SCHIP: Reauthorization, Increased
Cost Sharing, and Quality Initiatives
Betsy Shenkman
Institute for Child Health Policy
Department of Epidemiology and
Health Policy Research
University of Florida
June 2006
Key Issues


State policy changes and increased cost
sharing
Quality initiatives – What’s required?
What’s novel?
Illustration of Policy Changes in
Two States
Texas Title XXI Enrollment and Major Program Changes
600,000
Se p t , 2 0 0 3
( E n r o l l me n t 5 0 7 , 2 5 9 ) :
• B enef i t s el i mi nat ed f or hos pi c e, s k i l l ed nur s i ng, dent al , t obac c o c es s at i on, v i s i on &
c hi r opr ac t i c s er v i c es
• B enef i t s r educ ed f or i npat i ent & out pat i ent ment al heal t h
507,259
488,690
500,000
Oct, 2003
( E n r o l l me n t 4 8 8 , 6 9 0 ) :
• Cont i nuous el i gi bi l i t y r educ ed f r om 12 t o 6 mont hs
Feb, 2006
• 90 day wai t i ng per i od bef or e c ov er age i mpl ement ed
458,166
( E n r o l l me n t 3 1 0 , 9 8 1 ) :
• E x c ept i ons t o wai t i ng per i od: dec er t i f i ed f r om M edi c ai d & deemed CHI P el i gi bi l e, newbor ns & ot her c hi l dr en added t o c ur r ent enr ol l ee ac c ount , c hi l dr en
• Cos t s har i ng r ul es c hanged t o t he
di s enr ol l ed f or f ai l ur e t o r enew but whos e par ent s c ompl et e t he r enewal wi t hi n a s pec i f i ed t i me per i od
400,000
per f ami l y :
o 133%-150% FP L - $ 25
( E n r o l l me n t 4 5 8 , 1 6 6 ) :
• P r emi um enr ol l ment f ees
Jan, 2004
o 151%-185% FP L - $ 35
359,734
( E n r o l l me n t
i mpl ement ed:
o 186%-200% FP L - $ 50
340,101
416, 302):
o 100%-150% FP L - $ 15 per
326,557
• Di s enr ol l ment of f ami l i es
f ami l y per mont h
A ug, 2004
f or f ai l ur e t o pay mont hl y
o 151%-185% FP L - $ 20 per
300,000
f ol l owi ng per 6 mont hs enr ol l ment
416,302
N ov, 2003
pr emi ums s us pended
f ami l y per mont h
( E n r o l l me n t 3 5 9 , 7 3 4 ) :
N ov, 2004
• A s s et t es t i mpl ement ed f or
( E n r o l l me n t 3 4 0 , 1 0 1 ) :
o 186%-200% FP L - $ 25 per
f ami l i es wi t h i nc omes at or
• Col l ec t i on of pr emi ums at r enewal
f ami l y per mont h
abov e 150% FP L
s us pended
294,189
( E n r o l l me n t 3 2 6 , 5 5 7 ) :
• Copay ment c hanges
i mpl ement ed:
o Of f i c e v i s i t - $ 3-$ 7,
200,000
310,981
Se p t , 2 0 0 5
• Sept ember 2003 benef i t s
A pr , 2006
r es t or ed & ment al heal t h
( E n r o l l me n t 2 9 4 , 1 8 9 ) :
benef i t s i nc r eas ed
• Dent al benef i t r es t or ed wi t h
benef i t t i er s
dependi ng on i nc ome
o I npat i ent – I nc r eas e f r om $ 0
t o $ 10 f or f ami l i es l es s t han
100% FP L
• Cos t s har i ng c ap i nc r eas es
• E ar ned i nc ome di s r egar ds
el i mi nat ed
100,000
Enrollment
Apr-06
Mar-06
Feb-06
Jan-06
Dec-05
Nov-05
Oct-05
Sep-05
Aug-05
Jul-05
Jun-05
May-05
Apr-05
Mar-05
Feb-05
Jan-05
Dec-04
Nov-04
Oct-04
Sep-04
Aug-04
Jul-04
Jun-04
May-04
Apr-04
Mar-04
Feb-04
Jan-04
Dec-03
Nov-03
Oct-03
Sep-03
0
Florida Title XXI Enrollment and Major Program Changes
336,689
Fall 2004:
331,281
340,000
326,755
315,222
320,000
July 03:
• “No Growth”
budget enacted
300,000
• Program overenrolled,
wait list started
280,000
• No Title XIX to
Title XXI transfers
• Federal and
state funding for
Florida KidCare
Outreach eliminated
260,000
264,278
240,000
323,262
Apr. 04:
322,997
Begin
enrolling
Title XXI
Wait List
Dec. 03:
• 6-month
cancellation for
premium nonpayment
• No reinstatements
for breaks in
coverage
• Jan. 04: Only
CMSN
accepts Medicaid to
Title XXI transfers
(ended Mar. 04)
• Mar. 04: Legislation
enacted — wait list
funded, other
program changes
• Premium non-payment penalty
reverts to 60 days
• Reinstatements allowed if in
the data system before 3/12/04
• Hurricane Relief Provisions: No
disenrollments for failure to
provide renewal documents or
failure to pay premiums, credits
for those who did pay (3 months)
July 04:
• New income
documentation
& access to
employer health
insurance
requirements
(delayed due to
hurricanes)
December 04:
• Open enrollment announced
• Disenrollments for renewal noncompliance and unpaid premiums
implemented
• New enrollees
accepted only during
open enrollment
• Legislature reduced income
documentation requirements
• Loss of Medicaid for
over-income eligible
to apply outside of
open enrollment,
7/1/04
252,209
July 05: Year-round open
enrollment reinstituted;
application valid for 120 days
• FY 04-05
Appropriated Avr.
Monthly Caseload:
389,515
220,000
FY 05-06 Appropriated Avr.
Monthly Caseload: 388,862
220,533
Aug. 05: Back-toSchool campaign, post
cards
200,000
Jan. 05: Open enrollment
Jan. 1-30, 2005;
applications
202,433
processed, children
enrolled (ongoing)
180,000
Jul-02
Oct-02
Jan-03
Apr-03
Jul-03
Oct-03
Jan-04
Apr-04
Jul-04
Oct-04
Jan-05
Apr-05
Jul-05
202,615
Oct-05
Cost Sharing


