Call for Panels
Call for Panels
HCUP: A National Information Resource to Support
Children’s Health Care Research and to inform Health
Care Policy and Practice
Chair: Anne Elixhauser, Ph.D.
Saturday, June 25 • 10:00 a.m. - 11:45 a.m.
● Hospitalization Rates Among Children and Adolescents
in the U.S.
Anne Elixhauser, Ph.D., Tamar Lasky, Ph.D., Robert Baskin,
Ph.D.
Presented by: Anne Elixhauser, Ph.D., Senior Research
Scientist, Center for Delivery, Organization, and Markets,
Agency for Healthcare Research and Quality, 540 Gaither
Road, Rockville, MD 20850; Tel: (301) 427-1411;
Fax: (301) 427-1430; E-mail: aelixhau@ahrq.gov
Research Objective: Provide information on rates of
hospitalization for children and adolescents to help with
priority-setting under the Best Pharmaceuticals for Children
Act (BPCA).
Study Design: We conducted cross-sectional analysis of
hospital administrative data from the Healthcare Cost and
Utilization Project (HCUP) Kids' Inpatient Database (KID) for
2000. ICD-9-CM codes for principal diagnosis were
categorized using the Clinical Classification Software. We
calculated rates per 100,000 population (based on data from
the Bureau of the Census), relative rates, and 95% confidence
intervals around relative rates for 0-17 year olds, by age group
(0-1, 2-4, 5-11, 12-17), by gender, and by primary expected payer
private, Medicaid, other/uninsured).
Population Studied: Hospital discharges for children 0-17
years.
Principal Findings: The top three most common conditions
in the hospital for all 0-17 year olds were pneumonia (227
discharges/100,000), asthma (211/100,000), and acute
bronchitis/bronchiolitis (201/100,000). Fluid and electrolyte
disorders (number 4 with 124/100,000) and intestinal
infections (number 10, 66/100,000) also ranked in the top 10.
The 6th most common condition for all children was mood
disorders (103/100,000) and the 7th was maternal
complications for pregnant adolescents (86/100,000).
Appendicitis (number 5, 107/100,000), epilepsy/convulsions
(number 8, 79/100,000), and urinary infections (68/100,000)
were also high frequency conditions. Among 12-17 years olds,
5 of the top 10 conditions were related to adolescent
pregnancy (e.g., early or threatened labor). All pregnancyrelated conditions, combined, are the most common reason
for hospitalization among 12-17 year olds. Excluding
pregnancy and childbirth, analyses by age group revealed
some conditions that were common across multiple age
groups. Asthma and pneumonia are top 10 conditions for
every age group. Fluid/electrolyte disorders and UTI are top
10 conditions for 0-1, 2-4, and 5-11 year olds.
Chemotherapy/radiation therapy is in the top 10 for 2-4, 5-11,
and 12-17 year olds. Bronchitis/bronchiolitis, intestinal
infection, and URI are in the top 10 for 0-1 and 2-4 year olds.
Epilepsy/convulsions is in the top 10 for 2-4 year olds and 5-11
year olds. Appendicitis and mood disorders are top 10
conditions for 5-11 and 12-17 year olds. Birth complications,
premature birth and low birth weight, and viral infections are
the other top 10 conditions for 0-1 year olds. For 5-11 year olds,
appendicitis, arm fracture, and skin infections are top 10
conditions. For 12-17 year olds brain injury, leg fracture,
diabetes complications, poisoning by medications, and other
mental disorders are top 10 conditions. For the top 10
conditions overall, males were more likely to be hospitalized
than females except for maternal complications, mood
disorders, and urinary infections (all more common in
females). For the top 10 conditions, Medicaid patients were
more likely to be hospitalized than privately insured patients.
"Other" patients - primarily the uninsured - were less likely to
be hospitalized.
Conclusions: This study provides information on the most
common reasons for hospitalization among children and
adolescents and reveals variations by subgroup that are
related to developmental stage and social differences.
Implications for Policy, Delivery or Practice: These data are
useful in understanding the distribution of diagnoses
associated with pediatric hospitalization and variations by age,
sex and payer status.
Primary Funding Source: AHRQ, National Institute for Child
Health and Human Development
● Population-Based Volumes, Rates and Resource Use for
Pediatric Cardiac Procedures
Darryl Gray, M.D., Sc.D.
Presented by: Darryl Gray, M.D., Sc.D., Medical Officer,
Center for Quality Improvement and Patient Safety, Agency for
Healthcare Research and Quality, 540 Gaither Road, Rockville,
MD 20850; Tel: (301) 427-1326; Fax: (301) 427-1341;
E-mail: dgray@ahrq.gov
Research Objective: Congenital malformations of the heart
and great vessels affect roughly one million Americans.
Acquired conditions (generally of infectious origin) add to the
growing burden of pediatric heart disease seen in children and
adults. While relevant diagnostic and therapeutic options are
expanding, little is known in aggregate about the frequencies
of procedures used to treat these conditions. Administrative
data were used to estimate population-based volumes, rates,
and resource use for the inpatient cases estimated to
comprise ~90% of pediatric therapeutic cardiac procedures
(PTCPs).
Study Design: For a retrospective descriptive study, ICD-9CM procedure codes for discharges with PTCP performed via
surgical or transcatheter approaches were determined. Based
on the principal procedure coded, publicly-available, nationally
extrapolated aggregate data on inpatient PTCPs were obtained
from HCUPnet for HCUP’s Kids' Inpatient Database (KID)
and the Nationwide Inpatient Sample (NIS). HCUPnet is an
on-line query system that provides access to information on
hospital stays based on HCUP data. Hospital charges, which
exceed costs but exclude physician fees, were aggregated
(mean charges X admission volumes) and expressed in 2002
dollars using the Consumer Price Index (CPI). Volumes were
combined with Census data to generate population-based
rates.
Population Studied: Weighted, nationally representative
samples of admissions of 0-17 year olds (YOs).
Principal Findings: KID data from 1997 indicate that infant (<
1 YO) discharges with PTCPs accounted for 15,024 hospital
discharges (384.6/100,000 infants). A mean length of stay
(MLOS) of 23.0 days generated CPI-adjusted aggregate
charges of $147,091/discharge. Among 1-17 YOs, KID
estimated that 14,607 discharges with PTCP (21.9/100,000)
had an MLOS of 6.1 days and charges averaging
$61,458/discharge. Charges for 0-17 YOs totaled $3.1 billion.
For 1997, NIS estimated that 12,827 infant discharges with
PTCP generated a MLOS of 21.9 days, and charges averaging
$128,359/discharge. For 1-17 YOs, 14,067 discharges averaging
6.4 days generated charges of $48,984/discharge. Charges for
0-17 YOs totaled $2.3 billion. MLOS figures and the relative
contributions of infants versus older children to discharge
volumes and to charges remained relatively stable over time
and across databases.
However, for all ages, NIS absolute volumes rose from 20,657
in 1998 to 32,368 in 1999, and dropped to 23,400 discharges
in 2000. Aggregate charges were $1.6 billion, $3.0 billion and
$2.3 billion respectively. In 2000, KID estimated that 30,861
discharges generated $2.4 billion in charges. For 2002, NIS
estimated that 24,691 discharges generated $3.1 billion in
charges.
Conclusions: Nationwide PTCP volumes and resource use
appear to exceed prior estimates. Infants (including
newborns) account for roughly 1/2 of these discharges and
>2/3 of associated charges. While NIS appears annually, its
estimates for relatively rare procedures (PTCP’s) may
fluctuate. KID (released for 1997 and 2000; 2003 pending)
oversamples pediatrics discharges and may better capture
such care.
Implications for Policy, Delivery or Practice: The
considerable volumes and costs associated with pediatric
cardiac procedures indicate the societal importance of these
interventions. These figures argue for increased populationbased research on care patterns and outcomes, especially for
infants. Such research may use data from HCUP and other
sources to distinguish the effects of sampling variation or
artifact from those of major changes in actual procedure
volumes and/or resource use.
Primary Funding Source: Agency for Healthcare Research
and Quality, National Heart, Lung and Blood Institute
● Hospitalizations for Children with Mental Health and
Substance Abuse Conditions
Pamela Owens, Ph.D., Anne Elixhauser, Ph.D.
Presented by: Pamela Owens, Ph.D., Research Scientist,
Center for Delivery, Organization, and Markets, Agency for
Healthcare Research and Quality, 540 Gaither Road, Rockville,
MD 20850; Tel: (301) 427-1438; Fax: (301) 427-1430;
E-mail: powens@ahrq.gov
Research Objective: To compare pediatric hospitalizations
for mental health and substance abuse conditions (MHSA) to
pediatric hospitalizations for general medical conditions.
