Evaluation of the San Mateo County Children’s Health Initiative:
Third Annual Report
Embry Howell, Urban Institute
Dana Hughes, University of California, San Francisco
Brigette Courtot, Urban Institute
Louise Palmer, Urban Institute
September 2006
Submitted to:
San Mateo County
Children’s Health Initiative Coalition
225 37th Avenue
San Mateo, CA 94403
ACKNOWLEDGMENTS
We appreciate the help of all the individuals whom we interviewed, including members
of the Children’s Health Initiative coalition, school personnel, providers, employers, and
community members. We thank Vicky Shih and Min Zheng of the Health Plan of San
Mateo, who prepared the data. We especially appreciate the help and support of ST
Mayer, Marmi Bermudez, and Sosefina Pita of the San Mateo County Health
Department.
EXECUTIVE SUMMARY
This report, the third in a series of five annual reports from the Evaluation of the San
Mateo County Children’s Health Initiative (CHI), provides an overview of the Initiative
as well as a detailed look at particular aspects of the program and access to specific
services. During 2005 the initiative took on several new challenges, such as an increased
focus on improving retention in public programs, increasing use of preventive care, and
improving access to dental and mental health care. This annual report provides some new
data on several of these and other issues that are important to the continued development
of the initiative.
Using several data sources, the evaluation investigated issues that are of special
interest to the CHI. These include: the demographic and health status characteristics of
Healthy Kids served by the CHI; how demographic characteristics and service use have
changed over time; characteristics of high cost users of services and how they differ from
other children; access to dental services; access to mental health services; the role of
schools in outreach and enrollment; and the factors influencing employer decisions to
offer insurance for dependents. The data for the analysis come from the annual site visit
conducted in October 2005; health plan administrative enrollment and utilization data;
and interviews with employers.
Key findings include
•
The growth in the Healthy Kids program continued at a slow pace in 2005,
particularly for the youngest children (ages 0–5), despite special efforts to enroll
more children in this age group. Growth in the 6–18 age group continued at a
moderate pace, creating a challenge to the premium financing for these enrollees.
•
There was a moderate increase (of 4 percentage points) in the proportion of
children who were in the higher income group (250–400 percent of the federal
poverty level), and over 13 percent of children continuously enrolled in Healthy
Kids from 2003–2004 were in this group. Penetration of coverage within this
population was a specific priority for the CHI during the last year.
•
The use of preventive medical care, as well as dental and vision care, increased
from the first to the second year of enrollment in Healthy Kids. In addition,
overall use of ambulatory care increased from those who enrolled in 2003 to those
who enrolled in 2004.
•
Ten percent of publicly insured children account for a sizable proportion of
expensive medical (although not dental) care, particularly hospital and emergency
room care. These children, defined as “high cost users,” account for a substantial
portion of the total cost for all children enrolled in the Healthy Kids, Healthy
Families, and Medi-Cal programs (39.9 percent, 48.4 percent, and 72.8 percent,
i
respectively). High cost users are more often chronically ill and have frequent
contact with the health care system. Since it is possible to identify them through
the claims/encounter data, this group could be targeted for more intensive contact
by Certified Application Assistors (CAAs) or health plan staff, to assure that they
are receiving coordinated care and that they have good access to the specialty care
that they need. This might have the additional benefit of reducing high cost
emergency room and hospital care.
•
About 40 percent of Healthy Kids enrollees do not use dental services, indicating
potential access problems and the need to educate parents about the importance of
such care. Still, a relatively high percentage of the youngest children (ages 0–5)
used services. In addition, Healthy Kids enrollees are more likely to visit a private
dentist than to utilize public providers. This finding is in contrast to a widely held
perception that access to private dental providers for publicly insured children is
limited in the county.
•
Children with mental health diagnoses are much more expensive than their peers,
and these higher costs pertain to both mental health and other health services. Not
all children receiving mental health services under Healthy Kids or Healthy
Families are having their care coordinated by the San Mateo Health Department
Mental Health Services department, but those who are in that system are the most
expensive children.
•
School-based outreach and enrollment assistance is a high priority for the CHI.
The increased proportion of Healthy Kids enrollees who are from higher income
families is likely a result of this school-based approach, which may reduce the
stigma of applying for a public program. Because of the variation in intensity and
type of school-based outreach/enrollment from school district-to-district, the CHI
could learn from this variation by documenting which districts yield the greatest
number of applications and new enrollees.
•
Based on a limited sample of employer interviews (and complementing similar
findings from the evaluation’s client survey and focus groups with parents), there
is no evidence that employers of low wage workers have altered policies relating
to offering insurance coverage to dependents because of the availability of public
coverage for low income children in San Mateo County.
In the coming year, the evaluation of the San Mateo CHI will collect new data to
address a range of evaluation questions. The second wave of the client survey is currently
underway, with an over-sample of children ages zero to five. Data from this survey will
be used to measure the impact of the Healthy Kids program on access to care, use of
services, and health status. The survey will also provide information on prior insurance
coverage and parent satisfaction with the program. In addition, another site visit and two
client focus groups will provide qualitative information to help monitor the progress of
the CHI and interpret the findings from the client survey analysis. Administrative data on
enrollment trends will also be analyzed. Finally, the data from the Health Plan of San
ii
Mateo, such as that included in this annual report, will be used to continue to monitor
trends in enrollee characteristics and use of services across the three public health
insurance programs for children in San Mateo County.
iii
Contents
Chapter 1: Introduction....................................................................................................... 1
Chapter 2: The Context and Implementation of the CHI In 2005 ...................................... 3
Chapter 3: Who is Served by the San Mateo County CHI? Have Demographic
Characteristics and Service Use Changed Over Time? .................................................... 12
Chapter 4: Who Are the High Cost Users of Services and How Do They Differ From
Other Children Enrolled in Public Health Insurance Programs? ...................................... 20
Chapter 5: Do Healthy Kids Enrollees Obtain Needed Dental Health Services? What
Barriers Restrict Access? .................................................................................................. 30
Chapter 6: Do Healthy Kids Enrollees Obtain Needed Mental Health Services? What
Barriers Restrict Access? .................................................................................................. 38
Chapter 7: What Is The Role Of Schools In Outreach And Enrollment? ......................... 49
Chapter 8: What Factors Are Associated With Employer Decisions To Offer Private
Insurance Coverage To Low Wage Workers In San Mateo County? Has The CHI
Affected Employer Decisions? ......................................................................................... 55
Chapter 9: Conclusions and Recommendations ............................................................... 61
References ......................................................................................................................... 67
Appendix A: Research Questions of the Evaluation of the San Mateo Children's Health
Initiative
iv
Chapter 1: Introduction
The San Mateo Children’s Health Initiative (CHI) was launched in 2002, with a goal of
assuring that all children in the county have health insurance. To further this goal, a new
locally- funded Healthy Kids insurance program began in February 2003 to cover children
up to 400 percent of the federal poverty level who are not entitled to private or other
public insurance. The CHI also conducts outreach and enrollment for two other public
insurance programs, Medi-Cal (Medicaid) and Healthy Families (SCHIP). The San
Mateo County initiative is one of several similar initiatives being implemented in other
California counties, including Los Angeles, Santa Clara, and San Francisco Counties
among others.
The CHI partners decided to evaluate their program over the first five years of the
initiative. There are ten major research questions for the evaluation. During each year
different sources of information are available to address different questions, and some
questions will receive more attention than others over the course of the evaluation. 1
This year’s annual report addresses several evaluation questions and subquestions, including the following:
1
•
Who is served by the San Mateo CHI? Have demographic characteristics
and service use changed over time?
•
Who are the high cost users of services and how do they differ from other
children enrolled in public health insurance programs?
•
Do Healthy Kids enrollees obtain needed dental services? What barriers
restrict access?
•
Do Healthy Kids obtain needed mental health services? What barriers
restrict access?
Appendix A provides the full list of evaluation questions and the evaluation years when each is addressed.
1
•
What is the role of schools in outreach and enrollment?
•
What factors are associated with employer decisions to offer private
insurance coverage to low wage workers in San Mateo County? Has the
CHI affected employer decisions?
The data sources to answer these questions include information from interviews
conducted with key stakeholders during the annual evaluation site visit of October 2005
and tabulations from claims/encounter data for children enrolled in the Health Plan of
San Mateo for all three public programs (Healthy Kids, Healthy Families, and Medi-Cal).
As the evaluation proceeds over the remaining two years, different data collection
activities will occur each year, allowing for different types of analyses. The following
chapters include, first, an update of the implementation of the San Mateo CHI during
2005 as well as state and local economic and policy issues that affect the CHI. This is
followed by a series of chapters addressing each of the six evaluation sub-questions listed
above.
The evaluation is being conducted under contract with the Urban Institute,
consultant Dana Hughes of the University of California San Francisco (UCSF), and subcontractors Mathematica Policy Research and the Aguirre Group. This is the third annual
report to the San Mateo Children’s Health Initiative (CHI) partners. More detail on the
early years of the San Mateo County CHI can be found in the First 2 and the Second 3
Annual Reports.
2
3
The First Annual Report can be accessed at http://www.urban.org/url.cfm?ID=411003
The Second Annual Report can be accessed at http://www.urban.org/publications/411240.html
2
Chapter 2: The Context and Implementation of the CHI in 2005
County and State Economic and State Policy Context. Although the local economy has
not recovered completely from the major economic downturn in the early 2000s, at the
time of the annual site visit the economic health of San Mateo had improved substantially
over the previous year. For example, by 2005 the unemployment rate was only four
percent, down from 4.5 percent in 2004 and 5.2 percent in 2003 (San Mateo County
Controller 2006).
Meanwhile, the economic health of the state also continued to improve. The
state’s revised spending plan for 2006-2007 reflects a significant improvement in the
state’s fiscal condition, largely due to higher than anticipated 2006-2007 revenue
collections. Consequently, the May Revise (the document that modifies the original
January budget proposal) proposed some health care expansions, including a moderate
increase in health coverage to nearly 24,000 uninsured children for the 18 counties with
waiting lists for Healthy Kids programs. In the final budget negotiations in June,
however, this provision was removed from the budget. The budget did include increased
payments to Certified Application Assistors (CAAs) who help enroll children Healthy
families from $25 to $50 per successful application and rate increases for Medi-Cal
managed care plans to offset the five percent reduction in rates approved by the
Legislature as part of the 2003-2004 budget agreement (California Budget Project 2006).
The recent budget negotiations are part of an on-going debate in California
regarding state support for expanded children’s health insurance. During 2005 a bill was
approved by both branches of the legislature that would have made Healthy Kids a
statewide program by expanding Healthy Families to cover all children (including the
3
undocumented) with incomes up to 300 percent of the federal poverty level (similar to the
recent provision that was dropped from the budget). However, the governor vetoed this
2005 legislation for cost reasons. Most recently, a ballot initiative (The Tobacco Tax Act
of 2006) to achieve the same aim won sufficient signatures to be placed on the November
2006 ballot. At the time of this writing, its prospects remain uncertain.
The Health Plan of San Mateo. The Health Plan of San Mateo (HPSM—which
administers the Healthy Kids program for the CHI) experienced severe financial
difficulty during the first two years of the CHI, but during 2005 the finances stabilized
significantly, in part because of the new Medicare Advantage program. Increased revenue
from this program has helped to fund staff expansions in the member services
department. With this additional staff, HPSM is taking on more responsibility for health
education and renewal for Healthy Kids enrollees. HPSM staff plan to contact families
with a welcome call, as well as with phone calls to learn about whether the parent is
having difficulty accessing their primary care physician, especially if there is no evidence
of a visit within 120 days of enrollment. In addition, the HPSM now sends out quarterly
mailings to monitor address changes. Mailings are sent First Class so that the health plan
gets a change of address notification from the post office if the family has moved.
