suffer premature mortality due to quality
problems or disparities in health care delivery.
Principal Findings: Study 1: Each of 4 quality
improvement interventions to reduce or lower
NICU length of stay for Medicaid-covered very
low birthweight infants would save Medicaid
(State and Federal combined) almost $50 million
a year in hospital costs. Potential child life years
gained ranged from several thousand to
hundreds of thousands depending on the topic.
Conclusions: Now that there is evidence of the
effectiveness of quality improvement
interventions in children's health care, available
data and data sources can be used to estimate
roughly return on investment to large payers of
children's health care for some cost-saving
interventions, and impact on children's
prevented mortality. More research on quality
improvement and disparities reduction
effectiveness is needed to expand this approach
to other leading cost centers for Medicaid and
other leading causes of child mortality (e.g.,
injury). Additional large-scale and longitudinal
data sources linking health care interventions to
expenditures (beyond the hospital) and health
outcomes are essential to presenting for
presenting a comprehensive picture of long- and
short-term impacts.
Implications for Policy, Delivery or Practice:
Public and private policymakers may be more
inclined to focus on aspects of children's health
care delivery based on carefully-done analyses of
impact. Nonetheless, given children's relatively
low mortality and hospitalization rates compared
to older adults, more than numbers may be
needed to make the case for children compared
to other populations.
Primary Funding Source: AHRQ, All Children's
Hospital; National Initiative for Children's Health
Care Quality; Center for Health Care Services;
UMDNJ;MUSC
Call for Panels
Call for Panels
The Economics of Child Health
Chair: Denise Dougherty, Ph.D.
Saturday, June 24 • 10:15 a.m. - 11:45 a.m.
„ Saving Money, Saving Lives: Child Health
Care Quality Improvement
Denise Dougherty, Ph.D., Bernard Friedman
(Study 1), Ph.D., CMS Neonatal Outcomes ROI
Group (Study 2), varied, Charles Homer (Study
2), M.D., Lisa Simpson (Study 2), M.B., B.Ch.,
Melissa Romaire (Study 2), M.P.A.
Presented by: Denise Dougherty, Ph.D., Senior
Advisor, Child Health and Quality Improvement,
Office of Extramural Research, Education, and
Priority Populations, Agency for Healthcare
Research and Quality, 540 Gaither Rd, Rockville,
MD 20850; Tel: (301) 427-1868; Fax: (301) 4271562; E-mail: Denise.Dougherty@ahrq.hhs.gov
Research Objective: To demonstrate how a
series of evidence-informed health care quality
improvement initiatives can 1) provide a financial
return on investment to Medicaid (neonatal
outcomes improvement); 2) increase child
potential life-years gained (
Study Design: Each study used existing
literature demonstrating impacts of quality
improvement initiatives. In study 1, we
extrapolated estimates from 4 quality
improvement approaches that would reduce
hospitalization costs (e.g., smoking cessation,
reduced infection rates in Neonatal Intensive
Care Units) to national numbers of Medicaidcovered mothers or infants, and used charge
data from the Healthcare Cost and Utilization
Project state inpatient database to project how
much Medicaid could saved annually by
implementing the known-effective neonatal
improvement approaches. In Study 2, we used a
similar literature-informed approach extrapolated
to national mortality data and using standard
approaches to estimating potential life-years lost
to estimate potential child live years gained from
each of 4 quality improvement or disparities
reduction efforts (e.g., improvements in cancer
care for minority children, reduction in SIDS
deaths for African-Americans, reductions in
hospital inpatient deaths due to medical errors).
Population Studied: Study 1: very low
birthweight children and their mothers covered
by Medicaid. Study 2: American children likely to
„ Saving Money, Saving Lives: A Statewide
Approach for Perinatal Care
Edward Donovan, M.D.
Presented by: Edward Donovan, M.D., Director,
Child Policy Research Center, Cincinnati
Children's Hospital Medical Center, 3333 Burnet
Avenue, Cincinnati, OH 45229-3039; Tel: (513)
636-0182; Fax: (513) 636-0171; E-mail:
edward.donovan@cchmc.org
Research Objective: To demonstrate the
potential impact of a State-wide multi-provider
system approach to improving perinatal care,
specifically by reducing the risk of very preterm
birth and regionalizing care.
1
Study Design: Using State birth certificate files,
we determined race and regional differences in
risk of very preterm birth from 25 through 28
weeks of gestational age. We estimated potential
return on investment based on a 1996 analysis
by Luke and colleagues and the fact that roughly
30% of Ohio births are covered by Medicaid. We
also estimated the percentage of very pre-term
births in regionalized subspecialty settings in
Region 1. Our belief in the effectiveness of quality
improvement is based in part on the impressive
results of the Cincinnati Children's Hospital
Medical Center's Pursuing Perfection
demonstration project and a similar project in
Jonkoping County, Sweden.
Population Studied: Ohio children born at 25
through 28 weeks gestational age, overall and by
race and Ohio perinatal region.
Principal Findings: About 25% of very pre-term
births occur outside subspecialty centers in
Region 1. We found approximately 300 excess
African American very pre-term births across
Ohio per year. Differences between the best and
worst performing regions represent
approximkately 134 potentially preventable very
pre-term white births and 173 potentially
preventable very pre-term African-American
births. Annual savings for eliminating regionassociated preventable very pre-term births are
estimated at $60 million a year, with savings of
$20 million to Medicaid.
Conclusions: Applying quality improvement
strategies from Pursuing Perfection
demonstrations to a state-wide effort to improve
perinatal care in Ohio's perinatal regions could
substantially reduce mortality, disparities in
mortality, and provide savings to Ohio's payers.
Implications for Policy, Delivery or Practice:
These findings will be used to support a
proposal to the Ohio Department of Health to
further implement quality improvement
initiatives.
Primary Funding Source: No funding source,
Cincinnati Children's
using economic analysis, and engage in
discussion with CHSR participants about future
steps.
Study Design: n/a
Population Studied: n/a
Principal Findings: n/a
Conclusions: to be made at the session
Implications for Policy, Delivery or Practice: It
is critical for those interested in policy-relevant
child health services research to understand the
perspectives of decisionmakers in the private
health care sector.
Primary Funding Source: Kaiser
„ Making Children The Nation's First Focus
Christine Ferguson
Presented by: Christine Ferguson, Chief
Executive Officer and Director, c/o America's
Promise, First Focus, 909 North Washington
Street, Alexandria, VA 22314; Tel: (703) 684-5000;
Fax: ; E-mail: christinef@firstfocus.org
Research Objective: As Chair, Christine
Ferguson will provide an overview of the
purposes of First Focus, introduce the speakers,
and engage them and session participants in a
discussion of next steps in efforts to ensure that
the impacts of policy on children's health and
well-being, now and in the future, are well
explicated and understood in policy
communities.
Study Design: Not a study, but creation of an
organization: In 2004, The David and Lucile
Packard Foundation and Atlantic Philanthropies
undertook an effort to assess strategies and
options to protect and grow federal investments
for children and their families in our nation’s
budget. As a result of this effort they funded the
launch of the First Focus.
Population Studied: n/a
Principal Findings: n/a
Conclusions: n/a
Implications for Policy, Delivery or Practice:
To be developed during the session discussion.
Primary Funding Source: Other Foundation
„ Comments From a Private Sector
Policymaker
Paul Wallace, M.D.