Study Design: A cross-sectional analysis of 2002 Healthcare
Cost and Utilization Project (HCUP) Nationwide Inpatient
Sample (NIS) was conducted. The NIS is a stratified
probability sample of discharges from about 1,000 community
hospitals in 36 States. The Clinical Classifications Software
(CCS) and a new mental health substance abuse CCS
supplement was used to classify ICD-9-CM principal and
secondary diagnostic codes and identify three major
subgroups of pediatric hospital stays: 1) children with a
principal MHSA condition, 2) children with a secondary
MHSA condition only, and 3) children with no MHSA
condition. Age-specific national estimates of characteristics of
pediatric hospitalizations (length of stay, expected payer,
admission and discharge status and total charges) were
examined for each of the three subgroups.
Population Studied: U.S. community hospital stays for
children ages 0-17 years.
Principal Findings: Of the 1.7 million hospitalizations for
children 1-17 in US community hospitals, 13.8% were for
children with a principal or secondary MHSA condition. Of
those hospitalizations for a principal MHSA condition, most
were for mood disorders (54.1%), disruptive behavior
disorders (14.4%), alcohol and substance abuse disorders
(7.5%) and adjustment disorders (5.8%). Hospitalizations for
MHSA conditions occurred more frequently among older
children compared with younger children (3.1% of
hospitalizations for 1-4 year olds (YO), 11.0% for 5-9 YO,
21.5% for 10-14 YO, and 21.7% for 15-17 YO, p<.001).
Hospitalizations for children with a principal MHSA condition
were likely to be longer (mean length of stay (LOS) = 9.4 days)
compared with hospitalizations for children with comorbid
MHSA conditions (mean LOS = 4.9 days) or no MHSA
conditions (mean LOS = 3.2 days). Mean total charges of
hospitalizations for principal MHSA conditions (mean:
$14,000) were similar to total charges for hospitalizations
unrelated to MHSA conditions (mean: $13,500), but
significantly less than total charges for hospitalizations with
comorbid MHSA conditions (mean: $21,300) (p< .001).
Although no significant differences were noted in the
aggregate, age stratified analyses revealed significant
differences in expected source of payment for each of the
three subgroups of hospitalizations. For example,
hospitalizations for children ages 1-4, 5-9 and 10-14 for MHSA
were more likely to be billed to Medicaid than hospitalizations
for non-MHSA conditions (p<.05).
Conclusions: MHSA conditions account for a large portion of
hospital utilization for children, with over one-fifth of
hospitalizations for children 10-17 YO being related to these
conditions. Hospitalizations for MHSA conditions are longer
than hospitalizations for other conditions. Comorbid MHSA
conditions significantly increase the charges for hospital care.
Hospitalizations for MHSA conditions for children 1-14 are
more frequently billed to Medicaid than hospitalizations for
other conditions.
Implications for Policy, Delivery or Practice: These analyses
reveal significant differences in hospitalization by expected
payer, but further research is needed to determine if these
differences are related to variations in prevalence, or need for
care, versus variations in treatment setting, or system of care.
Primary Funding Source: Agency for Healthcare Research
and Quality (AHRQ)
Call for Panels
Quality Improvement in Medicaid: Using Research and
Policy to Improve Preventive and Developmental Services
for Your Children
Chair: Melinda Abrams, M.A.
Saturday, June 25 • 10:00 a.m. - 11:45 a.m.
● An Examination of Medicaid and SCHIP Coverage and
Payment Policies Promoting Early Childhood Development
Anne Markus, J.D., Ph.D., M.H.S., Sara Rosenbaum, J.D.,
Alexis Crumbley, J.D., Alexandra Stewart, J.D., Marisa Cox,
M.A.
Presented by: Anne Markus, J.D., Ph.D., M.H.S., Assistant
Research Professor, School of Public Health and Health
Sciences, Department of Health Policy, George Washington
University, 2021 K Street, N.W., Washington, DC, DC 20006;
Tel: (202) 530-2339; Fax: (202) 296-0025;
E-mail: armarkus@gwu.edu
Research Objective: Medicaid and SCHIP agencies play
important roles in ensuring that children have access to
quality care. Not only are they federally required to improve
quality, but as the largest purchasers of health care for lowincome children, they possess the leverage needed to align
coverage and payment policies to encourage adherence to
professionally acceptable standards of care. Additionally, the
implementation of HIPAA transaction standards in 2003,
which required all payers to conform to nationally-recognized
code sets, presents new opportunities and challenges for
reforming state payment policies of early childhood preventive
and developmental services to improve the quality of care for
children. The research objectives are to (1) examine, within a
HIPAA context, state coverage and payment policies of early
childhood preventive and developmental services delivered in
a primary care setting, and (2) compare these policies with (i)
existing professional guidelines related to health care for
young children and (ii) a typology of effective early childhood
interventions grounded in the scientific literature.
Study Design: Researchers used systematic documentary
review to examine all 50 Medicaid and 35 separate SCHIP
coverage and payment policies. Publicly-available state
documents, including provider fee-for-service manuals, fee
schedules, HIPAA crosswalks, managed care contracts, and
other related documents were collected in 2004. The analysis
focused on (i) coverage of assessment, intervention,
education, and care coordination services promoting early
childhood development and billable codes for each of these
services, (ii) required or recommended standards of care, and
(iii) general billing and payment requirements.
Population Studied: State Medicaid and SCHIP programs.
Principal Findings: (1) Even though states now use
standardized code sets, state reimbursement policy remains
extremely varied. (2) The majority of Medicaid fee-for-service
programs clearly spell out coverage expectations of early
childhood services, albeit with some variation in individual
services covered, (3) The majority of Medicaid fee-for-service
programs (n=41) have explicit payment policies for periodic
comprehensive preventive visits that recognize almost
uniformly the same billing codes; however, few programs
specify other codes used for additional services provided in a
primary care setting (e.g., developmental testing). (4)
Medicaid programs are more specific than SCHIP programs
in both their coverage and payment policies. (5) Both
Medicaid and SCHIP managed care programs usually do not
publicly list reimbursement codes.
Conclusions: Preliminary findings suggest that a discrepancy
exists between state promises of comprehensive preventive
pediatric coverage in early childhood development and the
services states actually reimburse. They also suggest that
physicians may have to accept payment of the periodic visit as
payment in full for all of the appropriate preventive and
developmental services they are expected to furnish according
to existing practice guidelines. Finally, they suggest that
managed care may present a particular challenge in conveying
coverage and payment expectations to plans and network
providers.
Implications for Policy, Delivery or Practice: HIPAA
provides an opportunity to address payment policy reform for
all payers, including Medicaid and SCHIP, to ensure actual
availability of coverage at a professionally acceptable standard
of care. This study provides the first step in understanding
existing gaps in state payment policies and providing the
knowledge base necessary to develop meaningful options for
improvement.
Primary Funding Source: CWF
● Using External Quality Review Organizations to Improve
the Quality of Preventive and Developmental Services for
Children
Henry Ireys, Ph.D., Tara Krissik, M.P,P., James M. Verdier,
J.D., Melissa Faux, B.A.
Presented by: Henry Ireys, Ph.D., Senior Researcher,
Mathematica Policy Research, 600 Maryland Avenue, S.W.,
Suite 550, Washington,DC 20024-2512; Tel: (202) 554-7536;
Fax: (202) 863-1763; E-mail: hireys@mathematica-mpr.com
Research Objective: Current federal regulations obligate
states to assess the quality of services provided to Medicaid
beneficiaries in managed care plans. State Medicaid agencies
typically contract with external quality review organizations,
EQROs, to review quality-of-care studies conducted by
managed care plans and to implement quality-related studies
focused on particular populations or services. Child health
policymakers have registered interest in the extent to which
states rely on EQROs to examine the quality of preventive and
developmental services for Medicaid-enrolled children, but
there has been no effort to gather systematic data on this
topic.
This research addressed the following questions: How many
states have used or are planning to use EQROs to conduct
studies of preventive and developmental services? When
faced with many services for which quality-of-care studies are
needed, what factors enhance the likelihood that states will
examine this topic? What factors are shaping states’ capacity
to conduct methodologically rigorous studies of these
services?
Study Design: This study used survey and qualitative
methods. Of 51 surveys sent to state Medicaid directors
(including the District of Columbia), 48 were returned
(response rate of 94%) and 25 directors (49%) indicated they
had commissioned EQRO work in this area. Of 25 states with
completed work, 19 indicated that 32 EQRO reports had been
completed. Of these 32 reports, 9 reports from 6 states
included methodologically strong analyses. We developed
case studies based on qualitative interviewing of staff in 5
states and conducted intensive reviews of 10 state RFPs and
key federal regulations.
Population Studied: State Medicaid agencies, selected
EQROs, and selected managed care organizations.
Principal Findings: In any one year, less than 10% of states
use EQROs to conduct quality-of-care studies on preventive
and developmental services for children in Medicaid; most
studies are methodologically weak, but several examples
demonstrate the potential impact of well-designed studies on
quality improvement efforts. Two factors play critical roles in
driving states to focus studies on preventive and
developmental services: influential “champions” and
attention-getting data demonstrating problems with these
services. Current federal regulations are prompting states to
expand research methods used in quality-of-care studies by
adding analysis of claims and survey data to traditional chartreview methods.