Personnel Changes. All three of the key organizations that have formed the core
staff for the CHI experienced personnel changes during 2005. However, since many of
the individuals with new CHI responsibilities have been involved in the CHI in various
capacities for some time, there is essential continuity of leadership.
4
Maya Altman was appointed to be Executive Director of the HPSM in June. She
formerly served as the Director of Finance and Administration of the San Mateo County
Heath Department, and she is familiar with and supportive of the CHI.
At the Health Department (formerly the Health Services Agency), Charlene Silva
replaced Margaret Taylor as the department director. Srija Srinivasan, previously of the
Peninsula Community Foundation, assumed many of Toby Douglas’ prior responsibilities
as the new Director of Policy, Planning, and Promotion. ST Mayer moved into the new
Health Policy, Planning and Promotion unit. Marmi Bermudez, as the new Program
Manager, assumed operational responsibility for CHI outreach and enrollment efforts, as
well as the CHI Oversight Committee and fundraising.
There have also been some changes in leadership in the Human Services Agency.
Maureen Borland retired as agency director, and Glen Brooks was acting in her role at the
time of our site visit, with Elsa Dawson assuming his previous position. Shannon Speak
has since taken over Elsa Dawson’s prior responsibilities.
CHI Financing. Table 2-1 shows funding for the CHI for 2005. There is
substantial consistency between the amount and sources of funding between 2004 and
2005, with approximately $7.2 million being raised to fund the CHI in both years.
However, for 2005 a higher percentage was spent for premiums than in 2004, when more
of the funds were used for outreach. The diversity in funding sources continues. (See the
Second Annual Report for more detail on funding levels and sources for 2004.)
The San Mateo CHI is facing near-term financial difficulties. While funding for
the CHI is available for 2006-2007, funding for children ages 6 to 18 is uncertain beyond
that time. (First 5 funding for children five years of age and younger is secure for 10
5
years.) The CHI’s unstable funding situation for older children is the major factor behind
the CHI partners’ enthusiastic support for the upcoming ballot initiative that would enact
a statewide Healthy Kids program.
Table 2-1: Funding for the San Mateo County CHI, 2005
Funder
Premium
Funding
Foundations:
David and Lucile Packard Foundation
United Way Bay Area
Kaiser Foundation
Lucile Packard Foundation for Children's
Health
California Endowment
Blue Shield
Lucile Packard Children's Hospital
California Healthcare Foundation
Sub-total, Foundations
Healthcare Districts:
Sequoia Healthcare District
Peninsula Healthcare District
Sub-total, Healthcare Districts
First Five Commission
San Mateo County
$1,350,000
$682,250
$2,032,250
$950,000
$2,700,000
Total Funding
$6,232,250
$250,000
$100,000
$100,000
$100,000
$550,000
Non-Premium
Funding
Total Funding
$88,200
$71,464
$25,000
$88,200
$71,464
$25,000
$15,000
$15,000
$250,000
$100,000
$100,000
$100,000
$749,664
$199,664
$813,902
$1,013,566
$1,350,000
$682,250
$2,032,250
$1,763,902
$2,700,000
$7,245,816
In spite of this generally problematic future for CHI funding, there have been a
few new sources of funding that have become available during 2006 to ease the strain on
funding premiums for children ages six to 18. Because the cost of services for Healthy
Kids enrollees has been lower than originally anticipated, the HPSM is returning 80
percent of any excess revenues it generates to the CHI. (Almost $2 million was refunded
by the time of the site visit in late 2005.) The excess revenue for children ages six to 18 is
being placed in a trust fund to cover additional children ages six and older. As a result of
this and other new funding, the CHI has avoided a cap on program enrollment. However,
these funds may or may not be available in the future.
6
A second source of ne w revenue is from Assembly Bill 495, which authorized a
waiver that provides federal matching funds for children with family incomes from 250
to 300 percent of the federal poverty level who otherwise meet the Healthy Families
eligibility requirements. The county is in the process of filing a retrospective claim to the
state for over $350,000 to cover the federal match for these children since 2004. They
have requested approval from the federal government to file a claim for 2003 (which is
needed since the time period for billing is usually two years).
A third new source of revenue for outreach/enrollment activities is Medi-Cal
Administrative Activities (MAA) funding. These funds cover some of the outreach
conducted by the San Mateo Medical Center (SMMC) and the Health Department’s
Community Health Advocates (CHAs). However, at the time of the site visit, the funds
had yet to be distributed to the county. MAA funding is estimated to be about $300,000
per year, more than initially anticipated.
Governance. There are no changes in the governance structure described in
previous reports, and the same organizations are represented on the CHI Oversight
Committee. The faith community, through Peninsula Interfaith Action, has become more
involved in the CHI, particularly the lobbying efforts for universal statewide coverage for
low- income children.
Outreach/Enrollment. No major changes have occurred in the methods of
outreach and enrollment. The number of outreach contractors is now six (California
Health Initiative, North Peninsula Neighborhood Services, Ravenswood Family Health
Center, Redwood City School District, Child Care Coordinating Council, and Cabrillo
Unified School District), all of which have a regional focus. Each of these contractors
7
also now receives additional small grants to support retention efforts and enrollments in
the county’s Adult Indigent Programs. Some new Community Health Advocates (CHAs)
have been added to both the SMMC and Health Department staffs. While they were
primarily added to enroll adults in the WELL 4 program, they also do enrollment for the
children in the family.
Healthy Kids Program. The design and structure of the Healthy Kids program has
remained largely the same as when the program began, except for an increase in the
premium for children in the 200-250 percent of poverty category, from $6 to $12, to be
consistent with the Healthy Families’ new premium structure. In addition, as of February
2005, the Human Services Agency no longer collects the family premium; instead, the
family is sent an invoice by the HPSM. This change has reduced the processing time for
enrollment from six weeks to five days. (A child may be enrolled for 60 days without a
premium payment.)
Figure 2-1 shows enrollment trends for the Healthy Kids program. There was a
gradual increase in the number of children enrolled in Healthy Kids during 2005, with the
number of young children (ages 0–5) growing slightly from 853 in January 2005 to 901
in January 2006, and the number of older children growing from 4548 to 5018 in the
same period. Since then, the growth has continued in the number of older children, so that
current enrollment in that age group exceeds the number of children originally budgeted
for the program. Unlike most other California counties with Healthy Kids programs, the
San Mateo CHI has avoided an anticipated program cap for the older children because
4
WELL stands for Wellness - Education - Linkage - Low cost. It is a program to provide health care
services for uninsured adults who are served in the San Mateo Medical Center and affiliated public clinics
who meet certain eligibility criteria.
8
growth continues to be gradual and because some new sources of funding were identified
to cover the additional children as described above.
Figure 2-1: Number of San Mateo Healthy Kids Enrollees by Age
7000
6000
Numbers Enrolled
5000
4000
3000
2000
1000
Ma
y-0
5
M
ar
-0
5
Ja
n-0
5
No
v-0
4
Se
p-0
4
Ju
l-0
4
Ma
y-0
4
M
ar
-0
4
Ja
n-0
4
No
v-0
3
Se
p-0
3
Au
g-0
3
Ju
n-0
3
Ap
r-0
3
Fe
b03
0
Month of Enrollment
0 to 5
6 to 18
Total
One-e-App. One-e-App is on- line software to process all applications for Healthy
Kids, Medi-Cal and Healthy Families. The purpose of One-e-App is to streamline
application preparation and processing and provide a single application for all three
programs. At the time of our second site visit in October 2004, One-e-App was not yet
operating as a streamlined alternative to paper applications for Medi-Cal and Healthy
Families. A year later, it was fully operational in the county and used by all application
9
assistors in all locations. Indeed, the county was awarded a “2005 County Challenge
Award” by the California Association of Counties for the implementation of One-e-App.
Although One-e-App is becoming more complex as more counties adopt it, since each
county has unique desired features and programs, those interviewed in San Mateo remain
very enthusiastic about it.
Healthy Kids Renewal. In the past year, the CHI has placed great emphasis on
improving renewal rates, which have been lower than expected. However, it has been
difficult to develop consistent data over time, making it difficult to monitor progress. One
of the possible reasons for lower than expected retention is the lack of centralized or
shared responsibility for renewals. At the time of the site visit the HPSM was beginning
to assume more responsibility for renewal. Another policy change is currently under
consideration that would require dropping the child from Healthy Kids if the family
cannot be contacted by mail.
A new small grant from the California HealthCare Foundation will develop more
consistent longitudinal data on retention rates over time. These will be available in future
reports.
Hardship Fund. A hardship fund covers the Healthy Kids premiums of families
who cannot afford them. During 2005 the One-e-App system was changed so that the
system prompts the application assistor to inform the parent about the fund’s availability,
for families with incomes below 150 percent of the federal poverty level who elect to pay
quarterly. (The fund is available to other families, but it is not actively advertised.) As a
result of this broader advertising, use of the hardship fund has increased. There were 550
children receiving premium assistance from the hardship fund at the time of our visit.
10
Provider Network. New efforts are being made to develop stronger relationships
with primary care providers (PCPs). The Provider Relations Department of the HPSM
regularly reviews how many PCPs have signed up with the plan comparing that to the
number of members to assure adequate capacity. Despite this, difficulties remain in
engaging providers, especially bilingual clinicians, largely due to low reimbursement
rates. In March 2006, however, providers serving Healthy Kids and Healthy Families
enrollees received an increase in their HPSM reimbursement rates (the health plan now
pays these providers 133 percent of the Medi-Cal fee schedule, an increase from 123
percent of the fee schedule).
11
Chapter 3: Who Is Served by the San Mateo County CHI? Have Demographic
Characteristics and Service Use Changed over Time?
Demographic Characteristics. There was substantial consistency in the demographic
characteristics of the children enrolled in Healthy Kids in the first two years of the CHI.
Table 3-1 compares the demographic characteristics of the children who enrolled in
calendar year 2003 (the first year of Healthy Kids) to those who enrolled in the second
year (2004). Healthy Kids enrollees are also compared to Healthy Families and Medi-Cal
children who were newly enrolled in the HPSM in 2004. 5
The age profile for children in the Healthy Kids program remained stable between
2003 and 2004. In spite of efforts to reach out to children below age six and enroll them
in Healthy Kids (where premium funding is secure), the proportion in that age group
remained at just over 20 percent, lower than initially anticipated. The children enrolling
in Healthy Kids and Healthy Families in 2004 were older on average than Medi-Cal
enrollees, with the large majority of children in both programs being over age six (78
percent for Healthy Kids and 64 percent for Healthy Families in 2004), in contrast to
Medi-Cal where only 38 percent of children were age six and older in that year.
Additionally, Healthy Kids continues to serve more adolescents than the other two
programs (33.7 percent of enrollees, compared to 18.9 percent for Healthy Families and
15.8 percent for Medi-Cal in 2004). These age differences in the programs are consistent
with program eligibility guidelines. Medi-Cal has more generous income levels for the
youngest children, and consequently, more young children are enrolled in Medi-Cal. In
5
All Healthy Kids and Medi-Cal children must enroll in HPSM in San Mateo County, while Healthy
Families parents may or may not choose the HPSM for their child.
12
addition, those born in the U.S. are citizens and therefore entitled to Medi-Cal or Healthy
Families.
