Using Consumer Incentives to Increase
Well-Child Visits
Among Low-Income Children
Jessica Greene,
Greene Ph.D.
Ph D
The University of Oregon
Background
Consumer incentive programs have recently been initiated
in some Medicaid &CHIP programs
 State
St t run programs: Fl
Florida,
id Idaho,
Id h K
Kentucky
t k
 Health plan run programs: California, Wisconsin
Policy Motivation
 To increase recipients
recipients’ personal responsibility
 To curb health care costs
 In response to Value-Driven Health Care Initiative
 In the future, in response to the Patient Protection and
Affordable Care Act
Evidence of Effectiveness


No evaluations of recent state incentive programs
There is a large
g literature on the impact
p of
consumer incentives, generally using small,
intervention studies
 Incentives
for one-time actions (e.g. vaccinations &
cancer screenings) are generally effective
Sutherland et al. MCRR. 2008
Kane et al. Am Journal of Preventive Medicine. 2004
 Mixed
results on effectiveness of incentives for
changing healthy behaviors (e.g. smoking cessation &
weight loss)
Volpp et al. NEJM 2009 & Volpp et al. Cancer Epi Bio 2006
Paul-Ebhohimhen & Avenell. Obesity Reviews 2008
Cahill & Perera Cochrane Reviews 2008
Idaho’ss PHA Program
Idaho
Beginning in 2007, CHIP children
automatically earned $30 points per
q arter if up-to-date
quarter
p to date with well-child
well child visits
isits
Year 1
 Vouchers for healthy
healthy-behavior
behavior products (bike helmets)




Recipient had to call and request voucher
CMS cancelled program after 8 months
V
Very
ffew used
d this
hi redemption
d
i approachh
Premium payment for overdue premiums
Year 2
 Automatic payment for current premiums


Eliminating the $10 monthly premium for those 133%150% FPL
Reducing the $15 premium for those 150%-185% FPL
Research Question
Has Idaho’s Preventive Health Assistance (PHA)
Program increased rates of well-child care?
 Did
the PHA program have a bigger impact for
children whose CHIP premium was eliminated versus
discounted?
 Did the PHA program impact children similarly across
different age groups (number of well-child visits)?
 Were there racial/ethnic, geographic, or gender
differences in program impact?
Methodology
Quasi-experimental
Q
i
i
l study
d
 Compare change in well-child care rates from the
baseline year to the first and second year of PHA
implementation for three groups (bivariate &
multivariate):




$10 CHIP Premium (eliminated premium)
$15 CHIP Premium (reduced premium)
M di id (comparison,
Medicaid
(
i
nott eligible
li ibl ffor iincentive)
ti )
Population of children aged 1 to 18 who received
Medicaid/CHIP in Idaho for 11 out of 12 months in any
of the 3 study years

There were 81,666, 87,620 & 88,344 children in the three study
years
Measures
Whether or not child was up-to-date with well-child
care, based upon claims data




Aged 3-6: HEDIS measure, 1 visit
Aged
g 12-18: HEDIS measure,, 1 visit
Aged 1-2: Did child have recommended number of
visits based on AAP schedule:1-4 visits
Aged 7-11: 1 visit

Until 11/07, AAP recommended annual visits for children at
8,10 and 11. In 12/07 AAP changed guidelines to annual
visits
Well-Child
Well
Child Care at Baseline
Percent Change in Well-Child Care
Baseline to PHA Year 2
Well-Child Care for CHIP Kids
by Race/Ethnicity
Baseline
B
li
%
(n-10,938)
PHA Year
Y
1
%
(n=9,884)
PHA Year
Y
2
%
(n=9,973)
White (non-Latino)
23
34
48
Latino
22
36
55
Other (African
American, Asian &
Native American)
23
32
38
Race/Ethnicity
Summary
Idaho’s incentive program was successful in increasing
well-child care




The larger relative incentive did not result in greater
program impact
Less impact among children aged 1-2, perhaps
because of repeat visits needed
More impact among Latinos than whites or others
More impact
p among
g rural children than urban (but
(
still
lower absolute levels)
Limitations



Claims data for well-child visits may underestimate
absolute levels of visits
Administrative data for race/ethnicity is somewhat
unreliable
Medicaid comparison group may be quite different
from CHIP recipients
Implications

Encouraging evidence that states can use consumer
incentives to improve health care use


Future work will examine whether there were spillover
impacts on ED use
Changing behavior, however, is where there could
be more substantial cost savings

Idaho & Florida evidence suggest changing repeat
b h i will
behaviors
ill be
b more off a challenge
h ll
Acknowledgements
I would like to thank the staff at Idaho’s Department
of Health and Welfare for their support of this
research. Without their help providing data,
answering programmatic questions, and providing
feedback the PHA would not have been evaluated.