Conclusions: Improving the quality of preventive and
developmental services for Medicaid-enrolled children
requires a “champion” who can make a convincing case that
this issue deserves attention in a state’s overall strategy for
improving Medicaid services. A convincing case depends on
methodologically strong data on gaps in the provision of
preventive and developmental services, the cost of failure to
provide them, or consumer demand for them.
Staff in state Medicaid agencies need help in understanding
how to apply contemporary research tools within a quality
improvement framework.
Implications for Policy, Delivery or Practice: Child health
service researchers can offer assistance to state Medicaid
agencies, managed care plans, and EQROs by helping to
design methods for evaluating projects aimed at improving
the quality of preventive and developmental services for
Medicaid-enrolled children. These research designs could
include newly-available measurement tools and policy-driven
strategies for synthesizing findings from the analyses of
administrative, claims, and survey data.
Primary Funding Source: CWF
● Research’s Impact on Improving the Delivery of
Developmental Services in Medicaid: Lessons Learned
From Two State Collaboratives
Neva Kaye, B.A.
Presented by: Neva Kaye, B.A., Program Director, National
Academy for State Health Policy, 50 Monument Square,
Portland, ME 04101; Tel: (207) 874-6524; Fax: (207) 874-6527;
E-mail: nkaye@nashp.org
Research Objective: Enhance developmental services
delivered to young children enrolled in Medicaid.
Study Design: The National Academy for State Health Policy
(NASHP), with funding the Commonwealth Fund, has
managed two collaboratives witha total of eight states to
improve the delivery of early childhood health and
developmental services. Each state conducted an individual
project with that goal. NASHP provided technical assistance
to the state efforts and identified and disseminated lessons
learned to a national audience. In each state research and
evidence played an important role in project development,
operation, and expansion. In this proposed presentation the
current project director will review project experience to
identify examples of the use of evidence in developing state
health policies—and the factors that enabled the research to
impact state policymaking.
Population Studied: State Medicaid agencies in CA, IA, IL,
MN, NC, UT, VT, and WA
Principal Findings: 1. Medicaid is a key partner in improving
the developmental services delivered to young children.
Agencies can re-engineer the delivery of care through quality
improvement, reimbursement and other strategies. Further,
all Medicaid agencies studied relied, to some extent, on
scientific evidence in policymaking.
2. The ABCD collaborative experience demonstrated that
research and scientific evidence can play an important role in:
identifying a need for policy change, developing and assessing
an intervention, and evaluating whether the intervention
should be continued or expanded. Two examples of specific
policy changes made by states based on scientific evidence
and/or their own research into an intervention’s effectiveness
are:
a) NC was interested in improving performance because
research had shown that the majority of children who needed
developmental services did not receive them. They selected a
standardized screen and implemented an intervention
designed to increase the number of children screened and
referred. Data collected at the end of the pilot project showed
significant improvement in performance and the screening
guidelines and model has now been expanded statewide.
b) Illinois submitted a state plan amendment to allow
Medicaid providers to screen for maternal depression even in
cases where the mother was not a Medicaid beneficiary.
Scientific evidence about the impact of maternal depression
on a young child’s development was instrumental to the
justification of serving a mother under a benefit targeted to
children.
Conclusions: Research and evaluation can be valuable tools
for state policymakers. But, state policymakers have little time
to identify pertinent information and few resources for
evaluation. Therefore it is critical that 1) Research be
accessible—both in terms of identifying pertinent information
and in being easy to understand; and 2) Measures that require
minimal resources to produce be developed and tested.
Implications for Policy, Delivery or Practice: Medicaid
agencies can significantly influence the quality of health and
developmental services provided to children and have great
interest in basing polices on scientific evidence but, due to
limited resources, they need assistance in translating research
into practice.
Primary Funding Source: CWF
Call for Panels
Using Medicaid Data to Optimize Child Health Policy
Chair: Joseph Thompson, M.D., M.P.H.
Saturday, June 25 • 11:45 a.m. - 1:45 p.m.
● Assessing the Potential Effect of Programmatic Changes
in Medicaid and SCHIP on Children’s Uninsured Rates
Matthew M. Davis, M.D., M.A.P.P., Rachel M. Quinn, M.P.P.,
M.P.H.
Presented by: Matthew M. Davis, M.D., M.A.P.P, Assistant
Professor, Child Health Evaluation and Research Unit,
Division of General Pediatrics, University of Michigan, 300
NIB, 6D20, Ann Arbor, MI 48109-0456;
Tel: (734) 614-3508; Fax: (734) 764-2599;
Email: mattdav@med.umich.edu
Research Objective: To estimate the potential effect on statelevel children’s uninsured rates of programmatic changes in
Medicaid and SCHIP, adjusting for other state factors relevant
to children’s insurance status.
Study Design: We hypothesized that children’s uninsured
rates at the state level are a function of sociodemographic and
economic factors in combination with Medicaid and SCHIP
programmatic decisions. The outcomes of interest were statelevel children’s uninsured rates for children overall and also
for low-income children alone, based on data from the Current
Population Survey (CPS) for the years 1999-2003 inclusive.
We examined associations between uninsured rates and
candidate concurrent state-level predictor variables;
programmatic variables included income eligibility thresholds
by age groups, asset tests, presumptive and continuous
eligibility, type of SCHIP program and SCHIP implementation
date, and premiums, copays, and enrollment fees for SCHIP.
We analyzed these associations first in bivariate and then in
multivariate time-series models. Given high collinearity
between the Medicaid eligibility threshold variables within
states, we ran separate models for eligibility thresholds for
ages 0-1, 2-5, 6-16, and 17-19 years; mean coefficient values
from these separate models are reported. All analyses
controlled for state child population; models for all children
also controlled for median income, and models for lowincome children controlled for type of SCHIP program.
Population Studied: The US population, as characterized in
CPS public use datasets.
Principal Findings: All children – Higher SCHIP eligibility
thresholds were associated with significantly lower uninsured
rates (increase of 10 points in SCHIP thresholds associated
with absolute decrease of .1% in the state uninsurance rate;
P<.05). Higher state population proportions comprised by
Hispanics were associated with significantly higher child
uninsured rates (1% absolute increase in Hispanic proportion
associated with .25% absolute increase in uninsured rate;
P<.001), and higher proportions of state populations
comprised by children were also associated with higher
uninsured rate (1% absolute increase in child proportion
associated with .35% absolute increase in uninsured rate;
P<.001). Low-income children – The lack of a Medicaid asset
test was strongly associated with lower uninsured rates
(absolute decrease of 2.5%; P<.05). Higher Medicaid eligibility
thresholds were associated with significantly lower uninsured
rates (increase of 10 points in Medicaid thresholds associated
with absolute decrease of .3% in uninsured rates; P<.05).
Similar to patterns for children overall, among low-income
children higher state proportions of Hispanics were associated
with higher uninsured rates.
Conclusions: Recent historical trends in uninsured rates
underscore the critical role of Medicaid and SCHIP in
providing insurance coverage to children. In addition, these
analyses illustrate the potential benefits to states of improving
outreach to their Hispanic populations, and to recognizing
states’ limitations in providing coverage to disproportionately
large populations of children.
Implications for Policy, Delivery or Practice: This analysis
may serve as a decision aid for policymakers considering
potential effects of legislated changes in Medicaid and SCHIP
eligibility thresholds for state child uninsured rates, and also
suggests a rationale for adjustment of the federal matching
rate to account for states with larger-than-average proportions
of their populations comprised by children.
Primary Funding Source: none
● Access to Specialty Care among Children with Chronic
Conditions in Managed Care
Elizabeth Shenkman, Ph.D., Lili Tian Ph.D., John Nackashi,
M.D., Des Schatz, M.D.
Presented by: Elizabeth A. Shenkman, Ph.D., Director,
University of Florida, 1329 SW 16th Street, Room 5130,
Gainesville, FL 32608; Tel: (352) 265-7220 x8633; Fax: (352)
265-7221; Email: eas@ichp.ufl.edu
Research Objective: Access to specialty care for children with
chronic conditions may be constrained within managed care
environments. The purpose of our study was to examine the
association between managed care organizational (MCO)
characteristics and outpatient physician specialist use among
children with chronic conditions who were 1) receiving care in
MCOs where primary care providers (PCPs) serve as
gatekeepers and 2) insured through a State Children’s Health
Insurance Program (SCHIP) where all MCOs provided the
same benefit package and co-payment structure but could use
different strategies to deliver the children’s health care. None
of the MCOs had financial penalties for specialty referrals.