Table 3-1: Demographic Characteristics
Children Continuously Enrolled in the Health Plan of San Mateo
2003-2004
Percent
Healthy
Medi-Cal
Healthy Kids
Families
Cohort 1 (Enrolled Cohort 2 (Enrolled
(Enrolled in 2004)
in 2003)
in 2004)
Age
0
1-5 years
6-12 years
13 years and above
0.7
21.4
44.5
33.4
1.3
20.6
44.4
33.7
0.9
35.4
44.8
18.9
34.4
27.4
22.4
15.8
Ethnicity/Language
Latino
Spanish
86.6
84.7
74.2
59.2
-
Income
< 150 percent of FPL
150-200 percent of FPL
>250 percent of FPL
76.7
14.0
9.3
75.8
10.6
13.3
-
-
Documented
6.7
12.4
-
-
4,378
2,313
919
7,299
N
Note: Each cohort includes children enrolled during the year who stayed enrolled for one
full year following enrollment
Table 3-1 also shows ethnicity/language for children enrolled in the three public
programs. Exact measures differ by program; for Healthy Kids and Healthy Families we
show the family’s preferred language (for receiving materials, applications, etc.). This is
Spanish for 84.7 percent of Healthy Kids enrollees in 2004, a percentage that did not
change substantially between the two years, and somewhat less (74.2 percent) for Healthy
13
Families enrollees. For Medi-Cal, the measure is self-reported ethnicity, which is Latino
for about 60 percent of enrollees.
Income and documentation status are available for Healthy Kids enrollees, and
there appears to be a small shift in the composition of enrollees according to these
measures. While only 9.3 percent of enrollees who joined the program in 2003 had family
incomes above 250 percent of the Federal Poverty Level, the percentage in that income
group increased to 13.3 percent among 2004 enrollees. Consistent with this slight shift in
the income distribution for Healthy Kids is a shift towards a higher percentage of children
who are documented (according to HPSM records), from 6.7 percent for the 2003 cohort
to 12.4 percent for 2004. This, combined with the shift in income, suggests that targeted
CHI outreach and enrollment efforts (for example, the school outreach discussed later in
Chapter 7) are reaching more of their intended clients, including higher income children,
who have been particularly difficult to reach through Children’s Health Initiatives in San
Mateo County and other counties.
Service Utilization. To examine trends in service use under the three public
programs, we examined annual rates of use for the two cohorts described above for
Healthy Kids. The first cohort is children who enrolled between February and December
2003. The second cohort is children who were newly enrolled in 2004. For Healthy Kids
cohort 1, we examined use rates during the first year of enrollment as well as during their
second year (for those who remained enrolled). For cohort 2, we examined use rates
during the first year of enrollment. These rates are compared to use rates in the first year
of enrollment for children who enrolled in the HPSM under both Healthy Families and
Medi-Cal during 2004.
14
The CHI has a goal of increasing preventive care service use among children
enrolled in public programs, particularly Healthy Kids. Last year’s annual report showed
that preventive care service use was low early in the program. Those interviewed during
the annual site visit emphasized that increasing use of preventive care services is a major
goal for the CHI.
Some felt that many parents are unfamiliar with the importance of preventive
care. As a result, the HPSM instituted a plan to contact families on a regular basis,
including calling if there is no evidence of services received within the first 120 days
after enrollment. The HPSM also attempts to encourage preventive care by offering a
higher provider reimbursement rate for the first physical examination. Finally, the
newsletter (which goes out to all members) provides health education messages that
encourage preventive care visits. In addition to these efforts by the HPSM, most CAAs
go over a newly designed New Member Packet with families at the time of enrollment.
The packet provides preventive care information and discusses the renewal process.
Figure 3-1 reveals potentially positive trends in preventive care service use from
this increased parental education. As shown, the annual rate of preventive care climbed
for Healthy Kids between the first year of enrollment of Cohort 1 and the first year of
enrollment of Cohort 2. Additionally, use of preventive care increased between the first
year and second year of enrollment from 33.7 to 37.9 percent of children having an
annual preventive care visit. This suggests that there may be an educationa l effect that
takes some time for parents to absorb and that does not become evident until the second
year of enrollment. Healthy Kids children who enrolled in 2004 still had a lower rate of
use of preventive care than for Healthy Families, although the gap is less than for 2003 as
15
reported in last year’s annual report. The Healthy Kids preventive care use rate was
similar to Medi-Cal, even though Medi-Cal children are younger on average and should
be receiving higher rates of preventive care according to professional guidelines. 6
Percentage with a visit in year
Figure 3-1
Percent of Children Having A Preventive Care Visit in a Year
Children Continuously Enrolled in the Health Plan of San Mateo
2003- 2004
60
54.6
50
40
37.9
40.4
39.6
33.7
30
20
10
0
Healthy Kids
Cohort 1, Year 1, 2003
Healthy Families
Cohort 1, Year 2, 2004
Medi -Cal
Cohort 2, Year 1, 2004
Annual service use of all types of ambulatory care (including care for sick
children) increased from the first year of enrollment for Healthy Kids (Figure 3-2). As
shown last year, use of any ambulatory care was substantially higher than the use of
preventive care, and approached national norms. 7 Presumably some sick care visits also
include preventive services.
6
CHDP claims/encounter records are included in the data. However, there is a lag in the inclusion of
CHDP claims in the HPSM files. This could explain in part the low Medi-Cal preventive care use.
7
In 2000 78.6 percent of all U.S. children had an ambulatory care visit. (National Center for Health
Statistics 2003)
16
Figure 3-2: Percent of Children Having An Ambulatory Care Visit in A Year
Children Continuously Enrolled in the Health Plan of San Mateo
2003-2004
90
Percentage
80
81.5
69.3
72.5
77.4
73.8
70
60
50
40
30
20
10
0
Healthy Kids
Healthy Families
Cohort 1, Year 1, 2003
Cohort 1, Year 2, 2004
Medi-Cal
Cohort 2, Year 1, 2004
If preventive and primary care are used appropriately, emergency room use could
decline. There is no evidence this trade off in the trends shown in Figure 3-3, since there
was almost no change in emergency room use over time for the Healthy Kids program.
Still, as observed in last year’s annual report, Healthy Kids use of emergency rooms
remains substantially below use in the other two public programs.
Figure 3-3: Percent of Children Having An Emergency Room Visit in a Year
Children Continuously Enrolled in the Health Plan of San Mateo
2003-2004
35
31.5
30
Percentage
25
20
16.4
15
12.5
12.7
12.5
10
5
0
Healthy Kids
Cohort 1, Year 1, 2003
Healthy Families
Cohort 1, Year 2, 2004
Medi -Cal
Cohort 2, Year 1, 2004
17
The higher rates of emergency room use for Medi-Cal children than for children
in the other two programs may not be completely due to overuse of the ER. Medi-Cal
children are younger and in poorer health, as shown in last year’s annual report.
Healthy Kids is providing new coverage for dental and vision care for most of the
children in the program. Figure 3-4 shows trends in dental and vision care use for the
Healthy Kids cohorts (complete data are unavailable for the other programs). As with
preventive care use, the use from Cohort 1 increased in their second year of enrollment.
Figure 3-4: Percent of Children Having Dental and Vision Visits in a Year
Children Continuously Enrolled in Healthy Kids
2003-2004
70
62.9
60
55.8
55.9
Percentage
50
40
30
20
8.3
10
9.6
8.9
0
Dental V isit
Cohort 1, Year 1, 2003
Vision Visit
Cohort 1, Year 2, 2004
Cohort 2, Year 1, 2004
For example, use of dental care increased from 55.8 percent of children having a visit in
the first year to 62.9 percent in the second year. The rates for vision care increased from
8.3 to 9.6 percent. This is also good news, since these are critical services and educational
efforts may also be playing a role in the increase in use. On the other hand, use for the
first years of Cohorts 1 and 2 did not change very much. The data also show that dental
18
visits are more common than preventive care visits, and approach the level of use of any
ambulatory medical care.
Conclusions. In conclusion, there is substantial stability in the types of children
enrolling in Healthy Kids. However, Healthy Kids enrollees differ from Healthy Families
and Medi-Cal children, with Healthy Kids enrollees being older and more often Spanishspeaking. The profile of Healthy Kids enrollees is shifting over time in small ways. For
example, it appears that some higher income, documented families are learning about the
program and enrolling their children. It will be important to continue to track these trends
over time.
While there is also substantial similarity in use of services over time, it appears
that Healthy Kids enrollees use more preventive care (as well dental and vision care)
during their second year of enrollment. In addition, the use of preventive care is
increasing over time, since the children enrolled in 2004 had higher rates of preventive
are than those enrolled in 2003 (although rates remain lower than desirable).
19
Chapter 4: Who Are the High Cost Users of Services and How Do They Differ From
Other Children Enrolled in Public Health Insurance Programs?
Other studies have shown that a small proportion of users of services account for a large
proportion of the cost of health care. For example, an early study of this issue showed
that the top 10 percent of users in cost nationwide accounted for 75 percent of all the cost
for the non- institutionalized population (Garfinkel et al. 1998). Since chronic
conditions—such as mental health problems (Buck et al. 2003) and other chronic
conditions (Kozyrskyj et al. 2005)—are more prevalent in the high cost group, there have
been special managed care initiatives for the high cost population in order to improve
quality and continuity of care, as well as reduce cost.
Less is known about the profile of children who are high cost users, but an
analysis of San Mateo CHI evaluation client survey data showed that about ten percent of
the children enrolled in Healthy Kids had six or more doctor visits in the six months prior
to the survey, suggesting that some children are experiencing chronic illness and frequent
use of services. Consequently, learning more about their health conditions, service use,
and cost may help to identify ways to address their particular needs under managed care.
In order to study this issue further, we requested tables for children continuously enrolled
in Healthy Kids during the period July 2003 to June, 2004 in order to compare the
diagnoses, use, and cost for the high cost children to other Healthy Kids service users.
The HPSM summarized the cost per child across all Healthy Kids users, and sorted the
data, in order to identify the children who fell into the top 10 percent of cost (called the
“high cost user”) group. It is important to note that the tables apply only to users of
20
services (and therefore those with some cost), as opposed to all enrollees as did the tables
in the previous chapter.
Figure 4-1 High Cost Users and Other Users
Children Continuously Enrolled in the Health Plan of San Mateo
July 2004 - June 2005
60
57.1
55.5
52.1
53.3
52.0
50.5
50
Percent Male
40
30
20
10
0
Healthy Kids
Healthy Families
High Cost Children
Medi-Cal
Other Children
Using this method, there were 220 high cost users in Healthy Kids during the time
period, which is approximately 10 percent of users, compared with 1973 other users (90
percent). The number of children for Healthy Families was 107 high cost users (10
percent) and 956 other users (90 percent), and for Medi-Cal it was 1,092 high cost users
(10 percent), and 9,828 other users (90 percent).
Demographics. High cost children in all three public programs are more often
boys (figure 4-1). There has been little data from previous research to show that boys are
more expensive than girls under public health insurance programs. The consistency in
this pattern across programs suggest that this is an area for further study, in order to
21
understand the special health care needs of boys that lead to higher costs. Adolescents are
also more often in the high cost group (figure 4-2) than are other children. This distinct
pattern is also consistent across all three public programs.
Percent Adolescent (13+)
Figure 4-2: Percent Adolescent (Age 13+)
High Cost Users and Other Users
Children Continuously Enrolled in the Health Plan of San Mateo
July 2004 - June 2005
45.0
40.0
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
41.8
31.4
24.3
26.1
22.6
16.8
Healthy Kids
Healthy Families
High Cost Users
Medi-Cal
Other Users
However, as figure 4-3 shows, the ethnicity differences between high cost and
other users vary according to program. For Healthy Kids, an almost equal percentage of
both groups are Spanish-speaking (about 85 percent). In the Healthy Families program,
the proportion of high cost users who speak Spanish (71.8 percent) is also similar to the
proportion for low cost users (78.1 percent). For Medi-Cal, a lower proportion of high
cost users are Latino (49.5 percent) than are users (62.7 percent). (Data on language
spoken are not available for Medi-Cal.)