Presented by: Paul Wallace, MD, TBA (currently,
Executive Director, Care Management Institute,
Kaiser, One Kaiser Plaza, Oakland, CA 94612;
Tel: (510) 271-5655; Fax: (510) 267-2107; E-mail:
Paul.Wallace@kp.org
Research Objective: Dr. Wallace will provide
comments on the challenge of making the case
for investing in children's health and health care
2
important to have a written care plan for their
child, only one-third said they currently had one.
Most parents (80%) indicated that written care
plans should be developed in partnership with
health care professionals, and many indicated
they would use sample written care plans or
forms for developing a plan for their child.
Conclusions: Written care plans could
potentially be useful for many families in
planning the care of their child in collaboration
with a health care professional. Parents
expressed concerns including difficulties in
adherence to the plan and the need for
assistance in developing the care plan. Providing
a care plan methodology that maintains history,
current and future needs and goals is important.
Parents want easy-to-work-with and flexible
templates or forms for written care plans.
Parents said written plans could eliminate the
need for repeating information, and help keep all
the important information in one place. This
would be helpful in emergency situations, school
settings and health care settings. In general
parents expressed that written care plans would
facilitate communication between those caring
for the child.
Implications for Policy, Delivery or Practice:
This study found that parents of children and
youth with chronic health conditions desire
meaningful and effective care planning and
coordination tools, such as written care plans.
Reasonable assurances relating to adherence to
the care plan need to be addressed by both
professionals and parents. Such plans could
help parents and health care providers save time,
stay well-informed about the plan of care
through changes in the status of child’s health,
and deliver efficient, effective and timely health
care and related services to the child.
Primary Funding Source: Other Government,
WA State Department of Health
Call for Panels
Care Coordination for Children with Special
Health Care Needs
Chair: Virginia Sharp, M.A.
Saturday, June 24 • 10:15 a.m. - 11:45 a.m.
„ Written Care Plans for Children with
Chronic Health Conditions: What do families
think?
Shervin Churchill, M.P.H., Linda Barnhart, R.N.,
Jean Popalisky, R.N., M.N., Nanci Villareale,
R.N., M.S.N.
Presented by: Linda Barnhart, RN, Nursing
Consultant, Dept of Health, Community and
Family Health, Children with Special Needs
Program, PO Box 47880, Olympia, WA 98504;
Tel: (360) 236-3491; Fax: (360) 586-7868; E-mail:
linda.barnhart@doh.wa.gov
Research Objective: Increasing emphasis on
care planning and coordination for children with
chronic health conditions has lead to many
efforts in this area. However, little is known
about what parents consider important in
developing, and maintaining a written care plan.
This qualitative study illuminates parents’ views
about the concept of care planning through
written care plans.
Study Design: Based on parent focus groups, a
27-item web-based questionnaire was developed
for parents of children with chronic health
conditions. The survey was piloted and refined.
The questionnaire was then linked to several
websites frequented by parents of children with
special needs, and information about the
questionnaire was sent to a variety of health care
professionals, parent groups and disease specific
listservs for distribution. The anonymous survey
included qualitative questions and selected
demographic questions. Parents were also asked
about their child’s main diagnosis, and if they
considered their child to have physical,
emotional/behavioral, and/or developmental
conditions.
Population Studied: Parents of children and
youth with chronic health conditions, ages 0-21
years, who responded to an Internet survey
about care planning, in Washington State.
Principal Findings: Seventy-three (73) percent of
respondents had children 0-12 years old, and
27% had teens, or young adults, 13-21 years old.
A majority (95%) indicated that the parent was
the primary coordinator of care for the child.
While 84% of parents indicated that it would be
„ Comparing Care Coordination Delivery
Methods for Children with Special Health
Care Needs: Health Plan versus Pediatric
Practice
Jean Popalisky, R.N., M.N., Tracy Fitzgibbon,
R.N., Virginia Sharp, M.S., Kristin Myers, John
Neff, M.D.
Presented by: Tracy Fitzgibbon, R.N., CSHCN
Project Adminstrator, Care CoordinationBurlington, Regence BlueShield, 333 E. Gilkey
Rd., Burlington, WA 98233; Tel: (360) 755-4446;
Fax: ; E-mail: TFitzgib@regence.com
Research Objective: This study set out to
determine the best practice for providing and
3
financing care coordination services for families
of children with special health care needs
(CSHCN).
Study Design: The health plan used Clinical Risk
Groups (CRG) software to identify CSHCN.
Families were screened by telephone to
determine need for care coordination services.
Families with care coordination needs were
placed in either an active care coordination
program within the health plan or followed to
address future needs. Level of service, nurse
time for care coordination, and a follow-up
screener with the family were used to evaluate
program efficiency and effectiveness.
Pediatric clinics involved in the study used a
combination of self-selection and enrollment
data provided by the health plan to identify
families. Primary care providers tracked care
coordination activities over a six month period
using a tracking form. They were asked to
complete a family-centered care plan for all
children requiring care coordination.
Population Studied: Children with special
health care needs 0-18 years of age covered by
Regence Blue Shield in five Washington
counties.
Principal Findings: Health plan care managers’
interactions with members included educating
them about the health care system and services
(32%), needs and health assessment (30%),
community service referral and coordination
(22%) and assisting with health plan issues
(13%). Physician offices spent the bulk of their
time doing face-to-face and telephone contact
with their special needs patients, providing
family support by advising the families on home
management, advocacy with schools and
specialty care providers, and meeting the
family’s immediate needs (49%); disease
management activities such as collecting,
interpreting, and explaining clinical data (28%);
managing medication and equipment needs
(13%) and referrals for specialty care (10%).
Engagement rates of health plan and primary
care setting varied considerably. The health plan
identified 315 CSHCN for screening for care
coordination needs, but provided care
coordination intervention to only 46 CSHCN
(14.6%).
The primary care clinics identified 200 children
for care coordination and interacted with 167
(83.5%) of these children.
Conclusions: Health plan care management
activities are contextually different than those
performed in the primary care setting. Both types
of interventions are beneficial to the families of
special needs children. The “best” method of
providing care management to the families of
CSHCN is through an interactive partnership
between the health plan and the primary care
physician.
The higher engagement rate with the family at
the pediatric office points to a more effective
method of reaching families in need of care
coordination. A mechanism for reimbursing the
primary care physician for care coordination
activities needs to be developed and agreed
upon between the health plan and primary care
physicians.
Implications for Policy, Delivery or Practice:
Given the high engagement rate of primary care
physicians with families of CSHCN, there is
strong evidence for vending the care
coordination activities back to the primary care
practice. Financial incentives for the primary care
physician and documented evidence of care
coordination activity for the health plan need to
be established.
Primary Funding Source: HRSA, Maternal and
Child Health Bureau
„ Measuring Coordination of Care for
Children With Special Health Care Needs:
Alternative Methods and Findings in National
and State Level Surveys
Christina Bethell, Ph.D., M.B.A., M.P.H.
Presented by: Christina Bethell, Ph.D., M.B.A.,
M.P.H., Director, The Child and Adolescent
Health Measurement Initiative, Oregon Health &
Science University, 707 SW Gaines Road,
CDRCP, Portland, OR 97239-2998; Tel: (503)
494-1892; Fax: (503) 494-2475; E-mail:
bethellc@ohsu.edu
Research Objective: To compare care
coordination (CC) measurement methods and
findings for children with special health care
needs (CSHCN) in national and state level
surveys.