Study Design: Using person-level health care
claims/encounter data and parent interview data, we identified
2,333 children with a chronic condition who had 1) functional
limitations, 2) increased use of health care services, and/or 3)
dependence on medications or equipment. Interviews were
conducted with administrators of nine MCOs participating in
SCHIP about MCO characteristics that might be associated
with specialty care use including prior authorization
procedures, the availability of PCPs who are pediatricians, PCP
reimbursement, and the use of financial incentives to promote
meeting pediatric quality of care standards. The odds of an
outpatient physician specialist visit one year after study entry
were examined as a function of child health and
sociodemographic characteristics and prior specialty use,
MCO characteristics, and provider availability in the MCO
service delivery area.
Population Studied: Children enrolled in Florida SCHIP in
2000.
Principal Findings: Children cared for in MCOs 1) with lower
percentages of PCPs paid fee-for-service (OR 0.60; 95% CI
0.43, 0.84), 2) with higher percentages of pediatricians in the
PCP network (OR 1.17; 95% CI 1.07, 1.29), and 3) offering
financial incentives for meeting quality of care standards (OR
1.71; 95% CI 1.28, 2.29), had higher odds of outpatient
physician specialist visits. African-American children had odds
of specialty care that were about one-half that of White
children (p=0.005). Children with prior physician specialist
use were 52% more likely to have a physician specialist visit in
the year after study entry (p=0.005).
Conclusions: A high percentage of pediatricians in the
network, the use of fee-for-service, and financial incentives are
associated with increased odds of specialty use.
Implications for Policy, Delivery or Practice: PCPs paid on a
capitated basis may be less willing to manage certain health
problems when discretion exists regarding the necessity for a
referral. Our findings suggest that blended payments
combining elements of fee-for-service and capitation may be
beneficial to promote access to care. Pediatricians may make
more referrals due to their in-depth pediatric training and
possibly greater awareness of potential complications when
compared to family practitioners. Finally, the use of financial
incentives focused on quality of care standards may foster an
increased emphasis on meeting children’s health care needs,
including the need for specialty referrals. Our study suggests
that MCOs using these strategies may provide better specialty
care access. However, further studies examining MCO
characteristics and specialty care use in the context of specific
clinical situations is needed.
Primary Funding Source: Agency for Healthcare Research
and Quality, and Health Resources and Services
Administration
● Identifying Opportunities for Improvement in Pediatric
Asthma Management
Kevin J. Dombkowski, Dr.P.H., Lisa M. Cohn, M.S., Sarah J.
Clark, M.P.H.
Presented by: Kevin J. Dombkowski, Dr.P.H., Research
Investigator, Child Health Evaluation and Research Unit
Division of General Pediatrics, University of Michigan, 300
North Ingalls, Room 6C07, Ann Arbor, MI 48109; Tel: (734)
615-6758; Fax: (734) 764-2599; Email: kjd@med.umich.edu
Research Objective: To assess opportunities for targeted
interventions in pediatric asthma care for Medicaid
beneficiaries by contrasting health plan performance within
and between different geographic regions.
Study Design: Retrospective analysis of administrative claims
data for 18 state Medicaid health plans. The four main
outcome measures were based on National Asthma
Education and Prevention Program (NAEPP)
recommendations for asthma management: annual
outpatient visits; asthma emergency department (ED) visits;
use of asthma controller medications; and influenza
vaccination. Outcomes were contrasted within plan by
geographic region.
Population Studied: The study population was 3,970
children 5-18 years old with persistent asthma who were
continuously enrolled in the same Michigan Medicaid health
plan for 2002 and 2003, with no other source of health
insurance.
Principal Findings: Aggregate outcomes varied significantly
(p • .05) between plans, e.g., the proportion of children with at
least one long-term asthma controller prescription ranged
from 66% to 88%, while the proportion of children with
influenza vaccination ranged from 3% to 46%. Plan ranking
varied depending upon the outcome measure used. Within
plans, variations became evident when outcomes were
stratified by geographic region. For example, the plan that
was observed to have the lowest aggregate proportion of
children with asthma controller prescriptions (66%) had
regional proportions that ranged widely, from 44% to 72%.
Another plan with an average proportion of asthma ED users
(28%) had regional results that ranged from 9% to 39%.
Some plans were observed to rank highly in one region and
substantially lower in other regions; similar region-by-plan
variation was found for each outcome measure.
Conclusions: Asthma outcomes measures can be derived
from administrative claims data to identify potential areas for
quality improvement. Asthma management practices may
vary for a given plan across geographic regions, and plan-level
results within regions may reveal outcomes which differ
substantially from statewide and regional averages.
Assessment of multiple asthma outcomes measures may
reveal health plan performance contrary to that suggested by a
single measure. Health plans can identify opportunities for
targeted intervention by assessing regional variations of
asthma outcomes.
Implications for Policy, Delivery or Practice: Aggregate
assessments of Medicaid pediatric asthma management
practices at the overall plan level may not be sufficient to
identify opportunities for improvement. Profiles of plan
performance that are sensitive to regional variations in plan
characteristics may be particularly useful in isolating and
prioritizing quality improvement opportunities. Medicaid
plans can capitalize on this information to gauge the adequacy
of existing provider networks in selected geographic areas and
to target areas that would benefit most from more intensive
intervention.
Primary Funding Source: Michigan Department of
Community Health
● Lack of Follow-up Testing Among Children with Elevated
Screening Blood Lead Levels
Alex R. Kemper, M.D., M.P.H., M.S., Lisa M. Cohn, M.S.,
Kathryn E. Fant, M.P.H., Kevin J. Dombkowski, Dr.P.H.,
Sharon R. Hudson, R.N., M.S.N., C.N.M.
Presented by: Alex R. Kemper, M.D., M.P.H., M.S., Assistant
Professor, University of Michigan, 300 North Ingalls, 6E08,
Ann Arbor, MI 48109-0456; Tel: (734) 615-3508;
Fax: (734) 764-2599; Email: kempera@med.umich.edu
Research Objective: Children enrolled in Medicaid have a
three-fold increased risk of lead poisoning. No data are
available regarding the care that children with elevated blood
lead levels receive. Follow-up testing after an abnormal
screening blood lead level is a key component of lead
poisoning prevention. Our objectives were to measure the
proportion of children with elevated screening levels who have
follow-up testing and to determine factors associated with
such care.
Study Design: We performed a retrospective observational
cohort study.
Population Studied: We included all Michigan Medicaidenrolled children <= 6 years who had an elevated blood lead
level between January 1, 2002 and June 30, 2003 and who
were continuously enrolled in Medicaid for the subsequent 6
months. Because we were interested in care for newly
detected cases, we excluded children who had an elevated
blood lead level in the previous 6 months. There were 3,682
children included in this analysis.
Principal Findings Follow-up testing was received by 53.9%
(95% Confidence Interval [CI]:52.2%-55.5%). In multivariate
analysis adjusting for age, screening blood lead level results,
and local health department catchment area, the relative risk of
follow-up testing was lower for Hispanic or non-white
children than non-Hispanic white children (0.91 [95%
CI:0.87-0.94] vs. 1), for children living in urban compared to
rural areas (0.92 [95% CI:0.89-0.99] vs. 1), and for children
living in high compared to low lead risk areas (0.94 [95%
CI:0.92-0.96] vs. 1). Among those who did not have followup testing, 58.6% (95% CI:56.3%-61.0%) had at least one
medical encounter in the 6-month period following the
elevated screening blood lead level, including for evaluation
and management (39.3% [95% CI:36.9%-41.6%]) or
preventive care (13.2% [95% CI:11.6%-14.8%]) visits.
Conclusions: The rate of follow-up testing was low, and
children with increased likelihood of lead poisoning were less
likely to receive follow-up testing. At least half of the children
had a missed opportunity for follow-up testing.
Implications for Policy, Delivery or Practice: This is the first
study to document the low rate of follow-up for children with
elevated blood lead levels. Without follow-up, testing does
not confer any benefit. New strategies are required to ensure
optimal care. This study demonstrates the role of Medicaid
administrative claims data in supporting the delivery of public
health services.
Primary Funding Source: Michigan Department of
Community Health
Call for Panels
Caught in the Middle: Youth at the Intersection of the
Mental Health and Juvenile Justice Systems
Chair: Alison Cuellar, Ph.D.
Saturday, June 25 • 11:45 a.m. - 1:15 p.m.
● How Do Youth with Emotional Disorders Fare in the
Juvenile Justice System?
Alison Cuellar, Ph.D., Pinka Chatterji, Ph.D.
Presented by: Alison Cuellar, Ph.D., Assistant Professor,
Health Policy & Management, Columbia University, 600 W.
168th Street, 6th Floor, New York, NY 10032;
Tel: (646) 769-0542; E-mail: ac2068@columbia.edu
Research Objective: Several studies have documented that
youth with emotional and substance use disorders are
overrepresented in the juvenile justice system. Whether the
justice system is biased against these youth has been the
subject of public policy concern, but there have been few
systematic, empirical tests of this claim. Using data from a
nationally representative sample of adolescents, this study
assesses whether youth who use substances or have
emotional disorders are sanctioned more heavily than other
youth by the juvenile justice system, controlling for the youths’
crime and criminal history.