22
Figure 4-3: Percent Latino/Spanish Speaking
High Cost Users and Other Users
Children Continuously Enrolled in the Health Plan of San Mateo
July 2004 - June 2005
100.0
Percent Latino or Spanish Speaking
90.0
85.0
87.5
78.1
80.0
71.8
70.0
62.7
60.0
49.5
50.0
40.0
30.0
20.0
10.0
0.0
Healthy Kids (% Spanish Speaking)
Healthy Families (% Spanish Speaking)
High Cost Users
Medi-Cal (% Latino)
Other Users
Diagnoses. Table 4-1 shows the prevalence of selected diagnoses for high cost
users and other users for all three programs. We differentiate diagnoses that are generally
more acute from those that generally require chronic care. The most prevalent conditions
among high cost children include some acute conditions (infectious disease, otitis media,
and skin disorders)—all of which are also relatively prevalent among other children—and
some chronic conditions (asthma, endocrine disorders, and mental disorders), which have
lower prevalence among the other children.
The prevalence of acute conditions is usually higher for the highest cost children,
but not always. In contrast, the prevalence of chronic conditions is at least twice as high
for high cost users, and often the disparity is much greater. This is especially the case for
some serious conditions such as congenital anomalies, diabetes, and neoplasms, which
are very rare for children who are not in the high cost groups.
23
Table 4-1: Prevalence of Selected Diagnoses
Children Continuously Enrolled in the Health Plan of San Mateo
July 2004 to June 2005
Healthy Kids
High
Cost
Users
Acute Conditions
Tuberculosis
Other Infectious Disease
Fractures
Otitis Media
Skin Disorders
Wounds
Chronic Conditions
Asthma
Congenital Anomalies
Diabetes
Other Endocrine Disorders
Mental Disorders
Neoplasms
Healthy Families
Medi-Cal
Percentage with Condition
High
High
Other
Cost
Other
Cost
Other
Users
Users
Users
Users
Users
4.4
11.2
3.9
9.3
14.1
3.9
7.3
8.9
1.1
5.2
8.1
1.2
0.0
18.8
2.0
10.9
14.9
4.0
1.0
8.0
2.6
4.4
11.3
1.2
0.5
17.8
5.4
16.7
15.3
2.8
0.5
13.2
1.6
10.6
12.1
2.8
14.6
5.4
1.0
10.2
15.1
2.9
5.0
1.0
0.1
3.2
2.0
0.4
31.7
2.0
5.0
9.9
12.9
2.0
5.0
1.0
0.6
3.4
1.9
0.1
17.8
16.0
1.6
7.1
4.5
6.8
2.1
0.1
2.9
0.7
Notes:
(1) Children may have more than one diagnosis reported in the table, and not all conditions are reported, so percentages do not add to
100%.
(2) Most Medi-Cal mental health services are not paid for by HPSM. For Healthy Families some mental health services are not paid for by
HPSM.
Utilization. Table 4-2 shows the annual use of ambulatory care by high cost and
other users, for several types of ambulatory care, both preventive care and other care.
Use rates are higher for the high cost users, across all three programs and for all types of
ambulatory care services.
In contrast to rates of use of other types of ambulatory care (including specialty
care), the rates of visits and the number of visits for preventive care are somewhat similar
between high cost users and other users. Still, a higher proportion of children who are
high cost users have preventive care of some type, indicating perhaps that once children
24
have contact with the health care system for their chronic conditions they are then more
likely to receive their preventive care visits. For example, 59.6 percent of Healthy Kids
high cost users had preventive care in the year, in contrast to 49.2 percent of other users
with at least some utilization of services.
Table 4-2
Annual Use of Ambulatory Care
High Cost and Other Users
Children Continuously Enrolled in the Health Plan of San Mateo
July 2004-June 2005
Healthy Kids
Outpatient/Clinic
Preventive Visits
- % with visit
- Average no. of visits
Other Visits
- % with visit
- Average no. of visits
Other Doctor
Preventive visits
- % with visit
- Average no. of visits
Other Visits
- % with visit
- Average no. of visits
Any Preventive Visit
- % with visit
- Average no. of % visits
Any Ambulatory Visit
- % with visit
- Average no. of visits
Healthy Famlies
Medi-Cal
High Cost
Other
High Cost
Other
High Cost
Other
48.2
0.7
41.3
0.5
37.4
0.5
30.6
0.4
26.2
0.5
18.2
0.3
91.4
6.8
65.1
1.8
86.0
4.9
50.5
1.1
87.9
7.1
58.6
1.6
13.6
0.2
10.9
0.1
33.6
0.5
27.9
0.3
25.4
0.5
26.6
0.4
38.2
3.6
16.8
0.4
48.6
4.8
39.4
1.0
66.0
3.5
49.7
1.6
59.6
0.9
49.2
0.6
64.5
1.0
55.0
0.7
45.6
1.0
40.6
0.7
99.6
11.3
95.0
3.4
100.0
10.7
94.7
2.8
96.2
11.6
90.5
4.6
In contrast, use of other (non-preventive) ambulatory care is much higher among
the high cost users. The greatest difference between high cost and other users was in the
percentage of high cost users with visits to outpatient/ clinics for services other than
preventive care. (This category includes care in specialty clinics.) For example, 91.4
percent of Healthy Kids high cost users visited an outpatient/clinic for non-preventive
25
care; corresponding rates for Medi-Cal and Healthy Families were 87.9 percent and 86.0
percent respectively. (Rates were much lower, from 50.5 to 65.1 percent, for other users.)
An even more striking difference in the use of this type of care was in the average
number of visits to such providers, which was at least three times as high for the high cost
users. A similar pattern pertains for visits to other (private) doctors for non-preventive
care.
The table shows a final measure, “any ambulatory care”, which includes all types
of ambulatory care, whether it is in outpatient/clinic settings or in other doctors’ offices,
and whether it is for preventive or non-preventive care. As shown, almost all users, either
high cost or other, had some ambulatory care in the year, so the main way that the high
cost groups differed is in their average number of ambulatory visits (11.3 visits for
Healthy Kids, 10.7 for Healthy Families, and 11.6 for Medi-Cal), which is two to four
times greater than for other users.
Moving to the use of other health care services, table 4-3 shows that hospital use
is a major determinant of high cost status. Only high cost children had any hospital care.
Rates of hospital care use were 14.5 percent of Healthy Kids high cost users, 10.3 percent
of Healthy Families high cost users, and a larger proportion (30.2 percent) of Medi-Cal
high cost users.
Another marker for being a high cost user was emergency room use. From 40 to
about 60 percent of high cost users had an emergency room visit, depending on the
program. Rates were much lower for other users. The rate of prescription drug use was
also much greater for high cost users, particularly for the Medi-Cal high cost users, where
26
94.2 percent of users had a prescription (for an average of 18.6 prescriptions per child), 8
compared to 91.6 percent for Healthy Families and 80.5 percent for Healthy Kids.
Table 4-3: Annual Use of Other Care
High Cost and Other Users
Children Continuously Enrolled in the Health Plan of San Mateo
July 2004 - June 2005
Healthy Kids
High Cost Other
Healthy Families
High Cost Other
Medi-Cal
High Cost Other
Hospital
- % with stay
- Average no. of stays
14.5
0.2
0.0
0.0
10.3
0.1
0.0
0.0
30.2
0.4
0.4
0.0
E R Visits
- % with visit
- Average no. of visits
40.6
0.6
15.3
0.2
50.5
1.0
16.3
0.2
56.3
1.4
35.3
0.6
Prescriptions
- % with prescription
- Average no. of prescriptions
80.5
5.4
47.5
1.1
91.6
7.9
54.1
1.4
94.1
18.6
71.7
3.0
Vision Visits
- % with visit
- Average no. of visits
15.5
0.2
10.9
0.1
-
-
10.5
0.1
7.0
0.1
Dental Visits
- % with visit
- Average no. of visits
63.2
1.7
66.7
1.9
-
-
-
-
Table 4-3 also compares use of vision and dental care between high cost and other
users. (Vision care data are available only for Healthy Kids and Medi-Cal, and dental
care for Healthy Kids). Interestingly, while a greater percentage of high cost users have
had a vision visit tha n other users (15.5 and 10.9 percent respectively for Healthy Kids,
for example), slightly fewer have had a dental visit compared to other users, as well as
fewer visits on average. This is in contrast to the use of other forms of preventive care,
which high cost children are more likely to have.
8
Prescription drug claims include other types of services such as durable medical equipment, supplies, and
nutritional supplements or vitamins, when these are prescribed.
27
Table 4-4 compares the average cost for the high cost children and other children
in all three programs, by type of service. Overall (and by definition), the high cost
children are much more expensive than other children. Those children’s average annual
costs range from $1,834 (Healthy Families) to $2.614 (Healthy Kids) to a much higher
$6,530 (Medi-Cal). In contrast (after excluding dental and vision care costs, which leads
to a more accurate comparison across programs), the average cost for non-high cost
children (who are 90 percent of the users on the programs) is very low and does not differ
greatly from program to program, ranging from $218 to $265.
Table 4-4: Average Annual Cost of Care, High Cost and Other Users
Children Continuously Enrolled in the Health Plan of San Mateo
July 2004 - June 2005
Healthy Kids
High Cost Other
Healthy Families
High Cost Other
Outpatient/Clinic
Other Physician
E.R.
Hospital
Vision
Dental
Prescriptions
Other
Total
$771
347
121
826
9
171
333
36
$2,614
$148
31
22
0
8
198
19
12
$438
$457
351
196
357
447
26
$1,834
Without Dental/Vision
$2,434
$232
$1,834
$86
72
24
0
Medi-Cal
High Cost Other
26
10
$218
$1,095
413
204
2,320
8
1,287
1,203
$6,530
$93
48
64
0
5
58
2
$270
$218
$6,522
$265
-
The cost patterns by type of service correspond to the patterns in utilization noted
above. For example, the costs for outpatient/clinic, other physician, emergency room,
hospital, and prescription services were all much higher for high cost children, with the
greatest disparities being for Medi-Cal children. A high cost of dental care, while the
most expensive service on average for non–high cost users, was not a marker of a high
cost user in the Healthy Kids program.
28
The total cost for children in the high cost group was a substantial portion of the
cost of all children enrolled in each program: 39.9 percent for Healthy Kids, 48.4 percent
for Healthy Families, and 72.8 percent for Medi-Cal (data not shown). Therefore the
heavy concentration of costs in a small number of children is not as prevalent in the
Healthy Kids and Healthy Families programs as for Medi-Cal and for the national
population including adults (as cited earlier).
Conclusions. In conclusion, the ten percent of children who have the highest
annual cost in a year are different in many ways from the average child on the three
public health insurance programs in San Mateo County. They are more often male and
adolescents, as well as more often have chronic health conditions. They have high rates
of contact with the medical care system, especially hospital and emergency room care,
and very high average costs, especially for Medi-Cal. It is possible that the care for these
children could be targeted for more intensive care co-ordination, both to the benefit of the
child in terms continuity of care as well as the programs in terms of reduced costs.
29
Chapter 5: Do Healthy Kids Enrollees Obtain Needed Dental Health Services? What
Barriers Restrict Access?
Tooth decay is a significant problem among California elementary school children, and
28 percent of them have untreated tooth decay. Poor children and children of color,
particularly Latino children, are much more likely to have tooth decay and suffer the
consequences of untreated disease (Dental Health Foundation 2006).
The San Mateo County Healthy Kids client survey described in the Second
Annual Report revealed problems with access to dental care for some children. Only 72.3
percent of parents reported that their child had a usual source of dental care, compared to
88.1 percent who had a regular source of medical care. Parents were also asked if there
had been a time when their child needed to see a dentist but did not; about 12 percent said
yes (in contrast to only 6.3 percent for specialist medical care). When asked why, only
three parents responded that the unmet need for dental care was due to the cost of care.