Study Design: CC survey items were identified
and measures constructed using data from the
National Survey of Children with Special Health
Care Needs (NS-CSHCN), the National Survey of
Children's Health (NSCH) and the Consumer
Assessment of Health Plans Survey-Children
with Chronic Conditions (CCC). Methods and
findings were compared both conceptually and
statistically for all and subgroups of CSHCN,
who were identified using the same CSHCN
Screener across all data sets.
Population Studied: Nationally representative
samples of children from the NS-CSHCN
(n=372,174) and NSCH (n = 102,353) and
4
children represented in CCC data in one state
Medicaid program (n=10,792)
Principal Findings: The NS-CSHCN includes 8
relevant items and focuses on parent perceived
need for and provision of professional CC. The
NSCH includes 9 items focused on whether
CSHCN get help accessing needed care from
specialists and/or other special services when
problems arise and also receive follow-up from
their personal doctor or nurse (PDN). The CCC
focuses on whether CSHCN receiving care from
more than one provider get CC assistance, a
method used to assess CC in the upcoming
2005-2006 NS-CSHCN.
In the NSCH over 60% of CSHCN with a PDN
needed specialist and/or other special care in the
past year. About 55% of these received follow-up
from their PDN after specialized services. Over
20% had problems accessing care and 74% of
these got help from their PDN to access care.
Approximately 52% received both help (if
needed) and follow up. In the CCC, 56% of
CSHCN needed care from more than one
provider and 55.6-72.5% of CSHCN across 14
health plans received CC help. CSHCN with a
PDN were more likely to have received CC (OR
1.89). In the NS-CSHCN only 11% of CSHCN had
parents reporting needing professional CC.
CSHCN experiencing emotional or behavioral
problems were more likely to report such a need
(20.5%) as were children with five or more
service needs (18.1%). About 20% did not
receive needed professional CC and 30%
needing a professional CC said they usually or
always received it. Nearly 50% said the
professional care coordinator operated out of
their child's primary care provider's office.
Wide, significant variations exist across states
and sociodemographic, insurance and health
status subgroups of CSHCN for NSCH and NSCSHCN findings.
Conclusions: Measurement of CC for CSHCN
varies by whether professional or primary-care
based CC is evaluated and whether objective vs.
subjective screening criteria determine the need
for care coordination. Methods also vary in
terms of whether continuity of care and having a
personal doctor or nurse are incorporated into
the concept of CC as well as whether both help
accessing care and integrating care are included.
Regardless of methods used, a large proportion
of CSHCN who need CC appear to have some
unmet needs in this area.
Implications for Policy, Delivery or Practice:
Given the importance of CC to the quality of care
for CSHCN, advances can and should be made
to further validate and align measurement
methods.
Primary Funding Source: HRSA, MCHB
Call for Panels
Powerful Data, Meaningful Answers -- The
HCUP Kids' Inpatient Database (KID) and the
Nationwide Inpatient Sample (NIS)
Chair: Anne Elixhauser, Ph.D.
Saturday, June 24 • 1:45 p.m. - 3:15 p.m.
„ Variation in the Use of Intracranial Pressure
Monitoring and Mortality in Critically Ill
Children with Meningitis in the United States
John M. Tilford
Presented by: John M. Tilford, Associate
Professor, Health Economics, Center for Applied
Research and Evaluation Department of
Pediatrics College of Medicine, University of
Arkansas for Medical Sciences, AR, E-mail:
TilfordJohnM@uams.edu
Research Objective: To describe patient and
hospital characteristics associated with the use
of intracranial pressure (ICP) monitors and inhospital mortality in critically ill children with
meningitis.
Study Design: A retrospective analysis was
performed using the 1997 and 2000 Kids’
Inpatient Database (KID) from the Healthcare
Cost and Utilization Project (HCUP) family of
hospitalization databases. Hospitalizations from
the KID with an ICD-9-CM primary or secondary
diagnosis code for meningitis and an ICD-9-CM
procedure code for mechanical ventilation were
selected and weighted to produce nationally
representative estimates. We also created an
indicator variable for whether the child received
ICP monitoring from ICD-9-CM procedure codes
and compared rates of ICP monitoring and inhospital mortality by selected patient and
hospital characteristics in univariate and
multivariate analyses. Finally, we used propensity
score matching methods to compare mortality
rates in children treated with and without an ICP
monitor.
Population Studied: All children younger than
19 years of age with a hospitalization for
bacterial, viral and fungal meningitis (ICD-9-CM
diagnosis codes: 320.0-320.3, 320.7-320.9, 321.0321.4, 321.8, 322.0-322.2, 322.9) requiring
mechanical ventilation (ICD-9-CM procedure c
Principal Findings: There was little difference in
the number of hospitalizations between the two
5
periods with 1,067 in 1997 and 1,170 in 2000.
Most of the hospitalizations (79%) involved
infants less than 1 year of age. ICP monitors were
used in 7% of hospitalizations with rates
increasing by age. In-hospital mortality was
19.6% and also increased with age. Other factors
associated with use of ICP monitoring were not
associated with variations in in-hospital
mortality. In the propensity score matched
sample, there was no difference in mortality
between subjects with or without an ICP
monitor, but LOS and hospital charges were
higher in the group with ICP monitoring.
Conclusions: Factors associated with greater
use of ICP monitoring did not translate into
reduced in-hospital mortality. Findings from a
propensity score-matched sample did not
support a protective effect of ICP monitoring.
Implications for Policy, Delivery or Practice:
Use of ICP monitoring varies considerably by
type of hospital and region of the country due in
large part to lack of guidance on whether
monitoring improves outcome. This study
cannot advocate for or against the use of ICP
monitoring in critically ill children with
meningitis, but illustrates some of the difficulties
associated with trying to address this question in
clinical trials.
Primary Funding Source: n/a
traffic accident involving other off-road motor
vehicles based on E-codes 821.0, 821.1, 821.8,
and 821.9. To avoid double-counting,
hospitalizations involving transfers to another
sho
Principal Findings: Hospitalizations for ATV
injuries increased substantially between 1997
and 2000 consistent with other reports. Injury
severity also increased between the two periods.
Rates of ATV hospitalizations were highest for
adolescent white males. Approximately 1% of
hospitalizations resulted in in-hospital death.
Total charges for ATV hospitalizations over the
study period were $74,367,677.
Conclusions: The study provides support for a
substantial increase in ATV-related
hospitalizations involving children. Continued
surveillance of trends in hospitalizations for ATVrelated injuries appears warranted in
coordination with efforts to reduce their
incidence.
Implications for Policy, Delivery or Practice:
Policies to prevent ATV-related injuries have the
potential to reduce the burden of injuries to
society and families. Families need to be aware
of the risks involved in allowing children to ride
on or drive ATVs.
Primary Funding Source: none
„ Pediatric Hospitalizations for Mental
Health and Substance Abuse Conditions in
US Community Hospitals, 1993-2003
Pamela L. Owens, Ph.D., Sarah M. Horwitz,
Ph.D., Joseph Woolston, M.D., Anne Elixhauser,
Ph.D.