Study Design: This study uses Wave III of the National
Longitudinal Study of Adolescent Health (AddHealth) and
offers several distinct advantages over existing research: First,
it relies on data from a large, nationally representative sample
of youth increasing the generalizability of the findings.
Second, youth in the sample are first interviewed in the
community rather than in institutions increasing the
interpretability of the results and allowing us to address the
question of bias in the juvenile justice system. Finally,
AddHealth data allow for the inclusion of important control
variables that are not present in previous studies. These
variables include the nature of the delinquent act committed,
delinquency history, emotional and substance abuse
disorders, as well as demographic and community variables.
This study uses multivariate regression where the unit of
analysis is the individual. Key outcomes variables include the
likelihood of being detained, the likelihood of conviction, the
likelihood of community placement, and the likelihood of
residential placement. The primary independent variable of
interest is whether the youth has an emotional and/or
substance abuse disorder. Other independent variables
include whether youth was treated for an emotional disorder,
demographic characteristics, family structure and living
situation, local neighborhood and community characteristics,
such as poverty, housing quality, and access to health care,
charge at time of arrest, and history of delinquency.
Population Studied: Add Health encompasses a nationally
representative the sample of 15,197 youth living in the
community who were interviewed in 2001/2002
Principal Findings: Early results of this study find evidence of
bias in the justice system, particularly against youth with
substance abuse and ADHD disorders.
Conclusions: Results of this study have important
implications for identifying a group of youth whose health
needs are not being appropriately recognized and who face a
greater likelihood of being punished as a result of their
disorder.
Implications for Policy, Delivery or Practice: If the justice
system is biased, whether intentionally or not, against youth
with emotional disorders then a concerted policy focus on
changing the behaviors of key players in the justice and mental
health systems is needed. Changes might include early access
to mental health screening and treatment information for
youth who become involved with the justice system; diversion
of youth to appropriate treatment services rather than further
court processing; or the development of more appropriate
sanctions that include treatment components. Ultimately, this
study has implications for outreach and education programs
in the justice system, as well as the delivery system of public
mental health services.
Primary Funding Source: none, university grant
● Can Community Mental Health Services Reduce Juvenile
Justice Involvement?
E. Michael Foster, Ph.D., Damon Jones
Presented by: E. Michael Foster, Ph.D., Professor, Health
Policy & Administration, The Penn State University, 204 E.
Calder Way, Suite 400, State College, PA 16801;
Tel: (814) 865-1923; Fax: (866) 369-6737;
E-mail: emfoster@psu.edu
Research Objective: Using longitudinal data on a group of
high-risk children and youth, examine the relationship between
the use of mental health services and subsequent juvenile
justice involvement.
Study Design: The data for these analyses were collected as
part of the Fast Track Project, a multi-cohort, multi-site
longitudinal study of children who are at risk for emotional
and/or behavioral problems. The project includes an
intervention component designed to prevent long-term
exacerbation of problems in children identified in kindergarten
as “at risk” for such long-term problems; these individuals
receiving such treatment are not included here. Rather, our
focus is on subjects who were (a) screened into the high-risk
comparison group, and (b) children not identified as at-risk,
but recruited as part of a “normative” sample to allow for
examination of outcomes in a representative group of youth.
When analyzed with probability weights, the resulting sample
from these combined groups is representative of children
from low-SES neighborhoods in the four sites.
Population Studied: The sample of 754 individuals are
representative of children and youth living in four diverse
areas—Nashville, TN; Seattle, WA, Durham, NC and rural
Pennsylvania. Thirteen waves of data are available describing
these youth’s experiences from kindergarten through the end
of high school.
Principal Findings: Since service use was determined by the
families themselves (as one would expect in a community
study), comparisons between youth who did and did not
receive services need to be adjusted for any enabling,
predisposing or need factors that otherwise will be
confounded with the effect of service use. Initial analyses
confirm this—simple comparisons between youth who do and
do not use services suggest that services actually worsen
mental health. However, we use propensity scores to adjust
for differences between the two groups (involving key baseline
characteristics, such parental education). Those adjustments
reveal that mental health services have small benefits. In
particular, these findings suggest that use of mental health
services reduces the likelihood of subsequent juvenile justice
involvement.
Conclusions: The costs of mental health services may be
partially offset by reductions in expenditures in other childserving sectors.
Implications for Policy, Delivery or Practice: Blended
funding may be a better way to deal with the needs of children
with emotional and behavioral problems.
Primary Funding Source: Other Govt, NIMH
● A National Assessment of Youth Involved with Child
Welfare: Prevalence of Emotional, Behavioral and
Substance Use Problems, Access to Specialty Treatment,
and the Role of Court Involvement
Anne Libby, Ph.D., Heather D. Orton, M.S., Richard P. Barth,
Ph.D., William Jones, J.D., John Landsverk, Ph.D.
Presented by: Anne Libby, Ph.D., Assistant Professor,
University of Colorado at Denver and Health Sciences Center,
School of Medicine, Nighthorse Campbell Native Health
Building, P.O. Box 6508, Mail Stop F800, Aurora, CO 80045;
Tel: (303) 724-1451; Fax: 303) 724-1474;
E-mail: anne.libby@uchsc.edu
Research Objective: Estimate the prevalence of emotional,
behavioral and substance use problems for adolescents
involved with child welfare, comparing in and out-of-home
cases. Measure access to specialty mental health and
substance abuse treatment, and the influence of court
involvement on referrals to treatment over time.
Study Design: Secondary data come from the National Study
of Child and Adolescent Well-Being (NSCAW), a three-year
longitudinal study of a nationally representative sample of
youth, their parents and caretakers who came into contact
with child welfare systems. Data include baseline, 18-month
and 36-month follow-up about the need for emotional and
substance abuse services and access to services, and court
involvement during that time period and whether such
services were mandated by the court. Youth and placement
characteristics are available at each wave to compare youth
with and without health insurance to assess the importance of
court involvement for service receipt.
Population Studied: Youth aged 11-14 at baseline who had
come into contact with child welfare systems via an
investigation of abuse or neglect. The complex sample and
survey design is weighted to create nationally representative
estimates of the U.S. population of children and adolescents
involved with child welfare.
Principal Findings: Nearly two-thirds of these youth were
assessed as having emotional or behavioral problems, and
nearly one-half with substance use problems. The majority
(roughly 85%) remained in-home compared to out-of-home
foster care cases. At 18 months, approximately 20% of youth
had come into contact with the court for a behavior offense,
and one-third of these were court-ordered to specialty mental
health or substance abuse treatment. Service referral and
utilization varies dramatically by type of need, health insurance
and court contact.
Conclusions: This study provides unique information about
the relationships between multiple youth-serving systems and
the role of the courts in getting access to emotional and
substance use treatment.
Implications for Policy, Delivery or Practice: These results
highlight the importance of understanding the interactions
between systems that come into contact with youth with
emotional, behavioral or substance use problems.
Opportunities for getting these youth into treatment before
delinquency is a factor is critical, and points of intervention for
prevention appear plentiful. Child welfare systems and
specialty treatment systems, in collaboration with state and
county administrators, can use this information to find ways
to improve efficiency and reduce system and human costs by
providing timely access to care with the goal of avoiding court
involvement for these youth.
Primary Funding Source: RWJF
● Experiences of Latino Juvenile Offenders in Seeking
Behavioral Health Care
Lisa Fortuna, M.D., M.P.H., Norah Mulvaney-Day, Ph.D,
Helena Hansen, M.D., Ph.D.
Presented by: Lisa Fortuna, M.D., M.P.H., Staff Psychiatrist,
Center for Multicultural Mental Health Research, Cambridge
Health Alliance, 120 Beacon Street, 4th Floor, Somerville, MA
02431; Tel: (617) 503-8485; Fax: (617) 503-8430;
E-mail: lfortuna@charesearch.org
Research Objective: This paper is about the perceptions of
mental health services among a sample of young adult Latinos
with a history of juvenile justice involvement and who are in
the process of community reentry. While a variety of factors
continue to produce mental health services inequalities for
this population, this paper reports on an investigation which
focuses on: 1) the mental health experiences of Latino young
adult ex-offenders and attitudes towards care and help seeking
and 2) how experiences of social support may relate to
improved mental health services for these young adults.
Study Design: We used a purposive sampling design at a
community based agency. We completed in-depth interviews
with Latino juvenile ex-offenders, community providers and
families. We employed ethnographic methods including
participatory observation at the community agency serving
this population over a one year period.
Population Studied: The study population consists of 20
young adult Latinos ages 18-26 years with a history of juvenile
detention, variable levels of mental health services experiences
and in the process of community reentry, living in the Boston,
MA area of the United States.
