1 AHRQ National Advisory Council on Healthcare Research and Quality Subcommittee on Children’s Healthcare Quality Measures for Medicaid and CHIP Progress Report to AHRQ National Advisory Council, July 24, 2009 Jeffrey Schiff, MD, MBA, Co-Chair Rita Mangione-Smith, MD, MPH, Co-Chair

Potential Impact of Core Measures Identification Work: 45% of America’s Children under Age 19 Sources: AHRQ, based on: Coverage estimates: Based on 2008 national participant and spending data derived from CMS and U.S. Census Current Population Survey data sources, reported by the National Center on Children in Poverty, CHIP estimates are for number of children in separate SCHIP programs. Medicaid estimates include children in Medicaid SCHIP programs. Coverage estimates reflect Medicaid and CHIP enrollees whether or not they received health care services. Total number of children under 19 interpolated from U.S. Census Bureau figures for number of children 17 and under (73.9 million) and children 19 and under (83 million).

3 Public Law Title IV- Strengthening Quality of Care and Health Outcomes Section 401 Child Health Quality Improvement Activities for Children Enrolled in Medicaid or CHIP Section 1139A Child Health Quality Measures By January 1, 2010, the Secretary shall identify and publish for general comment an initial, recommended core set of child health quality measures for use by ….

4 Public Law Title IV (continued) Initial core set that includes (but is not limited to): 1. Presence and duration of health insurance 2. Availability and effectiveness of Preventive services Services for acute conditions Services to promote healthy birth, prevent and treat premature birth, detect the presence or risk of conditions that could adversely affect growth and development Treatments to correct and ameliorate the effects of chronic physical and mental conditions (continued)

5 Public Law Title IV (continued) Initial core set (continued) 3. Availability of care Ambulatory Inpatient 4. Taken together – Used to estimate the overall national quality of health care for children Including children with special health care needs and comparing disparate populations

6 Public Law (continued) 1. Encourage voluntary and standardized reporting 2. Particular attention to techniques that Ensure the timeliness and accuracy of provider reporting Encourage provider compliance Encourage successful quality improvement strategies, and Improve efficiency in data collection using HIT 3. Valid, reliable, and evidence-based 4. Allow families and health care providers to understand the quality of care

7 Subcommittee on Children’s Healthcare Quality Measures for Medicaid and CHIP Programs Membership includes Two NAC members CHIP director Title V director Two Medicaid Medical Directors Organizational members American Academy of Pediatrics, American Board of Pediatrics, American Academy of Family Physicians, March of Dimes, National Academy for State Health Policy, National Association of Children’s Hospitals and Related Institutions, National Association of State Medicaid Directors, National Association of Pediatric Nurse Practitioners Individuals with expertise in dental care, mental health and chemical dependency, community health centers, children with special health needs, disparities, quality measurement

8 Goals of the First Meeting Reach consensus on the scope of the core measurement set Reach consensus on definitions for evaluation criteria:  Validity  Feasibility  Importance Identify a preliminary core set of quality measures that meet these criteria Establish the group process for arriving at the final recommended core set of quality measures by September 30, 2009

9 Conceptual Framework – Guiding Determination of the Scope for Core Measurement Set Grounded → Intermediate → Aspirational MeasuresMeasuresMeasures Lean towards recommending more grounded measures Grounded:10-25, currently feasible, many already in place Intermediate category: number to be determined, good specifications, some States already using them Aspirational: needed measures to fill in the gaps

10 Scope for Core Measurement Set 1. Must be realistic about staffing/funding needs for pulling/analyzing/reporting available data 2. Comprehensive effort to find good measures for all service categories, duration of enrollment, and other aspects of care required by the legislation; however, if no good measures currently exist for a given aspect of care, a measure will not be recommended for the core set 3. Include measures not currently used by Medicaid/CHIP  e.g. State and national measurement efforts 4. Choose measures that are actionable  There should be clear steps a State can take to improve on performance – the measure should inform what these steps need to be

11 Consensus on Criteria Definitions Validity  Measures must be supported by scientific evidence or, where evidence is insufficient, by expert consensus  Measures must support a link between: Structure and outcomes of care Structure and processes of care Processes and outcomes of care  The measure must represent an aspect of care that is under the control of health care providers and systems  The measure should truly assess what it purports to measure  Measures supported by evidence from unpublished data should be considered for inclusion