This suggests that there are other barriers to access, such as provider availability, for
some families. Focus groups with parents confirmed that dental care access was a
perceived problem more often than medical care access.
This chapter examines utilization and costs of dental care, describes the major
sources of dental services for Healthy Kids children, and identifies potential barriers to
services. The findings are based both on dental cla ims/encounter data and site visit
interviews.
The HPSM contracts with Delta Dental to provide dental services for children
enrolled in Healthy Kids, and in turn, the HPSM obtains claims/encounter records from
Delta Dental describing the use and cost of dental services for enrolled children. HPSM
30
produced tables on dental care for Healthy Kids enrollees for this report. (The plan does
not maintain data on dental services for children enrolled in Medi-Cal or Healthy
Families.)
Service Use. During July 1, 2004 through June 30, 2005, 1,788 children (64
percent of Healthy Kids who were enrolled for the full 12 month period) had at least one
dental service (Figure 5-1). Of the three age groups examined, adolescents (ages 13-18)
were the least likely to have a dental service (56.9 percent), while children ages zero to
five and six to 12 had higher rates (61.7 percent and 69.5 percent respectively). The high
Figure 5-1: Percent with Any Dental Service, by Age
Children Continuously Enrolled in Healthy Kids
July 2003 to June 2004
80.0%
69.5%
70.0%
63.9%
61.7%
Percent with Dental Service
60.0%
56.9%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
0-5
6-12
13-18
All children
Age
use rate for the youngest age group may reflect statewide efforts to promote early dental
examinations for very young children. The mean annual number of visits for those who
used any care was essentially the same across age groups: 3.0 visits for children ages 1-5;
2.8 for children ages 6-12; and 3.0 for children ages 13-18 (data not shown). While these
31
data on dental service use show a frequent use of services for many children, especially
the youngest children, it is important to note that 36 percent of continuously enrolled
Healthy Kids enrollees had no dental service during the year.
Table 5-1 shows that the majority of Healthy Kids who used dental services had
either one (25.6 percent) or two (27.0 percent) dental visits in the year. Conversely,
almost half had more visits, suggesting that they needed more than preventive dental
care. Among these children, 37.9 percent had between three and five visits, and a smaller
proportion (9.5 percent) had more than five. There was no difference in the frequency of
visits by age (data not shown).
Table 5-1: Average Number of Visits for Dental Service
Children Continuously Enrolled in Healthy Kids
July 2003 to June 2004
Number of Visits
1
2
3 to 5
More than 5
N
Percent
25.6
27.0
37.9
9.5
1788
The most common dental services provided to Healthy Kids were for diagnostic
and preventive care services, such as exams, x-rays, prophylaxis, sealants, and fluoride
treatment (table 5-2). Fully 90.8 percent of dental users had a diagnostic exam and 84.8
percent had X-rays, with lower rates for prophylaxis (80.3 percent), sealants (63.7
percent), and fluoride treatment (56.9 percent). On the other hand, many children had
more serious dental problems; for example, 17.7 percent of dental users had restorative
treatment.
32
Service Cost. Children who had dental care were more expensive for the Healthy
Kids program than those without dental services (table 5-3), and the cost of dental
services represented a substantial proportion of the overall cost of their care. As shown in
the table, the average total cost per child who had at least one dental service was $648
Table 5-3: Average Annual Cost per Enrollee for Dental and
Other Services
Children Continuously Enrolled in Healthy Kids
July 2004 to June 2005
Dental Care Costs
Other Care Costs
Total Costs
N
Dental
Other
All
Users Enrollees Enrollees
$294
$0
$187
$354
$338
$348
$648
$338
$535
1788
1012
2800
33
compared to just $338 for those without any dental care. The average annual cost for
other services was about the same for children with dental care ($354) and those without
dental care ($338). Increasing the number of dental care users—a program goal—would
increase the overall cost of care for Healthy Kids children, since there does not appear to
be an offsetting reduction in medical care cost among these children. Of the three age
groups, the average dental care cost was highest for adolescent dental users, suggesting
more dental treatment for those children (data not shown).
Types of Dental Care Providers. Table 5-4 shows the types of dental providers
who are seeing Healthy Kids enrollees. As shown, the most common type of oral health
providers are private dentists and just over a third are seen in the public system (either at
the San Mateo Medical Center clinic or one of the three affiliated clinics: Fair Oaks,
Willow, or Daly City). A very small percentage are seen at Sonrisas Dental Clinic—a
private nonprofit clinic in the Half Moon Bay area, which does not have a public clinic—
or by the Tooth Mobile.
Table 5-4: Healthy Kids Dental Users by Type of Dental Provider
Children Continuously Enrolled in Healthy Kids
July 2004 - June 2005
Provider
Percent of all Users
San Mateo Medical Center and County Clinics
39.1
Private Dentists
43.3
Private Dental Groups
20.9
Sonrisas Dental Clinic
5.8
Tooth Mobile
0.5
N
1778
Note: Percentages do not sum to 100% since some children saw more than one
type of provider.
34
The remainder of Healthy Kids, and the large majority, are seen by private
individual dent ists or by private dental groups. There were 25 private individual dentists,
and 15 dental groups, that billed for Healthy Kids services during the study period. Care
in the private sector was concentrated heavily in a few private providers; two individual
dentists saw more patients than all of the remaining individual dentists combined.
There is evidence that a wider network of private dentists is potentially available
to serve Healthy Kids. Recently, CHI staff called 21 private dentists and dental groups on
the list of Delta Dental participating dentists and found that all of them currently accept
Healthy Kids patients with relatively short waiting times for appointments (one to three
weeks). This is in contrast to waiting times for county clinics, which are one to four
months for dental care.
Access to Dental Care. As shown above, over 30 percent of Healthy Kids (and an
unknown percentage of other publicly insured children) have no dental care during a
year. Consequently, it is important to consider ways that dental care access in San Mateo
County could be expanded for publicly insured children.
During the most recent site visit, in order to better understand potential barriers to
access to dental services, we interviewed one public and one non-profit dental provider.
In the previous evaluation year, as reported in the Second Annual Report, we conducted
intensive interviews with five participating and five nonparticipating private dentists. The
individuals that we interviewed were unaware of the extent of availability of private
providers to serve Healthy Kids. Those interviewed felt that private dentists represent
only a small proportion of dental providers for low income children in the county. They
were aware that private dentists often serve low income children on a pro bono basis,
35
such as at the Samaritan House free clinic, Give Kids a Smile Day (where free dental
screenings are provided), or in their own offices on a limited basis. This perceived
preference to provide services for free, rather than to seek reimbursement from public
programs, was viewed as a reflection of low reimbursement rates and cumbersome
paperwork. For example, the dentists we interviewed said that it is sometimes difficult to
obtain prior authorization for services such as root canals and X-rays.
Although the data presented above, and the CHI survey of private dentists,
suggest that access to private dental providers may be better than perceived by many
stakeholders, gaining even broader private provider participation remains important to
improving access. The CHI has already taken steps to improve access and utilization in
two important ways: the establishment of a dental workgroup as part of the CHI
Oversight Committee and plans for the Health Plan Retention Specialist to contact
parents of children who do not utilize dental services to facilitate appropriate utilization. 9
We also heard the following suggestions for further improving provider participation:
•
Ensure that dentists are familiar with all three programs: Medi-Cal,
Healthy Families and Healthy Kids;
•
Offer training on how to complete paperwork for public patients
(especially Medi-Cal);
•
Align policies and procedures for reimbursement across the Medi-Cal,
Healthy Families, and Healthy Kids programs. (For example, Medi-Cal
claim codes are different from the claims codes used for Healthy Families
and Healthy Kids.)
Another likely barrier to care for many children is their parent’s lack of
knowledge about when and where to obtain dental services for their children, particularly
9
Delta Dental does not actively promote utilization of services.
36
if they are accustomed to using only the county clinics for care. For example, they may
be unaware that there are alternative sources in the private sector. On-going education to
families about the value of regular oral health care and sources of services could alleviate
this problem.
Conclusions. While access to dental care appears to be better than perceived by
many stakeholders, there are still a substantial number of Healthy Kids enrollees who do
not have any dental care during a given year. Our findings suggest that an improved
dialogue between the two sectors serving Healthy Kids (public and private) is likely to
improve planning for services. It appears that capacity exits in the private sector for more
Healthy Kids children and more children who have insurance could be diverted to the
private sector to improve their access to dental care. In addition, the public sector could
play an important role in monitoring indicators of quality of care in the private sector
(such as the frequency and types of services) through the data available from HPSM and
more regular contact between the two sectors.
37
Chapter 6: Do Healthy Kids Enrollees Obtain Needed Mental Health Services?
What Barriers Restrict Access?
Need for Children’s Mental Health Services. Natio nally mental health disorders affect as
many as one in five children. However, only about a fifth of children who need mental
health services receive them (Jellinek et al. 1999; DHHS 1999a), even though services
have been shown to prevent juvenile delinque ncy and improve cognitive, academic, and
social outcomes (Ramey and Ramey 1998; Zigler, Taussig, and Black 1992). Studies
indicate that Latino children have especially high rates of unmet need for mental health
services relative to other children (Kataoka, Zhang, and Wells 2002).
The prevalence of children’s mental health problems in San Mateo County
appears to be similar to national rates, at least for Healthy Kids program enrollees. The
evaluation’s survey of the parents of Healthy Kids enrollees, conduc ted in 2004, included
a series of questions about children’s emotional and behavioral health status. Parents
were asked, for example, whether their child was often unhappy, sad, or depressed, and
whether the child often did not get along with other children. Using these indicators,
about 20 percent of parents reported that their child had an emotional or behavioral
problem in the past 30 days. In addition, about 40 percent of those with school-age
children with a mental health problem (or about 8 percent of all children) indicated that
their child’s emotional and behavioral problem limited the child’s ability to do school
work (Howell et al. 2005). This lower rate is closer to the estimated 6 percent of children
nationally who have a serious emotional disturbance (SED) (DHHS 1999b).
Children’s Mental Health Services in San Mateo County. San Mateo County has a
history of innovative mental health services to address the needs of those with serious
38
mental health problems, including children. The county-organized system of care
provides a coordinated network of health and social services to low- income children with
severe emotional and behavioral problems.
All three public programs have generous mental health benefits, as compared to
many private insurance plans. There are no inpatient or outpatient benefit limitations for
children with SED. Under Healthy Kids and Healthy Families, inpatient mental health
services are limited to 30 days (no co-payment requirements). Outpatient mental health
and outpatient substance abuse services are limited to 20 visits per benefit year. A copayment of $5 per visit is required for outpatient care. Inpatient substance abuse services
only include hospitalization for detoxification. Children enrolled in Medi-Cal have no
benefit limits and have access to a broad array of services through the Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) program.
The San Mateo County Health Department/Mental Health Services Department
(MHS) organizes and manages the delivery of mental health services for children with
SED and some other children with mental health problems, for all three public programs.
These services are provided through contracts between the MHS and private providers.
We were told that the benefit limits specified by Healthy Kids and Health Families are
not applied these county-organized mental health services. These services are available,
without cost-sharing, to Healthy Kids and Healthy Families children who meet the
criteria for MHS services. Services must fall within the plan of care developed by MHS
clinicians.
The MHS bills the appropriate entity, which differs by program. For example,
MHS bills the state for Medi-Cal children, and it bills the HPSM for Healthy Kids
39
enrollees. Mental health services for Healthy Families enrollees who have SED are billed
to the state, while services for other children are billed to the HPSM. For the decade
ending in 2005, MHS was reimbursed a case rate per Medi-Cal child in the plan (the only
California county under this arrangement). Currently, reimbursement for all three
programs is through fee- for-service arrangements, but the care co-ordination functions of
the MHS are still in place.