Principal Findings: We find that social exclusion and
perceived irrelevance of mental health services to personal
experiences comprise an explanatory framework which is
repeatedly invoked by these youth in describing their
interaction with the mental health and substance abuse
services system. Experience and expectations of
mistreatment, clinical stereotyping and coercion by mental
health providers are key factors discouraging accessing mental
health services for assessment and treatment, and thereby
perpetuating mental health care inequalities. In contrast,
young people assert that supportive and sustained
relationships with adults in the community are essential,
because they provide the basic relational context that is
necessary for psychological well-being, healing, identity
development and successful community inclusion. Narratives
point to young people’s desires to work through their
difficulties with the support of others who understand the
process of community reentry, community life, and their
trajectory as young Latinos who have faced difficulties, losses,
isolation and disappointments. However, they also long to
have support from those who see their potential and care
about what they can contribute to community.
Conclusions: We conclude that participation and partnership
with the community are vital means by which to generate both
the objective and subjective inclusion. These are
requirements for accessible and appropriate mental health
and substance abuse services for young Latino ex-offenders
returning home. Healing and psychological development for
these young people is fundamentally relational and necessarily
occurs through continuous engagement and mutual
participation with others.
Implications for Policy, Delivery or Practice: These results
have implications for improving therapeutic alliance and
culturally appropriate treatment options for Latino juvenile exoffenders. With this information the mental health system
can consider ways to integrate services in cooperation with
culturally appropriate community based programs and
improve entry and retention of Latino ex-offending youth in
treatment.
Primary Funding Source: Other Govt, NIMH
Call for Panels
Maximizing the Use of the New National Survey Data Sets
Providing Information on Children and Youth with Special
Health Care Needs
Chair: Christina Bethell, Ph.D.
Saturday, June 25 • 2:30 p.m. – 4:15 p.m.
● Comparing and Interpreting Findings on the Prevalence
and Health and Health Care Service Need Characteristics
of Children and Youth with Special Health Care Needs
(CYSHCN) Across Three New National Data Sets
Christina Bethell, Ph.D., M.P.H., M.B.A., Debra Read, M.P.H.,
Paul Newacheck
Presented by: Christina Bethell, Ph.D., M.P.H., M.B.A.,
Director, Oregon Health and Science University,
Mail Code CDRCP, 707 S.W. Gaines Road, Portland, OR
97239-2998; Tel: (503) 494-1892; Fax: (503) 494-2475; Email:
bethellc@ohsu.edu
Research Objective: To compare findings on the prevalence
and health and health care service need characteristics of
children and youth with special health care needs identified
using the same screening method (CSHCN Screener) in the
2001 National Survey on Children with Special Health Care
Needs (NS-CSHCN), the 2000 Medical Expenditures Panel
Survey (MEPS) and the 2003-2004 National Survey on
Children Health (NSCH).
Study Design: Data from the NS-CSHCN, MEPS and NSCH
are used to calculate the proportion of children meeting
criteria for having one or more type of special health care need
using the standardized CSHCN Screener. Child health and
health care service needs as well as sociodemographic
characteristics of CYSHCN are compared to further
understand similarities and differences in the prevalence and
profile of CYSHCN provided by each of these datasets.
Several analyses consider whether differences observed may
be due to variations across surveys in (1) sampling (random
vs. over sampling; household vs. target child interview;
English vs. Non-English language), (2) administration (survey
introduction, order of items, incentives, survey length) and (3)
weighting. Differences in shifts in practice patterns between
survey years (2000 to 2004), such as increased use of
prescription medication among children and higher rates of
provider identification of children with mental or behavioral
health problems (e.g. ADHD), are also considered. In
addition, differences in characteristics of CYSHCN identified
using alternative methods (CSHCN Screener vs. condition
checklists) are also compared to further understand the
overall performance of the non-condition specific,
consequences-based CSHCN Screener across these three new
national data sets. Comparisons are made to the historically
used methods in the National Health Interview Survey.
Population Studied: Children age 0-17 who met standardized
parent-reported criteria for having a special health care need in
the NS-CSHCN, MEPS and the NSCH. (N= 68,217).
Principal Findings: The rate of CYSCHN in the NS-CSHCN is
13.6 (13.4-13.9) vs. 16.2 (14.7-17.7) for MEPS for English
language cases (MEPS English only). Once identified,
CYSHCN identified in each survey do not vary dramatically in
the health and health care service need consequences they
experience. We hypothesize higher rates of identification for
the NSCH due to variations in sampling and administration of
this survey compared to the NS-CSHCN and real shifts in
practice patterns in recent years. Results from this hypothesis
testing will be finalized when the NSCH becomes publicly
available in March 2005. We also hypothesize that
significantly fewer children will be identified using the CSHCN
Screener vs. a chronic condition check-list in both MEPS and
the NSCH and that these children experience more
functioning and health service need consequences compared
to children only identified using a condition check-list.
Conclusions: Important differences in the profile of CSHCN
provided across the new national data sets exist and involve
differences in methodology as well as potentially real
differences shifts in practice patterns and epidemiology of
CSHCN between survey years.
Implications for Policy, Delivery or Practice: Users of the
new national data sets need to understand differences in
methods used across surveys in order to validly interpret
findings on CYSHCN emerging from the NS-CSHCN, MEPS
and the soon to be released NSCH.
Primary Funding Source: none
● Maximizing the Use of the New National Data Sets for
Assessing Children and Youth with Special Health Care
Needs: An Evaluation of Alternative Subgroups for Risk
Adjustment Models
Matthew Bramlett, Debra Read, M.P.H., Christina Bethell,
Ph.D., M.P.H., M.B.A., Stephen Blumberg
Presented by: Debra Read, M.P.H., Oregon Health and
Science University, 3181 SW Sam Jackson Park Road, CB 669,
Portland, OR 97201-3098; Tel: (206) 494-2555;
Fax: (503) 494-4981; Email: readd@ohsu.edu
Research Objective: To identify and test alternative models
for discriminating among children with special health care
needs (CSHCN) identified using the non-condition-specific
CSHCN Screener.
Study Design: Two alternative models for identifying
subgroups of CSHCN identified in the NS-CSHCN and MEPS
were developed to address different research and policy
applications of these data sets. The Frequency Grouping
model assigns CSHCN to subgroups based solely on the
number of screening criteria met (1-5), whereas the Clinical
Grouping model assigns CSHCN to one of four mutually
exclusive subgroups: those whose conditions lead to ongoing
functioning limitations, those whose conditions result
primarily in a need for prescription medication, those whose
conditions result primarily in an increased need for medical
and community-based services, and those who require both
services and prescription medications. The ability of these
models to discriminate between groups of CSHCN was
explored using the NS-CSHCN and MEPS data sets.
Population Studied: Children age 0-17 years with special
health care needs, as determined by the CSHCN Screener.
The CSHCN Screener includes five questions on general
health care needs that could be the consequence of chronic
health conditions (e.g., need for special therapies, or need for
prescription medications); along with follow-up questions to
determine if the health care need is due to a chronic medical,
behavioral, or other health condition.
Principal Findings: Children’s health status, health care
service needs, and medical expenditures vary dramatically
across different robust sub-groupings of CSHCN for each of
the models tested. The Clinical Grouping model is most
discriminating for purposes of interpreting health care needs
for clinically meaningful groups of CSHCN, such as those who
require multiple medical and community based services or
whose primary health need is related to emotional,
developmental or behavioral issues only. The Frequency
Grouping model discriminates among children with higher
versus lower level of severity. Both models predict medical
expenditures and may be particularly useful for purposes of
risk adjustment in multivariate analyses.
Conclusions: When CSHCN are considered as a
homogenous population, many critical variations in health,
health care service need, and healthcare system performance
can be overlooked and can lead to erroneous conclusions and
recommendations for policy and practice.
Implications for Policy, Delivery or Practice: Users of the
new national data sets need to understand differences in
methods used across surveys in order to validly interpret
findings on CYSHCN emerging from the NS-CSHCN, MEPS
and the soon to be released NSCH.
Primary Funding Source: none
● User-Friendly Strategies to Expand the use of New
National Data Sets on Children's Health by Policymakers
and Consumer and Health Care System Leaders
Christina Bethell, Ph.D., M.P.H., M.B.A., Debra Read, M.P.H.,
Nora Wells
Presented by: Nora Wells, Director, Federation For Children
With Special Needs, 1135 Tremont Street, Suite 420, Boston,
MA 02120-2140; Tel: (617) 236-7210; Fax: (617) 572-2094;
Email: nwells@fcsn.org
Research Objective: To develop and evaluate the use of an
online data query tool to expand the use of the National
Survey on Children with Special Health Care Needs (NSCSHCN)and the 2003-2004 National Survey on Children's
Health among federal and state policymakers and program
leaders and family and health care system leaders.
Study Design: Federal and state policymakers and program
administrators and family leaders across the US were engaged
in a five phase process to assess interest, capacity and
support needed to use data resulting from the NS-CSHCN
and other similar data sets (n= 72 representing 36 states).