„ National Hospitalization Impact of
Pediatric All-Terrain Vehicle Injuries
John M. Tilford
Presented by: John M. Tilford, , Associate
Professor, Center for Applied Research and
Evaluation Department of Pediatrics College of
Medicine, University of Arkansas for Medical
Sciences,.AR, E-mail: TilfordJohnM@uams.edu
Research Objective: To characterize injury rates,
patterns of injury, hospital length of stay, and
hospital charges associated with all-terrain
vehicle (ATV) injuries in a nationally
representative sample.
Study Design: A retrospective analysis was
performed using the 1997 and 2000 Kids'
Inpatient Database (KID) from the Healthcare
Cost and Utilization Project (HCUP) family of
hospitalization databases. Hospitalizations from
the KID with external cause-of-injury codes (Ecode) consistent with off-road ATV-related
injuries were selected and weighted to produce
nationally representative estimates. ICDMAP-90
software was used with ICD9-CM diagnosis
codes to produce injury severity scores.
Population Studied: All children less than 19
years of age with a hospitalization for a non-
Presented by: Pamela L. Owens, PhD, Research
Fellow, 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:
pamela.owens@ahrq.hhs.gov
Research Objective: To examine national trends
in pediatric inpatient care for mental health and
substance abuse (MHSA) conditions in US
community hospitals between 1993 and 2003.
Study Design: A retrospective trend analysis was
performed using the 1993-2003 Nationwide
Inpatient Sample (NIS) from the Healthcare
Cost and Utilization Project (HCUP).
Hospitalizations from the NIS with a principal or
secondary ICD-9-CM diagnostic code for mental
health and substance abuse (MHSA) conditions
were selected and grouped into three categories
(principal and secondary MHSA diagnoses, only
principal MHSA diagnosis, only secondary
MHSA diagnosis). The Clinical Classification
6
Software for Mental Health and Substance
Abuse (CCS-MHSA) was used to further classify
diagnoses into MHSA categories. Trend analyses
were stratified by age (< 1 year, 1-4 year, 5-10
year, 11-14 year, 15-17 year).
Population Studied: All hospitalizations for
children and adolescents less than 18 years of
age.
Principal Findings: The percent of
hospitalizations related to MHSA conditions
increased dramatically over the ten years, in
almost all age groups. The most dramatic
increase was evident among 15 to 17 year olds
with nearly 1 in 4 hospitalizations being related
to MHSA by 2003. Within specific age groups,
other variations across time included source of
admission, diagnostic patterns, length of stay,
expected payer, region, and a disproportionate
increase in total charges.
Conclusions: This study provides support that
there has been a substantial increase in pediatric
hospitalizations in US community hospitals for
MHSA, which is often considered the most
costly and most restrictive type of psychiatric
care. Hospitalization rates for these conditions
should be monitored closely in coordination with
community-based services aimed at addressing
the MHSA needs of children and adolescents.
Implications for Policy, Delivery or Practice:
The results further suggest that since changes
were noted across time, there is the potential to
influence hospitalization rates. Policies directed
at the accessibility and affordability of
appropriate community-based services may be
one method of preventing unnecessary
hospitalizations for MHSA conditions.
Primary Funding Source: none
20037; Tel: 202-261-5374; Fax: 202-223-1149; Email: ihill@ui.urban.org
Research Objective: A growing proportion of
Medicaid and SCHIP enrolled CYSHCN are
included in mandatory capitated managed care
plans. Policy makers are concerned that
managed care plans do not have sufficient
experience serving the varied needs of CYSHCN.
States are encouraged to use contracts with
managed care plans as mechanisms to establish
minimum standards for the composition of the
provider panels, the scope of covered benefits,
and whether care is coordinated internally and
with outside agencies. Contract requirements
may not be effective tools if they are not fully
enforced; alternatively, they may not be binding if
market pressures force the plan to provide more
generous coverage. In this study we examine the
association between specifications in state
managed care contracts and perceived access to
care, plan adequacy, and satisfaction.
Study Design: Information extracted from state
Medicaid and SCHIP managed care contracts
from 2000 was linked to household survey data
from the National Survey of CYSHCN. Bivariate
and multivariate analyses are used to examine
the association between individual contract
specifications and the reported adequacy of the
insurance plan, the extent to which care is family
centered, and reported unmet needs. Analyses
control for child demographics, family structure,
maternal education, and household income.
Population Studied: CYSHCN aged 0-17 years,
enrolled in capitated plans
Principal Findings: Bivariate analyses indicate
that selected contract requirements result in
improved outcomes. For example, the presence
[absence] of requirements for full mental health
coverage result in higher [lower] rates of
perceived adequacy (53% [45%]), and lower
[higher] levels of unmet need (22% [27%]).
Similar patterns are seen for full specialty
coverage. The reverse association is found when
plans are required to have a preventive medical
necessity standard and to coordinate with
external agencies. Multivariate results that
examine the effects of contract specifications
jointly find that few individual contract
characteristics are significant. Factor analysis will
be used to identify latent factors underlying
multiple contract specifications and the
association between those factors and the
outcomes of interest.
Conclusions: Some managed care contract
requirements, such as having comprehensive
mental health or specialty care coverage, appear
to have positive effects on satisfaction and
Call for Panels
Access and Quality Impacts of Medicaid and
SCHIP Managed Care
Chair: Amy Davidoff, Ph.D.
Saturday, June 24 • 1:45 p.m. - 3:15 p.m.
„ Is There a Link Between State Medicaid and
SCHIP Managed Care Contract Provisions
and Satisfaction and Access for Children with
Special Health Care Needs?
Amy Davidoff, Ph.D., Ian Hill, M.S.W, M.P.P, Ian
Hill, M.S.W., M.P.P., Anne Markus, J.D., Ph.D.
Presented by: Ian Hill, M.S.W., M.P.P., Senior
Research Associate, Health Policy Center, Urban
Institute, 2100 M Street N.W., Washington, DC
7
access outcomes for CYSHCN. The
requirements for full coverage of mental health
and specialty services increase the likelihood that
services are received and that families perceive
that coverage is adequate to meet the needs of
their child. However some other requirements
do not appear to generate the desired results.
The different patterns may reflect the underlying
rationale for the policy. States experiencing
access problems for CYSHCN may incorporate
new contract requirements, resulting in a
spurious negative correlation between the
contract requirement and the desired outcome.
Implications for Policy, Delivery or Practice:
State contracts with managed care plans likely
represent a useful mechanism to help ensure
that plans meet the needs of CYSHCN. However
some plan requirements may be more effective
in achieving the policy outcomes than others.
Furthermore, mechanisms such as regular
monitoring and reporting on quality of care may
be equally important. Finally, states must
implement mechanisms to enforce the
provisions in state contracts.
Primary Funding Source: HRSA
probability models estimated the effects of MC
relative to FFS on the probability of using well
care services. The models controlled for child
and family demographics and plan
characteristics. Difference-in-difference estimates
captured the effects of managed care on racial
and ethnic subgroups.
Population Studied: Maryland Medicaid/SCHIP
children aged 3-6 and adolescents aged 12-21
from 1997 and 2004.