There are mental health services provided by providers outside the MHS network
that are billed directly to the HPSM for all three programs. For example, a pediatrician
may treat a child for ADHD, or a child may be hospitalized for a condition such as
anorexia on an emergency basis. In contrast, there are also low income children receiving
mental health services who are not tracked by either system, that is by the MHS or the
HPSM, for example children treated by county- funded therapists on the staff of the
Family Resource Centers operated by the Human Services Agency.
San Mateo County is in the process of planning an expansion of mental health
services due to the passage of Proposition 63 of 2004, which created the Mental Health
Services Act making available $750 million of new funding (with $5 million for San
Mateo County) to improve mental health. San Mateo County was among the first to begin
planning its use of these funds, although it is too early to know how the new services will
affect children with mental health problems. 10
Use of Mental Health Services. In order to investigate whether the use of mental
health services is low for children, as reported anecdotally during site visits, we requested
tabulations from the HPSM for the two programs for which HPSM receives mental health
10
Details about the County’s plan can be found at:
http://sanmateo.networkofcare.org/mh/home/prop63_sanmateo.cfm.
40
care claims, Healthy Kids and Healthy Families. (The plan does no t receive claims for
Medi-Cal, and for children with SED under Healthy Families.)
The tabulations cover all services reported to the plan for all children
continuously enrolled in both programs from July 1, 2004, to June 30, 2005. For those
children, the plan identified all children with a mental health diagnosis on at least one
claim, and tabulated the following: (1) number of children by mental health diagnosis; (2)
number of children with a mental health diagnosis according to the provider that served
them; and (3) average annual mental health and non- mental health cost per enrollee. The
health plan also supplied information about children who did not have any mental health
claims for comparison purposes. It is important to note that because the claims of
children with SED in Healthy Families are billed to and paid for by the state rather than
HPSM, our analysis under-represents the cost for Healthy Families enrollees with mental
health problems.
As shown in table 6-1, despite reports in the client survey that about 20 percent of
children had a mental health problem, only 5.7 percent of the 2,800 Healthy Kids
enrollees who were continuously enrolled from July 2004 to June 2005 had any claims
with a mental health diagnosis. The percentage of Healthy Families children with a claim
with a mental health diagnosis was even lower, 4.2 percent. (Note that this excludes
children with SED, possibly another 5 percent of enrollees.) For Healthy Kids, where the
data base includes all mental health claims, the prevalence was highest among
adolescents (ages 13–18), 7.4 percent of Healthy Kids enrollees, in contrast to a lower
rate among younger children.
41
Table 6-1: Number (and Percent) of Enrollees
with Any Mental Health Diagnosis, by Age
Children Continuously Enrolled in The Health
Plan of San Mateo
July 2004 to June 2005
Mental Health
Diagnosis
Healthy Kids
0-5 years
Age 6-12 years
13-18 years
Total
N
Healthy Families
0-5 years
Age 6-12 years
13-18 years
Total
N
5.1
4.7
7.4
5.7
159
4.8
3.9
4.3
4.2
57
Table 6-2 shows which mental health diagnoses were reported in the
claims/encounter data. Patterns were similar between the two programs and to national
patterns of children’s mental health disorders. Mood and anxiety disorders were the most
prevalent diagnoses, affecting about a third or more of all mental health users in both
programs. Attention-deficit and disruptive disorders affected 20 percent of Healthy Kids
mental health users, and an even larger portion of Healthy Families users (reflecting a
milder case mix given that SED children are excluded from the data). Developmental
disorders, including autism as well as milder learning and communication disorders,
affected about 20 percent of both Healthy Kids and Healthy Families children. Serious
psychotic disorders, such as schizophrenia, were very rare, as were substance abuse
42
disorders. The remainder of children had a variety of other mental health conditions, such
as eating disorders and sleeping disorders.
Table 6-2: Mental Health Diagnoses
Children Continuously Enrolled in the Health Plan of San Mateo
July 2004 to June 2005
Healthy Kids Healthy
(%)
Families (%)
Mood and Anxiety Disorders
33.3
40.4
Attention Deficit and Disruptive Behavior Disorders
23.3
33.3
Developmental Disorders
19.5
17.5
Substance Abuse Disorders
*
*
Schizophrenia and Other Psychotic Disorders
*
*
Other Disorders
24.5
12.3
Total Number of Children with a Mental Health Diagnosis
159
57
* Fewer than 5 children
Figure 6-1 displays health service use for children with mental health diagnoses in
Healthy Kids, as compared to the service use of all Healthy Kids program enrollees.
Children with mental health diagnoses were more likely to have received ambulatory
care, a preventive visit, or an emergency room visit when compared to all enrollees. The
magnitude of the difference varied according to the type of service. For example,
differences in the use of preventive care were small. Almost 48 percent of Healthy Kids
mental health users had a preventive care visit during the year, while 39.6 percent of all
program enrollees had a visit of that type during the same period. Differences in
emergency room and prescription drug use, however, were larger. About three times as
many Healthy Kids with mental health diagnoses had one or more ER visits, when
compared to the total enrollee population. Also, 62.2 percent of Healthy Kids mental
health users had one or more prescriptions in the time period, versus just 33.5 percent of
all program enrollees.
43
Figure 6-1: Health Service Use for Children with a Mental Health Diagnosis
Children Continuously Enrolled in Healthy Kids
July 2004 to June 2005
98.1
100
90
80
73.8
70
62.2
60
47.8
50
39.6
40
36.5
33.5
30
20
12.5
10
0
Percentage with Ambulatory
Visit
Percentage with Preventive
Care Visit
All Healthy Kids Members
Percentage with One or More
ER Visits
Percentage with One or More
Prescriptions
Healthy Kids Members with Mental Health Diagnosis
Table 6-3 compares the cost to the HPSM for children with a mental health
diagnosis to those without a mental health diagnosis for Healthy Kids and Healthy
Families. Costs are separated into those for claims with a mental health diagnosis and
other non- mental health costs. It shows that—for the services billed to the HPSM--the
average mental health cost is similar between the two programs, $432 per child per year
for Healthy Kids and $416 for Healthy Families. The average cost for non- mental health
care for the same children is somewhat higher for Healthy Families ($571 versus $642
respectively). If the cost of care for the SED children were taken into account, the cost for
mental health care would be considerably higher for Healthy Families children than for
Healthy Kids. For example, data from the San Mateo County MHS show that they
managed an average of 29 Healthy Families children with SED per month during July
44
2004 to June 2005, and that those children cost an average of over $10,000 per child per
year, in contrast to only $432 billed to HPSM for Healthy Kids for the year.
Table 6-3 : Average Costs Per Enrollee for Mental Health and Other Services
Children Continuously Enrolled in the Health Plan of San Mateo
July 2004 to June 2005
Mental Health Diagnosis
Mental Health
Claims
Other Claims
No Mental Health Diagnosis
Mental Health
Claims
Other Claims
Healthy Kids
$432
$571
$0
$295
Healthy Families
$416
$642
$0
$271
Note: Excludes dental and vision claims and claims from Healthy Families children with SED. One
extremely high-cost case was excluded from Healthy Kids.
The cost of non- mental health care is considerably higher for children with a
mental health diagnosis than for other children. For example, for Healthy Kids, the
average annual non- mental health cost was only $295 for those without a mental health
diagnosis and $571 for those with a diagnosis. 11
As table 6-4 indicates, a substantial proportion of children were served by either
the San Mateo Medical Center (43.4 percent of Healthy Kids and 29.8 percent of Healthy
Families mental health users in the HPSM database) or by the San Mateo County Mental
Health Department (27.7 percent and 31.6 percent respectively). For the services billed to
the HPSM, children enrolled in Healthy Families were more than twice as likely to
receive services through a private provider (28.1 percent) as Healthy Kids mental health
users (10.7 percent).
45
Table 6-4 : Percent of Children served by Type of Mental Health Providers
Children Continuously Enrolled in the Health Plan of San Mateo
July 2004 to June 2005
San Mateo Medical Center
San Mateo County Mental Health Dept.
San Mateo County Outpatient Clinics
Other Hospitals/Medical Centers
Other Clinics
Private Providers
Other
N
Healthy Kids
(%)
43.4
27.7
11.3
18.9
6.9
10.7
5.7
159
Healthy Families
(%)
29.8
31.6
10.5
17.5
*
28.1
*
57
* Fewer than 5 children
Note: Percentages do not add to 100 since a child may be served by more than one type of
provider.
Access to Care. In spite of the emphasis on expanded mental health services for
children in San Mateo County, in the second and third annual site visits (October 2004
and 2005) we learned that there are still some barriers to obtaining mental health services
for low income children. According to those we interviewed, one set of barriers relates to
parents’ lack of information and reluctance to bring their children for services. Parents
may not be aware of the mental health services available to their children, or they may be
unsure about whether their child’s behavior is sufficiently different from that of other
children to require help. Although the county health department has a web site 12 and a
toll- free number, the population served by Healthy Kids may not access this. Parents may
avoid treatment, even while realizing the need for professional help, because it could be
regarded as a personal failure. Furthermore, undocumented parents may believe that
11
The tables exclude one extremely high-cost Healthy Kids user; including this single case would have almost doubled
the “other” costs for Healthy Kids children with mental health diagnoses, illustrating the potential extreme effect of a
single or a few very high cost users on average program costs.
46
participation in the county mental health system could lead to identification of their legal
status. Such stigma and fear may be exacerbated by the limited number of Spanishspeaking mental health counselors and therapists in the county (although there have been
some improvements recently). Recruitment problems are exacerbated by San Mateo’s
high cost of living.
We heard several suggestions from stakeholders about how to address some of
these barriers. These included improved partnerships with schools in order to identify
children needing services and to provide them with more school-based services; a
relaxation of the requirement to demonstrate that a child has SED in order to qualify for
expanded services; and an increased emphasis on screening and early identification of
problems. Respondents were also very concerned that San Mateo County’s current model
of integrated care delivery be maintained in spite of the budgetary difficulties the county
has experienced recently.
Conclusions. About 5 percent of children enrolled in the Health Plan of San
Mateo had mental health services in a given year, according to information from the
database maintained by the Health Plan of San Mateo. Healthy Kids and Healthy
Families users in the health plan have similar patterns of mental health diagnoses, service
use, and service costs, according to these data. In both programs, enrollees with mental
health diagnoses had higher average costs—both for mental health care and other care-than other enrollees. Since the data analyzed here exclude services for Healthy Families
children with SED, it appears that, at this time, the children with mental health problems
in the Healthy Kids program have less serious mental health problems than for other
public health insurance programs. In next year’s annual report we will obtain data on the
12
The address for this website is: www.sanmateo.networkofcare.org
47
cost of Healthy Families children’s care outside the HPSM, in order to examine this issue
more thoroughly.
Similar to national patterns, the prevalence of mental health problems (as reported
by parents) is higher for Healthy Kids enrollees than the proportion of children using
mental health services. Key stakeholders indicated that there are barriers to mental health
care access for children served by Healthy Kids, Healthy Families, and Medi-Cal. It is
possible that, if these barriers are appropriately addressed, more children with mental
health problems will seek the care that they need. As with efforts to improve dental
access, however, it is also evident that this improved access could increase the overall
cost to public health insurance programs.
48
Chapter 7: What Is the Role of Schools in Outreach and Enrollment?
The San Mateo CHI has numerous outreach and enrollment strategies, as described in the
previous two annual reports. In particular, the CHI places an emphasis on school outreach
and enrollment efforts as a way to identify uninsured children who may not be reachable
in county clinics or other places. School-based enrollment also increases access to
enrollment assistance by establishing more locations where assistance is offered. In 2004,
about 17 percent of parents responding to the client survey said that they completed the
application for Healthy Kids at a school (Howell et al. 2005).