12 Consensus on Criteria Definitions Feasibility  The data necessary to score the measure must be available to State Medicaid and CHIP programs Administrative data, medical records data, survey data  Detailed specifications must be available for the measure that allow for reliable and unbiased scoring of the measure across States and institutions

13 Consensus on Criteria Definitions Importance  The measure should be actionable  Cost of the condition to the Nation should be substantial  Health care systems are clearly accountable for the quality problem assessed by the measure  The extent of the quality problem should be substantial  There should be documented variation in performance on the measure  The measure should be representative of a class of quality problems: “sentinel measure” of quality of care provided for preventive care, mental health care, or dental care, etc.

14 Consensus on Criteria Definitions Importance  The measure assesses an aspect of health care where there are known disparities  The core set should represent a balanced portfolio of measures and be consistent with the intent of the legislation  Improving on performance for the core set of measures should have the potential to transform care for our Nation’s children

15 Consensus on Criteria Definitions Transparency  For all measures recommended for inclusion in the core set: The level of scientific evidence supporting the measure will be reported  Example: U.S. Preventive Services Task Force grades A, B, C, or I; Level I, II, III The level of expected burden for obtaining the data needed to score the measure will be reported  Low, moderate, high

16 Pre-Work Process Completed by Sub- Committee Members Delphi process to assess validity and feasibility of measures in use by State Medicaid and CHIP programs  Round 1 completed prior to meeting  Measures scored on a 9-point scale 7-9 – Measure is definitely valid and feasible 4-6 – Measure has uncertain validity and feasibility 1-3 – Measure is not valid or feasible

17 Meeting July 22, 2009: Discussion of Delphi Round 1 Results Controversial measures  Validity or feasibility ratings with substantial disagreement among subcommittee members were discussed  Round 2 Delphi process for these controversial measures after meeting deliberations

18 Meeting July 23, 2009: Assessing Measure Importance Evaluated importance for measures with passing validity and feasibility in Round 1  Validity score of 7-9  Feasibility score of 4-6 Delphi process to assess importance  9-point scale 7-9: Measure of clear importance 4-6: Level of importance uncertain 1-3: Measure does not meet importance criteria Measures with an importance score of 4 or higher on the 9-point Delphi scale were retained in the preliminary set of core measures

19 Measures Having Passing Scores for Validity, Feasibility, and Importance Preventive Care Measures  Frequency of ongoing prenatal care  Smoking cessation and prevention  Chlamydia screening  Immunizations for 2-year olds  Adolescent immunization  Influenza vaccination  Well child care visit (WCV) rates - first 15 months  WCV Rates- 3, 4, 5, 6-year olds  Adolescent WCV - overall  Hearing screening  Vision screening

20 Measures having passing scores for Validity, Feasibility, and Importance Dental Care Measures  Comprehensive periodic oral health exams  Annual dental visit Acute Care Measures  Upper respiratory infection- Appropriate treatment  Pharyngitis- Appropriate testing Chronic Care Measures  Asthma- Appropriate medications for people with asthma

21 Measures Having Passing Scores for Validity, Feasibility, and Importance Mental Health Care Measures  Attention-Deficit/Hyperactivity Disorder (ADHD) care - Initiation phase  ADHD Care - Continuation and maintenance phase  Followup after hospitalization for mental illness  Depression management Family Experiences with Care Measures  Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS) For healthy children For children with special health care needs Access and Utilization Measures  Access to primary care practitioners, by age and total  Utilization of ambulatory services

22 Additional Measures in Use Proposed During Meeting Identify evidence supporting measure Identify who is currently using the measure Obtain specifications for the measure Delphi process for new measures to assess  Validity  Feasibility  Importance

23 Selection of Measures Recommended for Inclusion in the Final Core Set September 2009 meeting:  Further discuss and rate importance for preliminary core set and new measures identified as valid and feasible  Arrive at the most parsimonious set of measures that when assessed together will provide valid estimates of the overall national quality of health care for children insured by Medicaid and CHIP

24 Our View of the Opportunity Presented by the Legislation Long-term focus on health care quality for children beyond CHIP Opportunity to bring together efforts of disparate organizations/parts of government to create focus and move the child health quality agenda forward Need support from the NAC to build the bridge toward our aspirational long-term vision of being able to rigorously and comprehensively assess and improve on health care quality for the Nation’s children