Principal Findings: The percentage of children
receiving a visit increased from 41.9% under FFS
to 55.7% under MC. Under FFS, white and
Hispanic children had similar rates of preventive
service use while black children were significantly
less likely to receive services. MC had significant
positive effects on white children (+4.0%), and a
differential positive impact on black (+2.6%) and
Hispanic (+4.9%) children. There were equally
dramatic post MC increases in the percentage of
adolescents receiving a well care visit (21.1% in
1997 and 33.1% in 2004). Use rates for white
adolescents increased significantly (+5.0%)
under MC with positive differential effects for
black (+4.4%) and Hispanic (+6.9%)
adolescents. The addition of controls reduced
the magnitude of estimated effects of MC, but
effects remained significant for both children and
adolescents.
Conclusions: The transition to MC in Maryland
Medicaid resulted in increased use of well care
services for children and adolescents. The
positive differential effects on black and Hispanic
children reduced preexisting disparities in use of
services. Relative to FFS, black and Hispanic
children are more likely to receive preventive
treatment under MC than are white children. The
addition of control variables such as age, gender,
pre-existing health conditions and residence did
not mitigate the observed improvements in
access.
Implications for Policy, Delivery or Practice:
The transition to MC dramatically enhanced
access to preventive services for children and
adolescents. Managed care provided Maryland
with a level of control over care delivery that was
unattainable under FFS. The state can direct the
practices of participating MCOs in a manner that
could not have been accomplished under a FFS
approach such as mandated MCO outreach and
language appropriate assistance.
Primary Funding Source: none
„ Evaluating the Impact of Medicaid
Managed Care on Disparities in Health Care
Access for Children
Todd Eberly
Presented by: Todd Eberly, Senior Analyst,
Center for Health Program Development and
Management, University of Maryland Baltimore
County, 1000 Hilltop Circle, Baltimore, MD
21250; Tel: 410-455-1657; Fax: 410-455-6850; Email: Todd Eberly [teberly@chpdm.umbc.edu]
Research Objective: Faced with budgetary
limitations, many states have replaced traditional
fee-for-service (FFS) Medicaid programs with
managed care (MC) programs whereby private
insurers provide health care services. Managed
care was expected to increase preventive care
use via access to primary care providers and
quality monitoring requirements. Concerns were
expressed that vulnerable populations could
have difficulty navigating MC systems. Maryland
implemented a Medicaid MC program in 1998,
enrolling nearly 80 percent of all state recipients.
The objective of this study is to determine the
effect of the MC transition on child and
adolescent access to preventive health services
with an emphasis on the impact on health
disparities.
Study Design: Service utilization and enrollment
demographic data for children in Maryland
Medicaid were pooled for 1997 and 2004. Linear
8
„ What Are The Effects of Medicaid and
SCHIP Managed Care on Children With
Chronic Health Conditions?
Amy Davidoff, Ph.D., Ian Hill, M.S.W., M.P.P.,
Brigette Courtot, Emerald Adams, Emerald
Adams
and prescription drug use (-9.6%). Special MC
programs for children with CHC are associated
with increased physician visits. Few significant
effects are identified for children without CHC.
Conclusions: Our results suggest that the
effects of MC in Medicaid and SCHIP operate
primarily on children with CHC. Relative to FFS,
mandatory MC programs are associated with
reduced use of services commonly used by
children with CHC. The addition of behavioral
health or specialty carve-outs is associated with
even greater reductions in use. Reductions in ER
and hospital use are suggestive of improved
outpatient management; it is not possible to
determine whether reductions in other services
represent better care management or skimping.
However, despite the reductions in use, we did
not observe a corresponding increase in
perceived unmet need, thus, the net change may
represent improved care management.
Implications for Policy, Delivery or Practice:
Much debate surrounds the issue of whether MC
can work for children with CHC. In theory, MC
could improve coordination and integration of
care, but advocates are concerned that incentives
to control costs may lead plans to under-serve
these vulnerable children. This study does not
resolve this debate, but suggests that MC is
associated with improved outpatient
management without increases in unmet need,
and that specialty managed care models can
facilitate access to physician care.
Primary Funding Source: HRSA
Presented by: Amy Davidoff, Ph.D., Assistant
Professor, Public Policy, University of Maryland
Baltimore County, 1000 Hilltop Circle, Baltimore,
MD 21250; Tel: 410-455-6561; Fax: 410-455-1172;
E-mail: davidoff@umbc.edu
Research Objective: Managed care (MC) is an
established feature of many Medicaid programs
but is relatively new for some children with
chronic health conditions (CHC). The effects of
MC may be particularly strong for children with
CHC, for whom health plans have strong
incentive to coordinate care. Alternatively,
elevated baseline use by children with CHC may
be appropriate given their greater needs; MC
may exert its effects by disrupting established
provider relationships. The use by capitated
plans of behavioral health or specialty “carveouts,” while intended to direct children to
appropriate systems of care, may create
fragmentation and access barriers. MC programs
designed specifically for children with CHC may
ameliorate negative effects. The objective of this
study is to examine the effect of different types of
mandatory MC programs within Medicaid and
SCHIP on children with CHC.
Study Design: Pooled data from the National
Health Interview Survey (1997-2002) were
supplemented with county, year, and population
specific data on Medicaid and SCHIP MC
program types, assembled from annual CMS
Medicaid MC Enrollment Reports and other
sources. Children with CHC were identified
based on parent report of diagnosed conditions
or activity limitations. MC data were linked to
children based on state and year specific
eligibility for Medicaid or SCHIP. Linear
probability models estimated the effects of MC
program types relative to fee-for-service (FFS) on
access and use for publicly insured children, with
and without CHC.
Population Studied: Medicaid and SCHIP
eligible and enrolled children
Principal Findings: Relative to FFS, mandatory
capitated programs without carve-outs are
associated with decreased physician visits,
reduced likelihood of a specialist visit (-7.2%), ER
visits (-7.6%) and hospital stays (-3.1%). When
MC programs include carve-outs we also
observe reduced probability of mental health
specialty visits (-7.8%), vision care visits (-6.4%)
9
prompting systems and parent education
materials, and provider characteristics (gender,
FTE, age) was assessed. Informant interviews
(N=11 providers, N=6 health system leaders,
presentations at pediatric business meetings and
a system-wide strategic meeting was conducted
focusing on how findings can be reported and
used to shape and stimulate QI. Hierarchical
linear modeling assessed the presence of
provider level variations after adjustment for
child characteristics and provider and office-level
factors associated with these variations.
Population Studied: 5003 children under age 4
who are enrolled in a managed care organization
in the Pacific Northwest and the 56 pediatric
providers from whom these children had at least
one well visit in the past year.
Principal Findings: ProPHDS scores vary
significantly across pediatric offices on 4 of 6
quality measures and for all measures across
individual providers. Quality scores range from
25-81 with no provider or office scoring highest
or lowest on any measure. Nearly nine in ten
children had at least one or more unmet need,
indicating opportunity for improvement for
nearly all children. Offices with systems
addressing developmental services and
providers with electronic medical chart prompts
and parent education materials focused on
developmental services scored higher on the
ProPHDS. Key barriers identified by providers
include lack of office staff to assist in providing
developmental services and lack of awareness
about where parents are not having their
informational needs met. In order to
stimulate/design QI efforts, providers value and
want reports that provide general (compositelevel) and specific (item-level) findings with
graphic and narrative presentation of the data.
Benchmark data adds value/incentive to
improve. Health system leaders want reports
providing background evidence, how the PHDS
compares and contrasts to current quality data,
and office/provider characteristics associated
with higher quality.