Increased cost sharing in the form of
increased premiums a large portion of
the changes
Important issue because of Deficit
Reduction Act of 2005 so lessons to be
learned for SCHIP and Medicaid
Florida Premium Changes
PFPM Premium Amount
Prior to July
2003
July 2003
September 2003
October 2003
Forward
101%-150%
FPL
$15
$20
$15
151%-200%
FPL
$15
$20
$20
Family Income
Cost Sharing




Using Florida data, accelerated failure time
model (AFT) – enrollment length
Opportunity to examine potential changes in
behavior across time and with shifting
premiums
Followed 153,768 Title XXI children from July
1, 2002 to June 30, 2004
Included age, gender, and health status in
our analyses
Enrollment Length Ratios By Income and Premium Amount
Time Ratio
Premium = $15
Premium = $20
3
Premium = $20 for
151-200% FPL
Premium = $15 for
101-150% FPL
2
1
101-150% FPL
151-200% FPL
Time
Jul-02
Jul-03
Oct-03
Interaction of Premium
Change and Health Status



Children were classified into health status
categories using the Clinical Risk Groups
Interaction between premium and health
status not significant for children with
moderate chronic or major chronic conditions
In the short-term enrollment duration
decreased for children who were healthy, had
significant acute or minor chronic conditions
and were above 150% FPL and then
increased but not back to baseline levels.
Quality of Care in SCHIP

Annual CMS Report - Core quality
measures




Well child visits first 15 months of life
Well child visits 3rd, 4th, 5th, and 6th years
Appropriate medications for children with
asthma
Access to primary care practitioners
Quality of Care in SCHIP Mathematica Study


2005 report based on SFY 2003
Reporting
Core Measures reported





8 states use 4 measures
18 states use 3 measures
7 states use 2 measures
3 states use 1 measure
14 states use no measures
Quality of Care in SCHIP Mathematica Study



Most frequent – well child in 3rd, 4th, 5th, 6th
years – 33 states (13% to 73% compliance)
Least frequent – asthma medications – 15
states (52% to 70% compliance)
Goal Re: Quality



Improve consistency of reporting
Report something
Use performance data for quality improvement
Published Reports – Quality of
Care in SCHIP





Primary focus on access to care – usual
source of care
Continuity of care – continuity with usual
provider
Utilization of specific health services
Usually parent report
See increase in those with USC, greater
continuity, increased reports of preventive
care visits
Illustration: Texas Value-Based
Purchasing Initiative





Concept - buyers should hold providers of health care
accountable for both cost and quality of care
HEDIS core measures and Consumer Assessment of
Health Plan Survey (CAHPS) results reported
Additional adult measures used
Reported in a quarterly chart book by plan, service
delivery area, and overall
Annual encounter data certification and validation
performed
Illustration: Texas Value-Based
Purchasing Initiative





Established standards – usually average of
Medicaid plans reporting to NCQA
Validated calculations with the health plans
Three year process to reach validation stage
Plans submit goals to state health plan
managers and report on strategies to improve
performance
SFY 2007 – 3 goals and measures; increase
to 5-7 per year
Examples - Chart 17. HEDIS® Well-Child Visits in
the 3rd, 4th, 5th, And 6th Years of Life-TANF
STAR MCOs - March 1, 2004 to February 28, 2005
70%
68.61%
60%
TANF Enrollees in Age Group = 95,060
66.56%
60.68%
59.86%
Plan B
Plan C
68.45%
66.29%
63.48%
62.90%
Plan F
Plan G
50%
40%
30%
20%
10%
0%
Plan A
MCO Percent
Reference: TANF STAR Table PI-2
Plan D
Plan E
STAR MCO Mean = 65.27%
HEDIS 2004 Mean = 59.90%
Plan H
Illustration: Texas Value-Based
Purchasing Initiative



Health plan meetings and workgroups
Meet with state plan managers on status
Financial incentive




1% of premium at risk
Unearned funds available to those plans that excel
on selected measures
Exceptional performance – additional 0.5% of
available funds
Liquidated damages and remedies
Outcomes?


Even prior to implementation of valuebased purchasing – seeing indicator
improvement
Some studies – modest to no
performance increases
Pay for Performance




CMS/Premier P4P demonstration
Mostly private sector interest
Interest in Medicare
Some states P4P in Medicaid


New York, Michigan, California, RI, NC, PA
New York – 1% of premium and may
increase to 3% of premium
Potential Obstacles





Credibility of information
Lack of dissemination
Information not being used to initiate
change
Time, effort, and expertise
No requirement
Summary



Cost sharing changes, among others,
have an impact on enrollment and
access
Little required in terms of quality
measurement and little is known
Some innovations with financial
incentives but outcome uncertain