During the site visit in the fall of 2005, we interviewed six key people who are
involved in CHI school outreach, including a CHI school outreach coordinator, two CHIfunded Community Health Advocates (CHAs) who work primarily in schools, two school
district officials, and two school employees (a principal and a teacher). The purpose of
these interviews was to describe the following: how school outreach is organized in San
Mateo County; the outreach/enrollment activities that take place in schools; how those
activities vary from school-to-school and district-to-district; and stakeholders’
perceptions of what works best in school outreach.
School Outreach in San Mateo County. Through these interviews, as well as onsite observations in two schools, we learned that the number of schools that are involved
in CHI school outreach in the county continues to grow, and that outreach/enrollment
activities are quite variable from school- to-school and over time within schools. We were
told that each of the school districts has a somewhat different approach to school
outreach, and that each school district functions independently in determining which
activities to sponsor.
49
In San Mateo County there are 25 separate school districts. There are 20
elementary school districts, 4 high school districts, and 1 community college. This makes
it very complex and time-consuming to implement school outreach, since it is necessary
for the CHI to negotiate arrangements differently in each district. In order to facilitate
school outreach, the CHI has defined four regions of the county with a designated CHIfunded CHA 13 or a Community Based Organization CAA, or both assigned to each. The
regions are North County, Middle County, South County, and Coast, with about seven
school districts each except on the coast where there are only two districts.
While the CHI has a relationship with every school district, it has a more
intensive relationship with some districts. The CHI chose to initiate intensive efforts in
these districts either due to the large number of uninsured children in the district, or to
especially responsive school personnel, or to both. In these districts (Cabrillo, Jefferson
Elementary, Pacifica, Pascadero, Ravenswood, Redwood City, San Bruno, San MateoFoster City, Sequoia Union High, and South San Francisco) the CHI either supports a
designated district staff member who coordinates CHI activities or provides CHAs to
conduct periodic enrollment assistance in one or more school sites. There are currently
five CHI-staffed fixed school enrollment sites, which evolved from two (Cabrillo and San
Mateo-Foster City) in the first year of the CHI.
The CHAs enroll children from all around the school district, not just from the
school where he or she is placed. In some school districts, the role of CHAs is expanded
to include outreach for other types of services and health education. For example, the
CHA responsible for the Cabrillo School District coordinates with a project sponsored by
Stanford University that is designed to provide a range of family services in schools. She
13
The CHAs are bi-lingual certified application assistors who take a standard training program each year.
50
reminds families to use medical and dental care and renew their child’s insurance
coverage. The intensity of these efforts to maintain contact with parents and provide
broader health education varies from place-to-place around the county.
In all school districts (except the community college) the CHI sponsors a lessintensive form of outreach called the Request for Information (“RFI”) process. In this
process, an annual letter is provided to parents asking whether they need help applying
for health insurance for their child. The Consumers Union helped to design and launch
the RFI process in San Mateo County, as well as in some other counties around the state.
The CHI has a model RFI process that districts and schools are free to modify. A
model letter to parents is sent by the County Board of Education to each district
superintendent to alter and use as they see fit. The superintendent then sends the letter to
each principal, asking them to include it with an RFI flyer in all back-to-school materials
directed to parents. The flyer should provide basic information on insurance and a
questionnaire about whether the parent needs help applying for insurance for his/her
child. The principal may in turn modify the letter and flyer, and then choose whether and
when to send them to parents.
When visiting schools, we observed that the wording of the letter and flyer, as
well as the frequency, timing, and how they are sent to parents, varies greatly from
school- to-school. According to CHI staff, this is by design so that school outreach can be
tailored to the needs of each school. For example, we were told that some principals may
post a notice on the school’s bulletin board, rather than sending the RFI letter and flyer to
parents. Some choose to send them with information at the beginning of the school year,
while others send them later in the year.
51
According to the model process, the returned RFIs should be collected by each
school and forwarded to a central office at the Board of Education. These then go to a
CHI staff member who is responsible for coordinating the CHI response to each letter and
for summarizing information on returned RFIs. In following up on the returned RFIs, the
CHI seeks to assure that every parent who requests enrollment assistance will be
contacted by either the assigned CHA or a Community Based Organization CAA to
provide information and application assistance. Usually, the CHA or Community Based
Organization CAA contacts the parent by phone and makes an appointment for him/her
to come to a fixed enrollment site with the appropriate paperwork to fill out the
application.
We obtained the number of RFIs returned by parents for school year 2005–2006.
This information is maintained by the CHI staff member responsible for coordinating
school outreach. There were 2,946 returned questionnaires for the school year, with 845
“no”s and the rest (2111) “yes”s (that is, the parent requests help in applying). Of those
who said “yes,” by far the largest number (90 percent) are reported to be in three school
districts: San Mateo-Foster City, Jefferson, and Pacifica.
While there are no comparable data for previous years, we were told that the
frequency of returned RFIs is increasing. However, it is difficult to document how many
parents who requested information eventually enrolled their children. The CHI staff
hopes that new data from One-e-App will help with this tracking.
One factor that is reportedly very important in determining the success of the RFI
process in identifying uninsured children is a strong commitment to the process at both
the district and school levels. For example, one reason for more RFI returns in the San
52
Mateo-Foster City district is a special project called Teachers for Healthy Kids, a project
that is co-sponsored by the California Teachers Association and the California
Association of Health Plans, which promotes children’s health insurance in schools. The
San Mateo/Foster City School District is one of the districts in the state that is
participating in this project. This has led to considerable support from the superintendent,
principals and teachers for CHI efforts. The project also sponsors a special coordinator
who links the CHI to district schools and promotes the RFI process. The coordinator has
engaged the two district school nurses in connecting parents of children who need health
insurance to the CHI. Posters and flyers are available in this district’s schools to inform
parents about how to obtain assistance applying for health insurance. These posters
advertise the local CHI hot line number, and teachers, administrative staff and school
nurses all have additional forms to give parents if they ever learn of a child without
insurance.
In addition to the RFI process, CHI school outreach staff periodically do other
forms of school outreach in the “less intensive” districts. In 2005, for example, staff
conducted presentations at health fairs in three districts, one district sponsored a
“neighborhood walk”, and two other districts sponsored outreach in high school schoolbased clinics.
The CHI is beginning to use MAA funding for school outreach/enrollment
activities. (See chapter 2 for a description of this funding stream.) Schools can file claims
for Medi-Cal outreach if they complete a web survey of time spent with all the
individuals for whom they are claiming MAA reimbursement. This has become a
substantial funding stream for some school districts. In one interview, we learned of a
53
school district that anticipates receiving $100,000 for a single year. These funds go into
the school district’s general fund.
Conclusions. Those we interviewed are enthusiastic about school outreach. As
one CHA stated: “School outreach is successful because families don’t want to go to the
county clinic to enroll in a program.” Still, it is evident that the yield of children to enroll
is higher (per CAA) in clinics than in schools. Consequently it is important to be aware of
cost tradeoffs in planning school outreach. In particular, it is important to target the
highest- need schools (since the number of uninsured is now very small in most schools),
as well as to improve the tracking systems to assure that all families who need insurance
enrollment assistance are contacted. Using the One-e-App for this purpose may help in
improving the understanding of the most productive school outreach (in terms of
successful applications and renewals of coverage for all three public programs). Such a
system could also be used to track whether children identified in schools are easier (or
harder) to contact for renewing coverage, and whether they are more likely to use
preventive care. These are two important potential benefits of intensive school outreach.
54
Chapter 8: What Factors Are Associated with Employer Decisions to Offer Private
Insurance Coverage to Low Wage Workers in San Mateo County? Has the CHI
Affected Employer Decisions?
Employer-sponsored health insurance coverage forms a foundation for health insurance
coverage, with over half of the American population receiving health benefits from their
own or a family member’s employer (Kaiser Family Foundation 2006). Between 2000
and 2004, however, the rate of children covered by employer-sponsored insurance (ESI)
fell nearly 5 percent nationwide (Holahan and Cook 2005). Across the nation, there were
significant increases in private insurance premiums during that time period. Premiums for
family coverage increased by a national average of 59 percent compared with inflation
growth of just under 10 percent and wage growth of about 12 percent (Kaiser Family
Foundation and Health Research and Educational Trust 2005). Correspondingly, the
percent of private-sector employees with offers of health insurance who enrolled
decreased in California (from 86.7 to 82.2 percent) during the period (SHADAC and the
Urban Institute 2006).
Because the San Mateo County Healthy Kids program has a relatively high
income limit for program eligibility (up to 400 percent of the federal poverty level), a
primary concern for the CHI has been to assure that families or employers are not
substituting Healthy Kids coverage for other coverage that children could have (a
phenomenon termed “crowd-out’). 14 In our second annual report, we presented data from
the client survey on Healthy Kids coverage before enrolling in the program and access to
employer-sponsored health insurance. The analysis showed that very few Healthy Kids
enrollees have access to affordable health insurance, a finding that was confirmed by
55
information obtained in focus groups with parents of program enrollees (Howell et al.
2005).
To further explore the issue of crowd-out within the Healthy Kids program, and to
understand more fully how local employers view ESI coverage for dependent children,
the evaluation team conducted a series of interviews with employers in conjunction with
the October 2005 site visit. We interviewed eight individuals representing a range of
employers, including a community bank, a restaurant, a plant nursery, an environmental
consulting firm, an international-chain grocery store, a public transit authority, an
independent living center for the elderly, and a lumber yard. Two of the interviews were
conducted via telephone; all others were conducted in person, either one-on-one or in a
small group setting. We identified and recruited these local employers through
recommendations by the Chambers of Commerce in San Mateo, San Carlos, and Half
Moon Bay.
Context. A tight labor market in San Mateo County led historically to a high rate
of employer sponsored health insurance. According to employers we interviewed, it was
very difficult to fill vacancies in the service sector just five years ago because of
competition from growing firms in the Silicon Valley. Another factor they identified was
continued strong competition for workers from the public sector, which offers very
generous health insurance and other benefits.
Employers also reported several consecutive years of double-digit percentage rate
increases in health insurance premiums for local businesses in San Mateo County,
mirroring statewide reports of yearly premium increases ranging from 10 to 15.8 percent
14
In 2005, only 35 percent of lower-wage California firms offered health benefits to employees, compared
with 72 percent of higher-wage firms (California HealthCare Foundation & CSHSC 2006).
56
during the 2001–2004 period (California HealthCare Foundation & CSHSC 2006). These
health premium cost increases are compounded by other cost increases, such as the cost
of liability insurance. Small groups are particularly vulnerable to these increases, since
they have little bargaining power with their carriers.
Decision to Offer Health Insurance. The employers we interviewed believed that
it is necessary to offer health insurance in order to attract and retain good workers in San
Mateo County. One employer said, “Most of our employees can’t even afford to live in
this county, and this is one thing that we can do for them.” Employers also noted that,
“Retention is generally good [since] employees don’t want to give up…benefits;”
“Workers that aren’t interested in a job with benefits are probably not the type…you want
as an employee or the type…you want to retain;” and “[Our] benefits have contributed to
a stable workforce with little turnover.”
All the employers we interviewed offered insurance to their full time permanent
employees. Still, there was variation in the generosity of health insurance benefits they
offered, even among our small sample. For example, the portion of the insurance
premium covered by the employer varied. While most covered 85 percent or more of the
premium for their employees, one employer reported that the amount paid was dependent
on longevity (with 100 percent premium sponsorship only after 10,000 hours worked).
Most required employees to pay a larger share of premiums for dependents, and two of
the eight employers did not contribute to premiums for dependents. In six firms health
insurance was only available to full- time employees. (The definition of “full-time” varied
by employer from 30 to 40 hours per week.)