Conclusions: The provider-level Promoting
Healthy Development Survey (ProPHDS) is a
feasible and high-leverage tool for assessing
developmental services and shaping QI efforts at
the system, practice and office levels.
Implications for Policy, Delivery or Practice:
Tools such as the ProPHDS are needed to
advance the value of quality measurement and
improvement in health systems and ensures QI
efforts are aligned with the needs of parents and
children.
Primary Funding Source: CWF
Call for Panels
Consumer-Centered Quality Measurement
Guiding Policy, Measurement and
Improvement Efforts at a National, State,
Plan, and Practice-Level
Chair: Christina Bethell, Ph.D.
Saturday, June 24 • 3:30 p.m. - .5:00 p.m.
„ Parent-centered Quality Improvement (QI):
How a Parent-based Survey Can Be Used to
Design QI Efforts at a Plan-, Practice- and
Provider-level Focused on Developmental
Services for Young Children
Christina Bethell, Ph.D., M.P.H., M.B.A., Colleen
Reuland, M.S., Rasjad Lints, M.D., Scott
Shipman, M.D.
Presented by: Colleen Reuland, M.S., Senior
Research Associate, Pediatrics, The Child and
Adolescent Health Measurement Initiative,
Oregon Health and Science University, Mailcode
CDRCP, 707 SW Gaines Street, Portland, OR
97219; Tel: 5034940456; Fax: 5034942475; Email: reulandc@ohsu.edu
Research Objective: To demonstrate methods
for the valid and feasible implementation of the
Provider-Level Promoting Healthy Development
Survey (ProPHDS) at the system, practice and
provider level (simultaneously). To involve
providers and system leaders in the design of
reports based on consumer-reported quality data
that motivate and help shape multi-level, patientcentered quality improvement efforts. To
understand child, office and provider level
variations in ProPHDS findings within a large
health system and evaluate how they can be
used to identify leverage arms for QI.
Study Design: The ProPHDS measures quality
of care on each of the AAP recommended
categories of anticipatory guidance and parental
education, family psychosocial assessment,
developmental assessment and follow up and
family centered care. It was administered to a
stratified, random sample of parents of children
under age four enrolled in a managed care
organization who had at least one well-visit. The
sampling strategy was designed to allow for
office- and provider-level analyses (children
sampled = 5003; offices represented=10;
providers represented = 56). Quantitative
variation and association of ProPHDS scores by
office- and provider-level descriptive information
(including an office system inventory,
examination of electronic medical chart
10
the HDLC intervention, practices improved on
two out four of the topic-specific measures (%
improvement: ask about and address parental
concerns: 9.8%; ask about parental depression:
9%). The proportion of children who received at
least half of all recommended aspects of care
increased by 9.3%. Smaller practices (1-2
providers) were significantly more likely to
improve as compared to larger practices (3 or
more). Larger improvements were observed for
infants than for older children.
Conclusions: The ProPHDS provides a
quantitatively unique, child-level picture of
performance of communication-dependent
aspects of developmental care. The ProPHDS is
feasible for practice-level implementation and
assessment of QI interventions. Practices
improved on aspects of care for which targeted
interventions were implemented (e.g.
developmental and paternal depression
screening tools) as compared to a more general
efforts implementing parent handouts and/or
asking parents open-ended questions about
themselves.
Implications for Policy, Delivery or Practice:
Quality improvement efforts focused on
developmental services should be assessed by
reliable, valid data sources that can measure
communication-dependent aspects of care. The
provider-level Promoting Healthy Development
Survey (ProPHDS) is a tool that meets these
criteria.
Primary Funding Source: CWF,
„ Evaluating Practice-level Pediatric
Developmental Services Quality Improvement
Strategies
Colleen Reuland, M.S., Annette Rexroad, Ph.D.,
M.P.H., Kathryn Taffe McLearn, Ph.D., Annette
Rexroad, Ph.D., M.P.H., Brian Neelon, Ph.D.,
Christina Bethell, Ph.D., M.P.H., M.B.A.
Presented by: Annette Rexroad, Ph.D., M.P.H.,
Research Associate of Pediatrics, Adjunct
Assistant Professor of Obstetrics and
Gynecology, Pediatrics, Vermont Child Health
Improvement Program, University of Vermont
College of Medicine, Arnold 5, UHC Campus,
One South Prospect Street, Burlington, VT
05401; Tel: 802.847.4357; Fax: 802.847.8170; Email: Annette.Rexroad@uvm.edu
Research Objective: To assess the feasibility
and value of methods used to evaluate the
practice-based Healthy Development Learning
Collaborative (HDLC) using the Provider-Level
Promoting Healthy Development Survey
(ProPHDS).
Study Design: Participating intervention
practices (N=18) used the ProPHDS for a 12month period. For purposes of assessing the
HDLC QI intervention, the ProPHDS data was
administered at two time periods: baseline and
follow-up. At baseline, practices handed out the
ProPHDS in the waiting or exam room to a
stratified (by age of child) sample of parents of
children 3-48 months old, who had one or more
well-child visit in the participating office in the
last 12 months. A series of QI interventions were
applied based on findings. At follow-up, the
ProPHDS was given to a stratified sample of
parents after their young child’s well-child visit.
Parents were asked to complete the survey at
home and to mail it back. Composite measures
based on multiple ProPHDS items were created
mapping to the HDLC QI intervention focus
areas (anticipatory guidance & parental
education; ask about and address parental
concerns; ask about parental depression; ask
about other psychosocial and safety issues in the
family). A global composite measure was created
summarizing the number of topic-specific
aspects of care the child received.
Population Studied: 18 pediatric practices in the
Northeastern and Southeastern United States.
Principal Findings: A total of N=1779 ProPHDS
surveys were collected, n=1001 at baseline and
n=778 at follow-up. Baseline findings indicate
significant opportunities for improvement
(scores ranged from 27-63). No practice scored
the highest or lowest on all measures. Following
„ Variations in the Quality of Developmental
Services by Characteristics of the Pediatric
Provider Workforce
Colleen Reuland, M.S., Scott Shipman, M.D.,
M.P.H., Christina Bethell, Ph.D., M.B.A., M.P.H.
Presented by: Scott Shipman, M.D., M.P.H.,
Assistant Professor, Department of Pediatrics,
Center for the Evaluative Clinical Sciences,
Dartmouth Medical School, 7251 Strasenburgh
Hall, Hanover, NH 03755; Tel: 603-650-1810; Fax:
5034942475; E-mail:
scott.shipman@dartmouth.edu
Research Objective: To assess whether
systematic variations in the quality of
developmental services for young children exist
according to characteristics of the pediatric
provider workforce.
Study Design: The Provider-Level Promoting
Healthy Development Survey (ProPHDS) was
administered by mail to an age-stratified,
random sample of children who received wellchild care in the last year from one of 56
11
pediatric providers affiliated with a managed care
organization (MCO) in a metropolitan area (n =
5003). ProPHDS results were linked to the
provider a child was enrolled with and saw for
the majority of well-child care in a one year
period. Multivariate regression analyses on six
quality of care scores were conducted,
controlling for child (age, gender, birth-order),
parent (depression) and provider characteristics
(age, gender, FTE level, having their own
children). Beta coefficients (Beta) for each
provider characteristic were evaluated.
