented
458,166
400,000
o 100%-150%FPL - $15 per
f amily per month
o 151%-185%FPL - $20 per
f amily per month
J a n, 2 00 4
( E nr ol l me nt
416, 302):
• Disenr ol lment of f amil ies
f or f ai lur e to pay monthl y
o 186%-200%FPL - $ 50
340,101
326,557
A ug, 20 0 4
( E nr ol l me nt 3 5 9 , 7 3 4 ) :
• Asset test i mpl emented f or
pr emiums suspended
N ov , 2 0 0 4
( E nr ol l me nt 3 4 0 , 1 0 1 ) :
• Coll ecti on of pr emiums at r enewal
f amil ies wi th i ncomes at or
above 150%FPL
o 186%-200%FPL - $25 per
Illustration of Policy Changes in
Two States
o 133%-150%FPL - $ 25
o 151%-185%FPL - $ 35
359,734
f amily per month
• Copayment changes
310,981
Sept , 2 0 0 5
( E nr ol l me nt 3 2 6 , 5 5 7 ) :
• September 2003 benef its
r estor ed &mental health
suspended
i mpl emented:
o Of f i ce visi t - $ 3-$ 7,
200,000
f ol lowing per 6 months enr ol lment
per f ami ly:
416,302
N ov , 2 0 0 3
( E nr ol l me nt 4 5 8 , 1 6 6 ) :
• Pr emi umenr ol lment f ees
i mpl emented:
300,000
Fe b, 2 00 6
( E nr ol l me nt 31 0 , 9 8 1) :
• Cost shar i ng r ules changed to the
• Exceptions to wai ti ng per i od: decer ti f i ed f r omMedicaid &deemed CHIP eli gibile, newbor ns &other chil dr en added to cur r ent enr ol lee account, chi ldr en
disenr olled f or f ai lur e to r enew but whose par ents complete the r enewal withi n a specif ied ti me per i od
294,189
A pr , 2 0 0 6
( E nr ol l me nt 2 9 4 , 1 8 9 ) :
• Dental benef i t r estor ed with
benef it ti er s
benef its incr eased
dependi ng on income
o Inpati ent – Incr ease f r om$0
to $ 10 f or f ami li es l ess than
100%FPL
• Cost shar ing cap incr eases
• Ear ned income di sr egar ds
eli minated
100,000
Apr-06
Mar-06
Jan-06
Feb-06
Oct-05
Nov-05
Dec-05
Jul-05
Aug-05
Sep-05
Apr-05
Jun-05
Mar-05
May-05
Jan-05
Feb-05
Oct-04
Nov-04
Dec-04
Jul-04
Aug-04
Sep-04
Apr-04
Jun-04
Mar-04
May-04
Jan-04
Feb-04
Oct-03
Nov-03
Dec-03
Sep-03
0
Enrollment
Florida Title XXI Enrollment and Major Program Changes
336,689
Fall 2004:
331,281
340,000
326,755
315,222
320,000
• “No Growth”
budget enacted
300,000
• Program overenrolled,
wait list started
280,000
• No Title XIX to
Title XXI transfers
• Federal and
state funding for
Florida KidCare
Outreach eliminated
260,000
264,278
Begin
enrolling
Title XXI
Wait List
Dec. 03:
July 03:
• No reinstatements
for breaks in
coverage
• Jan. 04: Only
CMSN
accepts Medicaid to
Title XXI transfers
(ended Mar. 04)
• 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)
July 04:
• New income
documentation
& access to
employer health
insurance
requirements
(delayed due to
hurricanes)
• 6-month
cancellation for
premium nonpayment
December 04:
• Legislature reduced income
documentation requirements
252,209
July 05: Year-round open
enrollment reinstituted;
application valid for 120 days
• FY 04-05
Appropriated Avr.
Monthly Caseload:
389,515
FY 05-06 Appropriated Avr.
Monthly Caseload: 388,862
220,533
Aug. 05: Back-toSchool campaign, post
cards
Jan. 05: Open enrollment
Jan. 1-30, 2005;
applications
202,433
202,615
processed, children
enrolled (ongoing)
200,000
180,000
Jul-02
Oct-02
Jan-03
Apr-03
Jul-03
Oct-03
Jan-04
Apr-04
Jul-04
Oct-04
„
• Disenrollments for renewal noncompliance and unpaid premiums
implemented
• Loss of Medicaid for
over-income eligible
to apply outside of
open enrollment,
7/1/04
220,000
Cost Sharing
• Open enrollment announced
• New enrollees
accepted only during
open enrollment
• Mar. 04: Legislation
enacted — wait list
funded, other
program changes
240,000
323,262
Apr. 04:
322,997
Jan-05
Apr-05
Jul-05
„
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
Oct-05
1
Florida Premium Changes
Cost Sharing
PFPM Premium Amount
„
Prior to July
2003
July 2003
September 2003
October 2003
Forward
101%-150%
FPL
$15
$20
$15
151%-200%
FPL
$15
$20
$20
„
Family Income
„
„
Enrollment Length Ratios By Income and Premium Amount
Time Ratio
Premium = $15
Premium = $20
3
Premium = $20 for
151-200% FPL
Premium = $15 for
101-150% FPL
Interaction of Premium
Change and Health Status
„
„
2
„
1
101-150% FPL
151-200% FPL
Time
Jul-02
Jul-03
Annual CMS Report - Core quality
measures
„
„
„
„
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.
Oct-03
Quality of Care in SCHIP
„
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
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
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
2
Quality of Care in SCHIP Mathematica Study
„
„
„
Published Reports – Quality of
Care in SCHIP
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
Illustration: Texas ValueBased 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
Examples - Chart 17. HEDIS® Well-Child Visits in
the 3rd, 4th, 5th, And 6th Years of Life-TANF
STAR MCOs - March 1, 2004 to February 28, 2005
70%
68.61%
TANF Enrollees in Age Group = 95,060
66.56%
60.68%
„
„
„
„
„
„
„
„
„
59.86%
„
„
50%
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
Illustration: Texas ValueBased Purchasing Initiative
„
62.90%
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
Illustration: Texas ValueBased Purchasing Initiative
68.45%
66.29%
63.48%
60%
„
Health plan meetings and workgroups
Meet with state plan managers on status
Financial incentive
40%
„
30%
„
20%
10%
0%
Plan A
Plan B
Plan C
MCO Percent
Plan D
Plan E
STAR MCO Mean = 65.27%
Plan F
Plan G
„
Plan H
HEDIS 2004 Mean = 59.90%
Reference: TANF STAR Table PI-2
„
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
3
Outcomes?
„
„
Even prior to implementation of valuebased purchasing – seeing indicator
improvement
Some studies – modest to no
performance increases
Pay for Performance
„
„
„
„
CMS/Premier P4P demonstration
Mostly private sector interest
Interest in Medicare
Some states P4P in Medicaid
„
„
Potential Obstacles
„
„
„
„
„
Credibility of information
Lack of dissemination
Information not being used to initiate
change
Time, effort, and expertise
No requirement
New York, Michigan, California, RI, NC, PA
New York – 1% of premium and may
increase to 3% of premium
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
4