Phases included (1) in-person focus groups, (2)a standardized
self-reported survey, (3) in-depth structured interviews to
identify preferred features and content for an online data query
tool and resource center and (4) a workshop to further discuss
needs and options for designing the Data Resource Center
(DRC) and (5) an in-person website demonstration and
evaluation session. Input obtained during ten in-person
educational workshops on the DRC and the use of the DRC by
over 12,000 users (65,000 hits) was evaluated to assess the
usability and value of the DRC in expanding the use of
national data sets by non-research audiences essential to
engage in the use of data to inform and stimulate the design
of health care programs and policies for children and youth.
Population Studied: Federal and state Title V leaders in the
area of children and youth with special health care needs
(CYSHCN) and family CYSHCN leaders participating in the
Family Voices consortium. (N = 72 for pretest; N = approx.
12,000 for beta test).
Principal Findings: Over 85% of participants indicated that
they were "extremely interested" in being able learn about and
directly access and query national and state level child health
and health care quality data sets. Over 83% indicated that they
would be "extremely likely" to routinely use a Data Resource
Center website designed to assist them in learning about and
easily using this data. Over 60,000 hits to the DRC were
recorded during the nine month start up period of the DRC.
The vast majority of visits were to use the online interactive
data query tool. Examples of uses of data findings derived
from the DRC include grant applications, legislative testimony,
popular press public education, stakeholder education and
engagement and state block grant needs and performance
assessments as well as many other applications. E-mail and
telephone technical assistance are central to the success of
any DRC-like effort as well as in-person and other more indepth trainings on how to think about, query and
communicate data findings in a scientifically valid and
effective manner.
Conclusions: State and federal policymakers and health care
program leaders as well as family/consumer leaders have a
strong interest in being able to directly access and validly use
data findings from national and state surveys on child and
adolescent health and health care.
Implications for Policy, Delivery or Practice: Without a
DRC-like resource it is unlikely that essential policy, consumer
and health system leaders will make use of the new national
and state data on child and adolescent health and health care
will. Design of any DRC-like resource must be developed with
ongoing and in-depth input from target users. If US health
care policy continues to emphasize consumer engagement it
will be even more important to provide publicly available, nonproprietary DRC-like resources to assist consumers,
policymakers and others to easily access data they would
otherwise not have the skills, capacity or resources to use
Primary Funding Source: HRSA
● Methods for Evaluating Within-State Variation Using the
National Survey of Children with Special Health Care
Needs
Virginia Sharp, M.A.
Presented by: Virginia Sharp, M.A., Senior Research
Associate, Seattle Children's Hospital & Regional Medical
Center, 1100 Olive Way, Suite 500, MPW5-2, Seattle, WA
98101; Tel: (206) 527-5709 x2; Fax: (206) 527-5705;
Email: virginia.sharp@seattlechildrens.org
Research Objective: The primary objectives of this research
project were to (1) develop and test a methodology for
identifying rural-urban differences in access to care for
children and youth with special health care need (CYSHCN)
using the National Survey of Children with Special Health Care
Needs (NS-CSHCN), and (2) evaluate rural-urban differences
in access to care for CYSHCN between two seemingly similar
states, Oregon and Washington.
Study Design: Zip code level Rural Urban Commuting Area
(RUCA) codes were linked to zip code of residence recorded
for all Washington and Oregon respondents to the NSCSHCN and grouped into four categories--urban, suburban,
large town, small town/rural. These RUCA groupings were
used to analyze variables related to access to care and unmet
service needs in the NS-CSHCN.
Population Studied: The population included all children
identified as CYSHCN in the NS-CSHCN residing in
Washington (n=746) and Oregon (n=745). CYSHCN were
identified using the CSHCN Screener, a set of five multi-part
questions that identify children as having special health care
needs based on the consequences of their health condition,
rather than a list of specific diagnoses.
Principal Findings: The NS-CSHCN includes information on
need for and receipt of 14 types of child services and 4 family
support services. At the state level, Oregon and Washington
look very similar, with no statistically significant differences
between the states for any of these 36 variables. However,
when the RUCA codes are used to disaggregate each state’s
data, different patterns of access to care and unmet needs
appear for the two states. For child services generally, in
Oregon children living in suburban areas tend to be less likely
to receive all needed routine preventive care, dental care and
vision services; in Washington, children residing in large
towns are more likely to have unmet needs, especially for
dental care, specialized therapies, mental health care, and
vision services. These same patterns also hold true for family
services. In Oregon, suburban families have more unmet
needs, while in Washington, families living in large towns have
more unmet family service needs. Comparing RUCA
categories across the two states uncovers additional
interesting differences in CYSHCN care needs and patterns of
care.
Conclusions: Even though Oregon and Washington are
generally perceived to be very similar socially, politically,
geographically and in other ways, they are not similar in terms
of rural-urban disparities in access to care for CYSHCN. While
the state sample sizes in the NS-CSHCN were too small to
produce statistically significant differences for most access to
care variables, those rural-urban disparities that were
significant exhibited distinctly different patterns in the two
states.
Implications for Policy, Delivery or Practice: This analysis
highlights the need for more research on both intra- and interstate patterns of health care resource distribution.
Primary Funding Source: none
Call for Panels
Providing Continuity of Coverage to Low-Income Children:
Policy and Program Impacts
Chair: Susan Haber, Sc.D.
Saturday, June 25 • 2:30 p.m. – 4:15 p.m.
● What Happens to Children Who Lose Coverage from
SCHIP or Premium Assistance Programs?
Janet B. Mitchell, Ph.D., Susan G. Haber, Sc..D., Sonja
Hoover, M.P.P.
Presented by: Janet B. Mitchell, Ph.D., Director, Division for
Health Services and Social Policy Research, RTI International,
411 Waverley Oaks Road, Suite 330, Waltham, MA 02452;
Tel: (781) 788-8100 x 135; Fax: (781) 788-8101;
E-mail: jmitchell@rti.org
Research Objective: Evaluate health insurance coverage and
access to care for low-income children who have disenrolled
from Oregon’s SCHIP and premium assistance programs,
and compare differences between the two programs. Income
eligibility requirements are identical for these two state
programs (170% of FPL or less).
Study Design: Telephone interviews were conducted in 2002
with the parents of children who had recently disenrolled from
Oregon’s SCHIP and the state’s premium assistance
program.
Population Studied: Children who have recently disenrolled
from Oregon’s SCHIP program or the state’s premium
assistance program (n=505). Children transitioning to
Medicaid were excluded.
Principal Findings: The most common reasons for loss of
coverage was that parents no longer met, or believed they
would no longer meet, the income eligibility requirements.
While almost all children (85%) had at least one parent who
worked, few had access to employer-sponsored insurance. The
majority of children were uninsured at the time of the
interview, with SCHIP children significantly more likely to be
uninsured than those who had received premium assistance
(67% vs 47%). Uninsured children were more likely to have
lost their usual source of care, to have not seen a physician
since disenrolling, and to report unmet need for care.
Controlling for demographics and health status, there were no
differences between SCHIP and premium assistance
disenrollees in usual source of care, physician visits, or unmet
need; whether the child was currently insured was the most
important predictor.
Conclusions: SCHIP and other public programs for low
income children were intended to serve as a bridge between
Medicaid and private health insurance, particularly as parents
moved into the workforce. Prior studies have documented
high rates of disenrollment from these programs, but little has
been known about outcomes for these children. This study
shows that many of these children have become uninsured.
Although their families’ incomes have increased, they are still
unable to afford insurance. With the loss of coverage, these
children also lose their attachment to a usual source of care
and access to physician services.
Implications for Policy, Delivery or Practice: SCHIP
provides health insurance coverage to children whose family
incomes are too high for Medicaid. Given the high cost of
premiums and lack of access to employer-sponsored
insurance for many working families, however, SCHIP and
other program income eligibility ceilings may be too low.
Policymakers may want to consider either raising the limits or
introducing a graduated premium assistance program (e.g.,
where the size of the premium subsidy declines as income
rises).
Primary Funding Source: AHRQ, David and Lucile Packard
Foundation, HRSA
● Dynamics of Children’s Enrollment in Public Health
Insurance: A Three-State Comparison
Susan G. Haber, Sc.D., Andrew Allison, Ph.D., Elizabeth
Shenkman, Ph.D.
Presented by: Susan G. Haber, Sc.D., Senior Economist,
Division for Health Services and Social Policy Research, RTI
International, 411 Waverley Oaks Road, Suite 330, Waltham,
MA 02452;
Tel: (781) 788-8100 x 152; Fax: (781) 788-8101;
E-mail: shaber@rti.org
Research Objective: Although Medicaid and SCHIP can be
viewed as complementary programs as families’ incomes
fluctuate, few studies have looked at enrollment in public
health insurance (PHI) generally. Previous studies have
mainly looked at Medicaid and SCHIP separately and have
found that many children receive only episodic coverage
through these programs. We examine children’s patterns of
coverage in PHI to understand the relationship between
SCHIP and Medicaid, and to compare children’s coverage
based on type of eligibility (SCHIP, TANF, and poverty-level
Medicaid).