Population Studied: Children 3-48 months old
who had at least one well-child visit in the last
year and were continuously enrolled in the MCO
for 12 months or since birth. Providers of wellchild care (N=56) in an MCO (82% pediatricians,
18% non-MD pediatric providers; 42% c
Principal Findings: Of 2163 respondents, 2019
met criteria for assignment to one provider. Six
quality measure scores ranged from 25-81 (0-100
scale) and varied significantly (p<.05) across
providers. No provider scored the highest or
lowest on all measures. Variation by gender was
not observed in bivariate analyses. In
multivariate analyses females were less likely to
discuss recommended anticipatory guidance and
parental education topics (-4.28 Beta; p = .01)
and to ask parents about their concerns ( -.27
Beta; p=.03). Females were more likely to screen
families for substance abuse and firearms at
home (4.06 Beta; p=.07). Providers with clinical
FTE > .75 scored lower on the anticipatory
guidance and parental education (AGPE)
measure (-3.70 Beta; p=01) and family-centered
care (FCC) measure (-2.02 Beta; p = .06). Higher
clinical FTE providers had higher substance
abuse and firearm screening (SAF) measure
scores (3.89 Beta; p = .05) as were providers with
children of their own (6.34 Beta; p = .01).
Gender-stratified analyses controlling for the
same child and parent variables and provider
age, clinical FTE level and having own children
showed that male providers aged > 50 had
higher quality scores than younger males on the
SAF quality measure (4.59 Beta; p=.05). Female
providers aged > 50 scored higher than younger
females on the psychosocial assessment of
families measure (2.71 Beta; p=.03) and lower on
the FCC measure (-1.64 Beta; p=.03). While not
observed for males, females with a clinical FTE >
.75 had lower scores on the AGPE measure (3.94 Beta; p = .02) and FCC measure (-2.97;
p=.02) compared to lower clinical FTE females.
Conclusions: Pediatric providers who vary in
gender, age and clinical FTE level appear to
systematically vary in their provision of well-child
care. Research on why is indicated.
Implications for Policy, Delivery or Practice:
Parents often choose their child’s provider based
on characteristics such as provider gender,
whether he/she is full-time and whether he/she
has children of their own. These findings shed
light on the validity of parental assumptions
about the quality of care provided by providers
with different characteristics.
Primary Funding Source: CWF,
„ Measuring the Quality of EPSDT Services in
Medicaid: A Consumer-centered and
Integrated Model for Measuring and Driving
Improvement in Developmental Services For
Young Children.
Susan Castellano, Colleen Reuland, M.S.,
Christina Bethell, Ph.D.
Presented by: Susan Castellano, Manager,
Maternal and Child Health Assurance,
Minnesota Department of Human Services, P.O.
Box 64986, St. Paul, MN 55164-0986; Tel:
651.431.2612; Fax: 651.431.2612; E-mail:
susan.castellano@state.mn.us
Research Objective: To assess the quality of
developmental services provided to young
children enrolled in Minnesota Medicaid and for
multiple population subgroups using the
Promoting Healthy Development Survey-PLUS
(PHDS-PLUS). To assess the feasibility, value
and findings from a collaborative and integrated
consumer-centered model for measuring of
EPSDT services provided to young children using
the Promoting Healthy Development SurveyPLUS (PHDS-PLUS).
Study Design: The PHDS-PLUS was
administered to parents of children under age 4
and enrolled in Medicaid in Minnesota. The
sample was stratified by age of child, type of
health plan (fee for service vs. managed care)
and an oversample was drawn for Hispanic
race/ethnicity. Data was weighted to represent
characteristics of continuously enrolled children
in Medicaid. Seven EPSDT related measures of
care and an overall composite measure was
constructed and these child-level survey findings
were integrated with other child-level variables
regarding program participation type of health
care provider, organizaton of care, utilization of
well-child visits and other services. A
collaborative team representing multiple state
agencies and stakeholders collaborated through
the project and guided strategies to
communicate findings in order to inform and
stimulate efforts to improve policy and practice
12
within Medicaid, among health care providers
and other state agencies.
Population Studied: Children age 3-48 months
of age who were continuously enrolled in
Medicaid since date of birth or last 12 months
and who also had at least one well-visit during
the same time period. (n=2000; weighted N =
49,481).
Principal Findings: EPSDT measure
performance varied significantly according to a
wide-range of policy relevant variables such as
program participation, care setting and type and
continuity of provider, priority population
subgroups (e.g. racial/ethnic groups, CSHCN),
organization of care and geographic area.
Quality measures on well-child visits were not
predictive of performance on the aspects of
EPSDT services assessed by the PHDS-PLUS.
Data collected enabled the broad application of
findings and engagement of multiple state
partners to begin to improve care.
Conclusions: The integration of child-level
PHDS-PLUS, program participation, utilization
and other data enabled more efficient,
comprehensive and actionable measurement of
EPSDT services, including understanding where
parents’ have unmet informational needs on
recommended anticipatory guidance and
parental education, addressing children at-risk
for developmental problems and family
psychosocial assessment. Findings are effective
in generating commitment, partnerships and
resources for improvement.
Implications for Policy, Delivery or Practice:
Consumer-based measures enable future policy
and improvement efforts to be focused on areas
of care for which the consumer has noted the
largest gaps between what is recommended and
what is received.
Primary Funding Source: CWF
Call for Panels
Achieving Universal Coverage for Children:
Design Challenges and Lessons Learned from
Recent Initiatives
Chair: Ian Hill, M.P.A.
Saturday, June 24 • 3:30 p.m. - 5:00 p.m.
„Toward Universal Child Coverage in
California—Findings from Healthy Kids
Program Evaluations in Los Angeles, San
Mateo, and Santa Clara Counties
Ian Hill, M.P.A., M.S.W., Embry Howell, Ph.D.,
Christopher Trenholm, Ph.D., Dana Hughes,
Dr.PH
Presented by: Ian Hill, M.P.A., M.S.W., Principal
Research Associate, Health Policy Center, The
Urban Institute, 2100 M Street, NW,
Washington, DC 20037; Tel: 202/261-5374; Fax:
202/223-1149; E-mail: ihill@ui.urban.org
Research Objective: Seventeen of California's 58
counties have implemented Children’s Health
Initiatives (CHI) designed to provide universal
health coverage to children; 14 more counties are
in the planning stages. Primarily funded by
tobacco taxes and philanthropic donations, these
programs target children in working poor
families who are ineligible for Medicaid and
SCHIP. CHIs in Santa Clara, San Mateo, and Los
Angeles Counties are being evaluated to assess
implementation and impacts on children’s
coverage, access to care, and health status.
Study Design: The CHI evaluations use similar
designs with multiple components, including:
case studies of implementation; focus groups
with parents; monitoring of administrative
outreach, enrollment, and utilization data;
analyses of CHI effects on uninsurance and
Medicaid and SCHIP enrollment; and household
surveys to assess impacts on children’s access
to and use of care, and health status.
Population Studied: Children in Los Angeles,
San Mateo, and Santa Clara Counties
Principal Findings: Because of their eligibility
rules, Healthy Kids Programs within CHIs
primarily serve undocumented immigrant
children. Since inception, the programs have
enjoyed strong support from stakeholders.