57
Those interviewed indicated that offering health insurance is more important for
attracting and retaining certain types of employees than others. For example, young
people, who are more likely to be temporary or part-time workers, are believed to be less
concerned about an offer of health insurance. In addition, while all employers thought
that offering health benefits was a factor in hiring and retention, other factors, such as
promotions and wage levels, were thought to be just as or more important.
The decision of whether to offer health benefits (and at what level) was also
affected by the industry involved. Employers said they considered the offers of their
competitors when making decisions about benefit levels. For example, we heard that
most businesses in the restaurant industry do not offer insurance (with an exception for
higher- level management positions), and those that do have higher operating costs and
make less profit. Most nursery employers offer health insurance, but costs to employees
are high and dependent coverage is not usually offered. On the other hand, businesses
hiring professionals said that they must offer health benefits, as “people with a
professional background aren’t likely to take a position without the benefits.”
Recent Changes in Employer Health Insurance Coverage. The employers in our
small sample said that the recent slackening of the labor market due to the “dot-com
bust” had not yet caused them to change their decisions to offer health insurance, nor
were they contemplating such a radical change. However, due to health insurance
premium increases, nearly all employers reported that they have made, or are
contemplating, smaller benefit changes to lower their costs. Two employers stopped
offering a choice between a health maintenance organization and a preferred provider
58
organization, and two others were considering this. Other employers have increased
employee cost-sharing.
Take-up of Insurance. In this small sample, employee take- up of health insurance
offers appeared to be directly related to the level of employer contribution to coverage.
Those employers who contributed 85 percent or more to an employee’s premium reported
that ‘most’ or ‘nearly all’ of their workforce accepted the offer. In contrast, the employers
that did not cover the premium for dependents reported that almost no employees
purchased insurance for their children.
Awareness of and Use of Public Health Insurance by Employees. One major
purpose of the interviews was to investigate whether employers might be considering
dropping coverage of dependents, since Healthy Kids is now available for children in
families up to 400 percent of the federal poverty level. However, none of the employers
were aware that any of their employees used the Healthy Kids program. Indeed, only two
of the eight employers interviewed had heard of the CHI before they received the
recruitment call for participation in our evaluation activities, and only one individual had
any significant knowledge of the initiative or its purpose.
One employer was aware that their employees use Healthy Families as a source of
dependent coverage. Interestingly, the same employer reported that when surveyed last
year, most employees indicated a disinterest in the employer subsidizing their dependent
coverage, and preferred instead to remain eligible for Healthy Families (reasoning that
when they signed up for employer coverage, they would no longer qualify for Healthy
Families).
59
Conclusions. Although our sample was small, the employers that we interviewed
as part of the October 2005 site visit represented several different industries and each had
adopted unique approaches to offering health insurance benefits to employees and their
dependents. The account given here represents only views of employers that offer health
benefits. Even so, it is clear that small employers face many challenges in deciding
whether to sponsor health insurance, and at what level, for their workforce. Rapid health
insurance premium increases are of primary concern to this group, and have resulted in
cost containment measures such as the narrowing of options for health plan enrollment
and increases in employee cost-sharing. Despite the challenges, the majority of
employers that we interviewed agreed that offering health benefits to full time permanent
employees was not only a reasonable responsibility of all businesses, but was also an
important factor in maintaining a stable and well-qualified workforce.
There is very little evidence that employers are even aware of the Healthy Kids
program, and absolutely no evidence that the presence of the program has affected their
decision to offer health insurance coverage. Still, because of continued financial pressure
facing employers of low wage workers, it will be important to monitor employer
decisions in the future as they respond to the higher health insurance costs they are
facing.
60
Chapter 9: Conclusions
The San Mateo County Children’s Health Initiative continues its successful efforts to
provide coverage to children in the county who would otherwise be uninsured. In
addition, during 2005 the initiative took on several new challenges such as an increased
focus on improving retention in public programs, increasing the use of preventive care,
and improving access to dental and mental health care. This annual report provides some
new data on several of these and other issues that are important to the continued
development of the initiative.
Enrollment Growth. The growth in the Healthy Kids program continued at a slow
pace in 2005. Since funding for premiums for the youngest children (ages 0–5) is secure,
the CHI strove to increase enrollment in that age group, but growth was limited. While
data on the number of uninsured children in that age group are unavailable, it appears that
the demand is diminishing and many of those children may now be enrolled in some form
of insurance. Growth in the 6–18 age group continues at a moderate pace, creating a
challenge to the premium financing for these enrollees. We did not study the growth in
Healthy Families and Medi-Cal children for this annual report, a topic that will be
revisited next year. The Healthy Kids population continues to have more older children
than the other public programs, and the demographic composition of program enrollees
(for example, age and ethnicity) did no t change very much from year to year. One change
has been a moderate increase in the proportion of children who are in the higher income
group (250–400 percent of the federal poverty level). It should be noted that increased
penetration of coverage within this population was a specific priority for the CHI during
61
the last year. Given the early success, it is possible that there is potential for further
growth among this population.
Trends in Service Use. The report shows that there have been some positive trends
in preventive service use for the Healthy Kids program. The use of preventive medical
care, as well as dental and vision care, increased from the first to the second year of
enrollment in Healthy Kids for all three services. In addition, overall us e of ambulatory
care increased from those enrolled in 2003 to those enrolled in 2004.
High Cost Users of Services. High cost users are a special group of children
worthy of further attention by the CHI. These children are heavy users of expensive
medical (although not dental) care, particularly hospitals and emergency rooms. They are
more often chronically ill and have frequent contact with the health care system. Since it
is possible to identify them through the claims/encounter data, this group could be
targeted for more intensive contact by CAAs and/or health plan staff, to assure that they
are receiving coordinated care and that they have good access to the specialty care that
they need. Reducing their costs—even if only moderately through, for example, reduced
hospital and emergency room use—could have an impact on the overall cost of care, and
provide additional funding to cover other children.
Dental Care Access and Costs. The information we obtained from interviews with
stakeholders suggested that dental care access was poor for some children, especially
access to private providers who do not like the paper work associated with public
programs. However, this finding was not confirmed by the data analysis nor the recent
survey of private dentists by health department staff. This more recent information
indicates that there are private dentists who are already serving Healthy Kids and others
62
who are willing to do so. This is also possibly true for children in other public programs,
although we did not have quantitative information from those programs to study the
issue. Consequently one problem appears to be a lack of communication between the
public and private sectors, as well as a knowledge gap among parents who may be
unaware that they can use priva te dental providers. This suggests the need for more
education and outreach at several levels in order to improve access and reduce waiting
times for appointments.
Mental Health Access and Cost. As indicated in last year’s report, Healthy Kids
enrollees have emotional or behavioral problems at a rate that is comparable to national
rates, and yet many children with mental health problems do not seek or get care. In
addition, the most common mental health diagnoses for Healthy Kids members are
consistent with the most common diagnoses for children nationally. In comparing the two
public programs for which there are data from the HPSM, we found that children with
mental health diagnoses are much more expensive than their peers, and these higher costs
pertain to both mental health and other health services. Given that some very expensive
Healthy Families children are excluded from the data base, Healthy Kids children with
mental health problems are less expensive than those in the Healthy Families program.
It is also clear that not all children receiving mental health services under both
Healthy Kids and Healthy Families are having their care coordinated by the San Mateo
Health Department Mental Health Services, but that those who are in that system are the
more expensive children. The CHI should consider whether it wants to undertake an
effort to link more children to the MHS when they are receiving mental health services
outside that system, or whether—alternatively—having children receive services outside
63
the formal mental health system may help to overcome the stigma of receiving mental
health services. There may be a need to educate primary care providers about the mental
health needs of publicly insured children and about the additional services available to
them through the MHS. For example, mental health screening could become a part of the
required initial visit through the HPSM.
Since not all children with mental health problems are receiving services, the CHI
should consider how to increase use of services. One idea might be to use the linkages
with schools that have been established for outreach and enrollment to advertise the
availability of mental health services through the MHS.
School Outreach and Enrollment. The CHI continues to experiment with
innovative ways to reach and enroll uninsured children in schools around the county.
Because there is so much variation in what is going on in different school districts, and
schools within districts, the CHI could capitalize on this “natural experiment” to learn
more about what is working well in terms of completed applications. To do this, it is
important to obtain more detailed information in all school districts on, for example, the
number of RFIs that are distributed and returned (with requests for help) and the number
of completed applications by school where the RFIs have been distributed. The One-e-Ap
system should help in learning about these patterns. After obtaining this detailed
information, the CHI may want to revisit its “model” school outreach/enrollment process
and refine the process accordingly. It is possible, for example, that the RFI process is not
yielding any applications in some places, in spite of concerted efforts, or that it could
yield more in others, if efforts were more concentrated and intense.
64
Employer Sponsored Health Insurance and Crowd-Out. Employers of low wage
workers in San Mateo County face many of the financial strains of other similar
employers around the country, but they are in a labor market where it is difficult to attract
and retain workers (because of the high cost of living and other factors). Consequently,
the employers with whom we spoke—while a small select group—felt that they need to
offer health insurance benefits to their employees. However, two of the eight did not
cover the dependents of their employees, and most of the businesses did not cover parttime or temporary workers. This means that the children of those working in such places
may be uninsured.
In no case was there any evidence that employers had changed their decisions to
cover dependents because public coverage was available for low income uninsured
children. Indeed, most were unaware of the CHI, and had not been exposed to the
outreach activities of the initiative. The CHI may want to cautiously reach out to
employees of selected businesses that do not offer dependent coverage, or that have many
part-time or temporary workers, in order to provide information to parents who cannot
afford to purchase coverage for their children. Given that the financ ing for children ages
6-18 is still uncertain, it might be possible to target such outreach to parents of very
young children where premium financing is more secure.
Next Steps in the Evaluation. In the coming year, the evaluation of the San Mateo
CHI will collect new data to address a range of evaluation questions. Results from that
analysis will be contained in next year’s annual report. The second wave of the client
survey is currently underway, with an over-sample of children ages zero to five. Data
from this survey will be used to measure the impact of the Healthy Kids program on
65
access to care, use of services, and health status. The survey will also provide information
on prior insurance coverage and parent satisfaction with the program. In addition, another
site visit and two client focus groups will provide qualitative information to help monitor
the progress of the CHI and interpret the findings from the client survey analysis.
Administrative data on enrollment trends will also be presented. Finally, the data from
the HPSM, such as that included in this annual report, will be used to continue to monitor
trends in enrollee characteristics and use of services across the three public health
insurance programs for children in San Mateo County.
66
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Survey. An Oral Health Assessment of California’s Kindergarten and 3rd Grade
Children.” Oakland, CA: Dental Health Foundation.
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———. 1999b. Mental Health: A Report of the Surgeon General. Rockville, MD:
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APPENDIX – A
Appendix A
Research Questions of the Evaluation of the San Mateo Children's Health Initiative
1
Who was served by the San Mateo CHI? How did the
composition of enrollees change over time?
2
Did the CHI have an impact on access to care for children who
enrolled?
3
What services did Healthy Kids enrollees receive as part of the
initiative? Did the CHI have animpact on where those services
were received or the cost of their care?
Year 1
Year 2
Year 3
Year 4
Final
Report
P
P
P
P
P
P
P
P
P
P
P
5
Did the CHI increase community-wide collaboration to address
issues of the uninsured?
Did public coverage replace private coverage? If so, what were
the factors associated with employer and beneficiary decisions to
drop private coverage?
6
Did the level of health insurance coverage change for children in
San Mateo County?
7
Did the CHI have an impact on the health status of children who
enrolled?
8
Did the CHI have an impact on school performance or quality of
life?
9
Were parents satisfied with the new program and services? Were
providers satisfied?
P
10
Did the CHI enhance the delivery and stability of the community
health care system?
P
4
P
P
P
P
P
P
P
P
P
P
P
P
P
P