Study Design: We linked SCHIP and Medicaid eligibility
records for children in Kansas, Oregon, and Texas to create
complete records of enrollment in PHI. Transitions between
different types of eligibility, as well as patterns of enrollment in
and disenrollment from PHI, are analyzed using descriptive
and multivariate methods.
Population Studied: Children in Kansas, Oregon, and Texas
enrolled in SCHIP or in Medicaid through TANF or povertylevel eligibility during the first 3-4 years of SCHIP operation.
Principal Findings: A large proportion of SCHIP children in
Kansas and Oregon move directly between SCHIP and
Medicaid eligibility. One-third of SCHIP children in Kansas
and two-fifths in Oregon move directly into Medicaid when
they leave SCHIP. Although only 11% of SCHIP children in
Texas move immediately into Medicaid when they disenroll, a
large proportion re-joins PHI after a 1-3 month break in
coverage. Most children in all three states are continuously
covered by PHI for relatively brief periods of time. Less than
60% of the children in Kansas and less than half in Oregon
were still covered by some type of PHI 12 months after their
initial enrollment. In Texas, less than 30% of Medicaid
children and 55% of SCHIP children still had PHI after 12
months. However, children in Texas are far more likely than
those in Oregon and Kansas to re-enroll after a brief lapse in
eligibility. Within a year after their initial enrollment, 49% of
TANF children and 38% of poverty-level Medicaid children in
Texas have disenrolled from PHI and subsequently reenrolled, compared to 15% or less of the children in Oregon
and Kansas.
Conclusions: There are considerable differences in continuity
of PHI coverage among the states in our study, which may be
related to administrative procedures. Unlike the free-standing
programs in Texas and Kansas, Oregon’s SCHIP is fully
integrated with Medicaid. This likely explains the high rate of
transition between programs in Oregon. The large numbers
of children in Texas who re-enroll in PHI after a brief break in
eligibility suggests that children may be disenrolled for
administrative reasons rather than true changes in eligibility
status.
Implications for Policy, Delivery or Practice: Policymakers
need to understand the extent to which SCHIP operates as a
complement to Medicaid, both to accurately assess the
continuity of PHI coverage provided to low-income children
and to design appropriate policies to educate families and
coordinate coverage as they move between programs and
across eligibility categories. Further work is needed to
understand the impact of brief disruptions in eligibility on
continuity of coverage.
Primary Funding Source: Other Foundation, David and
Lucile Packard Foundation
● Increased Family Cost-Sharing in SCHIP: How Much
Can Families Afford?
Elizabeth Shenkman, Ph.D., Bruce Vogel, Ph.D.
Presented by: Elizabeth Shenkman, Ph.D., Professor,
Department of Epidemiology and Health Policy Research and
the Institute for Child Health Policy, University of Florida, 1329
SW 16th Street, Room 5130, Gainesville, FL 32608;
Tel: (352) 265-7220, ext. 86333; Fax: (352) 265-7221;
E-mail: eas@ichp.ufl.edu
Research Objective: In July 2003, Florida increased the
premium for families from $15 per-family-per-month to $20
per-family-per-month for those receiving subsidized
premiums. The Centers for Medicare and Medicaid Services
later determined that $20 per-family-per-month exceeded
federal cost-sharing limits (5% of family income) for some
families at or below 150% of the federal poverty level (FPL). In
October 2003, Florida reduced the premiums to $15 for those
at or below 150% FPL and kept the premiums at $20 for those
above 150% FPL. During the 2005 session, the Florida
Legislature will consider increasing premiums up to 4% of the
family income effective July 1, 2005. The purpose of our
analyses were to examine the impact of the 2003 premium
increases on children’s disenrollment and to use this
information to estimate the potential impact of the proposed
premium increases on families.
Study Design: We used SCHIP enrollment files and health
care claims/encounter data provided by the state for 2000
through 2004. The Clinical Risk Groups (CRGs) were used to
classify children into health status categories using diagnostic
information found in the claims/encounter data. Cox
proportional hazards models were used to estimate the
responsiveness of disenrollment to premium changes, age,
sex, income, CRG, and months enrolled.
Population Studied: Children in the Healthy Kids Program,
the largest SCHIP program component in Florida
Principal Findings: Prior to the premium increases, about 2%
of the children disenrolled from the program monthly.
Disenrollment increased after the July 2003 premium change
to 3.6% in August 2003 and to 4.7% of the children in
September 2003. When the premiums were reduced, a
decline in disenrollment was observed. Families with incomes
at or below 150% FPL were 36% more likely to disenroll in the
post-premium change period when compared to the prepremium change period. Families in rural areas were 6%
more likely to disenroll post the premium change than
families in urban areas, even after considering the children’s
health status and family income. Children with significant
acute or chronic conditions were 8% to 17% less likely to
disenroll compared to healthy children. Using this
information we estimated a price elasticity for the
disenrollment hazard rate of 2.2, indicating that disenrollment
from SCHIP is very sensitive to price changes. For example,
given this price elasticity, a 10% increase in the monthly
premium would produce a 22% increase in the disenrollment
hazard rate, Similarly, an increase in the premium from $15
per month to $20 per month (a 33% increase), would increase
the disenrollment hazard rate by approximately 73%., or from
a baseline hazard rate of 1.4% to 2.4%.
Conclusions: Small premium increases are likely to have a
large impact on disenrollment. The impacts are greater for
healthy children, lower-income children, and children residing
in rural areas.
Implications for Policy, Delivery or Practice: States need to
consider premium increases carefully and the impact these
increases can have on the lowest income families and those
residing in rural areas. Moreover, premium increases can
contribute to increased disenrollment among healthy children,
which may result in adverse retention in SCHIP.
Primary Funding Source: Other Foundation, The Healthy
Kids Corporation
● The Impact of Premium Increases in SCHIP Programs:
The Experience of Three States
Genevieve M. Kenney, Ph.D., Andrew Allison, Ph.D., Julia
Costich, Ph.D., J.D., Jim Marton, Ph.D., Josh McFeeters,
M.P.P.
Presented by: Genevieve M. Kenney, Ph.D., Principal
Research Associate, The Urban Institute, 2100 M Street, N.W.,
Washington, DC 20037; Tel: (202) 261-5668;
Fax: (202) 223-1149; E-mail: jkenney@ui.urban.org
Research Objective: States increasingly have used premiums
as a cost containment tool in SCHIP programs in recent years.
In 2003 alone, 13 states raised the premiums in their SCHIP
programs. While SCHIP premiums have varied substantially
both across states and over time, very little is known about
how premiums affect enrollment among children. In this
paper, we analyze the impacts of SCHIP premium changes on
enrollment in three different states—Kansas, Kentucky, and
New Hampshire that increased premiums in 2003 to gain
insights about how enrollment responses vary across states
and with the size of the premium increase.
Study Design: The primary data source for this analysis is
state enrollment files for Medicaid and SCHIP. These files
contain information on the child’s age, race, eligibility
category, and residential location. We assess enrollment
patterns during the period prior to the premium hike and the
period following the premium hike. We analyze changes
following the increases in premiums that were introduced in
2003, in monthly enrollment, new enrollment, and
disenrollment. We assess the extent to which disenrollment
due to premium non-payment appears to increase following
the premium hike, and we examine whether the premium
changes have spillover effects on enrollment in Medicaid or in
non-premium paying categories under SCHIP.
Population Studied: The population studied includes
children ages 0 to 18 enrolled in Medicaid or SCHIP in
Kansas, Kentucky, and New Hampshire in the period prior to
and following the premium increases in 2003.
Principal Findings: Our preliminary analysis indicates that
premium increases may have had negative enrollment effects
in all three states. Enrollment declined in the premium-paying
category in Kentucky by about 19 percent following the
imposition of the new $20 per family premium. Enrollment in
that category remained at the lower level until the end of the
study period, nine months after the premium was
implemented. Total enrollment in SCHIP and Medicaid
declined between December 2003 and January 2004 and did
not rise back above the December 2003 level until March
2004. Transfers between SCHIP and Medicaid enrollment
increased slightly after of SCHIP premium hike, but it is
unclear if the premium hike in SCHIP was the cause. Initial
analysis of the data from New Hampshire indicates that
enrollment in the SCHIP program declined by about four
percent after the implementation of the $5 per child premium
increase. The $20 to $30 premium increase for Kansas SCHIP
families in January 2003 coincided with a small drop in the
total SCHIP caseload, which began in February and lasted
approximately three months. Caseload growth, which had
been nearly continuous since SCHIP implementation in 1999,
did not resume until approximately 10 months following the
increase in premiums.
Conclusions: This study indicates that premium increases
reduce enrollment in public health insurance programs.
Reduced enrollment growth or declines in enrollment can
persist for several months after a premium increase. Future
work will address the consequences of premium increases on
overall coverage levels.
Implications for Policy, Delivery or Practice: This research
can help policymakers assess the impact on program
enrollment of increasing premiums in public health insurance
programs.
Primary Funding Source: Other Foundation, The David and
Lucile Packard Foundation