Diverse community-based organizations conduct
intensive, culturally appropriate outreach and
enrollment assistance to enable children’s
coverage under Medicaid, SCHIP, and Healthy
Kids. This approach has helped over 86,000
children statewide obtain Healthy Kids coverage
13
in just two years, while also having a positive
"spillover" effect on Medicaid and SCHIP; in
Santa Clara, enrollment in those programs was
raised by 28 percent. Parent focus groups
suggest that the programs’ applications are
simple, benefit packages are comprehensive,
managed care systems are affording good access
to care, and that sliding-scale premiums and
copayments are not posing barriers to
enrollment or service use, except perhaps for
children with special needs. Program data
suggest low utilization rates despite high needs
among enrollees; for example, over one-quarter
of parents in San Mateo report that their children
are in fair or poor health. Still, household surveys
find that Healthy Kids programs are reducing
unmet needs for primary, specialty, and dental
care; contributing to increased service use; and
increasing access to a usual source of care.
Without a stable tax base, however, all CHIs are
now facing severe financing challenges and
several have had to close enrollment to eligible
children.
Conclusions: Early implementation of CHIs has
been successful. Qualitative findings and
administrative data indicate that programs are
effectively targeting and serving a population of
undocumented immigrant children that are
known to be particularly vulnerable. Household
surveys confirm the programs' positive effects
on children's access to care and reduction of
unmet need. Sustaining programs into the
future, however, will remain a challenge unless
stable funding sources are identified.
Implications for Policy, Delivery or Practice:
Early evidence suggests that SCHIP-like
programs, free of “public charge” stigma,
providing broad benefits and utilizing
community-based, culturally-appropriate
outreach and health care providers can succeed
in extending comprehensive coverage to
uninsured, largely undocumented children.
Policymakers must identify stable, long-term
financing if universal coverage initiatives are to
be sustained.
Primary Funding Source: Other Foundation,
First 5 LA, The California Endowment, The David
and Lucile Packard Foundation,
62763; Tel: 217/782-2570; E-mail:
steve.saunders@idpa.state.il.us
Research Objective: The State of Illinois, under
Governor Rod Blagojevich, will be the first in the
nation to guarantee health care coverage for all
uninsured children, irrespective of family income
or citizenship, when it implements the All Kids
Program on July 1, 2006. This presentation will
discuss the design and early development of All
Kids program outlining the rationale for crafting
this insurance program as a public sector
expansion of Medicaid and the State Children's
Health Insurance Program.
Study Design: The presenter, a senior state
official serving as Medical Officer for the Illinois
Medicaid program, has been closely involved
with every aspect of policy and program design.
As such, he will summarize the deliberations and
decisions made by Illinois policymakers with an
eye toward identifying lessons for officials in
other states.
Population Studied: Child health policy
development in Illinois
Principal Findings: Illinois, in 2005, set out to
create a program that would do for the state's
children what Medicare did for seniors--that is,
create a universal health coverage program for
all children, regardless of income or citizenship
status. Legislation creating the All Kids program
was passed in November 2005 and state officials
have been working since that time to design the
policies that would guide program
implementation. In doing so, policymakers had
to consider a broad range of options affecting
outreach, enrollment, benefits, service delivery,
cost sharing (including sliding scale premiums
and copayments), and crowd out. Decisions and
rationales for each will be elaborated, and design
challenges will be discussed. As the program will
not begin until July 2006, no implementation
experiences or data will be available. However,
the program's plans for roll-out will be covered
and strategies to enhance provider participation
will be highlighted. Finally, mechanisms to
finance the expansion will be reviewed, including
plans for a comprehensive disease management
program, and transformation of the state's feefor-service delivery system into a Primary Care
Case Management system.
Conclusions: By systematically considering the
various implications of a host of policy options,
state officials along with a broad array of
stakeholders can successfully design a universal
child health program that promises to meet the
needs of uninsured children.
Implications for Policy, Delivery or Practice:
The experience in Illinois in designing a
„ Designing the Illinois All Kids Program
Stephen Saunders, M.D., M.P.H.
Presented by: Stephen Saunders, M.D., M.P.H.,
Medical Officer, Medicaid Program, Illinois
Department of Healthcare and Family Services,
201 South Grand Avenue E., Springfield, IL
14
comprehensive child health insurance program
will be useful for other states considering similar
efforts. Issues and barriers confronted, and
lessons learned to date will be discussed.
Primary Funding Source: none
termination of the original program and recent
decisions by Governor to re-institute CHP; rules
for eligibility determination, benefit coverage,
service delivery, and cost sharing; state fiscal
year 2006 funding and caseload levels; waiting
list policies; and, strategies for targeted outreach
based on the “Kids Get Care” model.
Discussions of the ESI Project will review prepilot enrollment levels and estimated savings,
full pilot project enrollment and savings
estimates for 2006-2007, and challenges faced
in designing and implementing employersponsored insurance initiatives.
Conclusions: Washington State has a long-held
commitment to improving the health of the
state’s children and expanding publicly funded
health coverage for children. The launching of an
initiative that draws on federal, state, and private
sector funding while integrating Medicaid,
SCHIP, the Basic Health Plan, and the Child
Health Program holds tremendous promise for
achieving the Governor’s goal of insuring every
child in Washington by 2010.
Implications for Policy, Delivery or Practice: A
major challenge will be for the state to reduce
growth rates in state-purchased health care in
order to afford state-financed coverage for
children. It is anticipated that doing so will
strengthen employer-sponsored dependent
coverage for children. For this strategy to be
successful, there cannot be further degradation
in employer-sponsored coverage for low and
moderate income working families. To this end,
the Governor will be working with the state
legislature and insurance Commissioner to
develop strategies to strengthen the small-group
market for employers with fewer than 50
employers.
Primary Funding Source: none
„ Covering All Children by 2010 -- The
Washington Children's Health Program
Robin Arnold-Williams, Ph.D.
Presented by: Robin Arnold-Williams, Ph.D.,
Secretary, Washington State Department of
Social & Health Services, , PO Box 45010,
Olympia, WA 98504; Tel: (360) 902-7800; Email: arnolr@dshs.wa.gov
Research Objective: This presentation will
discuss the planning and initial implementation
of the Washington Children’s Health Program
(CHP), an initiative to provide publicly financed
health coverage for low-income children who are
not eligible for Medicaid or State Children’s
Health Insurance Program (SCHIP) due to their
citizenship status. The presentation will also
discuss the implementation of an employersponsored insurance (ESI) project that is
enrolling children and families into employersponsored coverage.
Study Design: The presenter, Washington
State’s Secretary of the Department of Social &
Health Services, will provide: (1) an overview of
Washington’s state-financed health coverage
programs for children; (2) a history of the initial
CHP program and the recent decision by
policymakers to re-institute CHP; (3) an overview
of the ESI project and pre-pilot experience to
date; and (4) an overview of challenges faced in
attempting to provide health coverage for all
Washington’s children.
Population Studied: Child health policy in
Washington State
Principal Findings: Washington State is relying
on a combination of public sector and employerbased coverage for children living in families
with incomes up to 250 percent of the federal
poverty level, and employer- and individualbased coverage for children in families earning
more than 250 percent of FPL, to ensure that
children have access to health care coverage. In
line with this strategy, the Governor has taken
the lead in re-establishing CHP so that lowincome children who are not citizens have
access to affordable health care, and in
implementing an ESI project to leverage
employer-sponsored health insurance.
Discussions of the CHP will focus on such
issues as historical and expected caseload
growth; policy development surrounding the
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