SCHIP's Impact on Access and Quality: Findings from Karen VanLandeghem, Consultant, CHIRI™ Cindy Brach, Agency for Healthcare Research and Quality

The Child Health Insurance Research Initiative (CHIRI™)  9 studies of public child health insurance programs and health care delivery systems, funded by AHRQ, the David and Lucile Packard Foundation, and HRSA.  Emphasis on vulnerable children, e.g., minority children and children with special health care needs.  Role of policymakers: provide input into research and products, disseminate products, implement findings.

Presentation Overview CHIRI™ Methods CHIRI™ Methods Who’s Enrolled in SCHIP: AL, FL, IN, KS, NY Who’s Enrolled in SCHIP: AL, FL, IN, KS, NY Implications of Enrollment Findings Implications of Enrollment Findings Impact of SCHIP: FL, KS, NY Impact of SCHIP: FL, KS, NY Impact Conclusions Impact Conclusions Areas for Improvement Areas for Improvement CHIRI ™ Products CHIRI ™ Products AHRQ Findings on “What SCHIP Really Costs” AHRQ Findings on “What SCHIP Really Costs”

Methods Telephone surveys of new SCHIP enrollees Telephone surveys of new SCHIP enrollees Longitudinal impact analysis Longitudinal impact analysis – Shortly after enrollment to assess access and quality of care 12 months before SCHIP enrollment – 12 months later to assess access and quality of care after 12 months of SCHIP enrollment – In comparisons of sub-populations regression techniques to control for other factors were used

Who’s Enrolled in SCHIP?

Most Enrollees from Families with Income ≤ 150% of FPL *Adolescents Only

About One Third of SCHIP Enrollees Are Adolescents * CSHCN Only

A Significant Proportion of SCHIP Enrollees Were Black and Hispanic *Adolescents Only CSHCN Only - Hispanic - Other- Black, Non-Hispanic † †

More CSHCN in SCHIP Than General Population *Adolescents Only - CSHCN in general population (Source: NCHS) - CSHCN in SCHIP population

Implications of Enrollment Findings The unique needs of adolescents, minority children, and CSHCN should be considered in health care services design and delivery, e.g., The unique needs of adolescents, minority children, and CSHCN should be considered in health care services design and delivery, e.g., – Reproductive services and confidentiality – Language services and cultural competence – Breadth of services for complicated conditions

What is SCHIP’s Impact?

SCHIP Increased Percent of Children with a Regular Source of Care Florida p=.00 p=.44 KansasNew York AdolescentsAll Children Adjusted estimates; p-values represent difference before vs. after within each state

Unmet Needs Decreases Under SCHIP, But Still Substantial Florida p=.00p=.12p=.00 KansasNew York AdolescentsAll Children Adjusted estimates; p-values represent difference before vs. after within each state

SCHIP Increased Percent of Children with Preventive Visit, But 20-30% Still Don’t Get Visit Florida p=.02p=.00p=.09p=.06 KansasNew York AdolescentsAll Children Adjusted estimates; p-values represent difference before vs. after within each state

Families More Satisfied with Health Care Under SCHIP Florida p=.00 p=.07 KansasNew York AdolescentsAll Children Adjusted estimates; p-values represent difference before vs. after within each state

Most Black and Hispanic Children Share in SCHIP USC Gains Adjusted estimates FloridaKansasNew York Adolescents All Children BlackWhiteHispanic

SCHIP Increases Percentage Black Children with Preventive Visit, But Not Hispanic Children Adjusted estimates FloridaKansasNew York AdolescentsAll Children BlackWhiteHispanic

SCHIP Improved Rating of Health Care for Both CSHCN and Other Children Adjusted estimates FloridaKansasNew York Adolescents All Children CSHCNNot CSHCN

SCHIP Reduces Percent of Children with Unmet Needs, But Almost 1/3 CSHCN Had Unmet Needs After SCHIP Adjusted estimates FloridaKansasNew York Adolescents All Children CSHCNNot CSHCN

SCHIP Eliminates Preventive Visit Disparities Between Long-Term Uninsured and Others FloridaKansasNew York Adolescents All Children Insured at Least Part-Year Uninsured All Year

SCHIP Increases Satisfaction for Both Long-Term Uninsured and Others FloridaKansasNew York Adolescents All Children Insured at Least Part-Year Uninsured All Year

NY SCHIP Reduces Unmet Need for Dental Care; Overall Need for Dental Care Remains

NY SCHIP Improves Quality of Care for Children with Asthma Percent with Problems Getting Care or Meds if Asthma Attack Before and After Enrollment in New York SCHIP p<.05 % Yes

Some Measures of Quality Remain Suboptimal after SCHIP Enrollment* Percent of Children with Moderate/Severe Asthma Who Had: % p = NS *Before and 1 Year After Enrollment in New York SCHIP

SCHIP Impact Conclusions SCHIP improves access to and satisfaction with care. SCHIP improves access to and satisfaction with care. “All boats rise with the tide” – SCHIP improvements are shared by members of vulnerable populations, including adolescents. “All boats rise with the tide” – SCHIP improvements are shared by members of vulnerable populations, including adolescents. SCHIP levels the playing field of the long- term uninsured. SCHIP levels the playing field of the long- term uninsured.

Targeting Areas for Improvement Consider strategies to address remaining unmet needs of enrollees, especially those with special health care needs. Consider strategies to address remaining unmet needs of enrollees, especially those with special health care needs. – Conduct needs assessments, identifying CSHCN and ASHCN, and monitor. – Risk-adjust capitation rates. – Collaborate with Title V MCH programs, primary care providers, and educational agencies. Ensure SCHIP enrollees’ access to dental care benefit. Ensure SCHIP enrollees’ access to dental care benefit. Address areas where suboptimal quality remains in spite of SCHIP (e.g., Tune-up visits and preventive meds for enrollees with severe asthma). Address areas where suboptimal quality remains in spite of SCHIP (e.g., Tune-up visits and preventive meds for enrollees with severe asthma). Collect data to assess SCHIP’s effectiveness in providing quality health care to diverse populations. Collect data to assess SCHIP’s effectiveness in providing quality health care to diverse populations.

Targeting Areas for Improvement (continued) Implement strategies to increase the proportion of children that receives a preventive visit. Implement strategies to increase the proportion of children that receives a preventive visit. – Educate parents. – Provide incentives to providers. – Assess adequacy of health plans’ pediatric and family physician network. – Collaborate with public health, primary care providers, and others to promote preventive care use.

What Role Does SCHIP Play in the Patchwork Insurance System for Children?

Conclusions Children who disenrolled around active recertification (NY and KS) were much more likely to become uninsured. Children who disenrolled around active recertification (NY and KS) were much more likely to become uninsured. Pre-SCHIP insurance is a predictor of post-SCHIP insurance. Pre-SCHIP insurance is a predictor of post-SCHIP insurance. CSHCN could be at greater risk of losing insurance. CSHCN could be at greater risk of losing insurance. Disenroll more quickly (especially around recertification). Disenroll more quickly (especially around recertification). More likely to become uninsured after SCHIP. More likely to become uninsured after SCHIP.

Conclusions Little evidence that unmet needs affect enrollment and disenrollment decisions. Little evidence that unmet needs affect enrollment and disenrollment decisions. Some evidence that health care use prior to enrollment predicts insurance status following SCHIP disenrollment. Some evidence that health care use prior to enrollment predicts insurance status following SCHIP disenrollment.

Examples of CHIRI ™ Products “Who’s Enrolled In SCHIP?” – CHIRI™ Issue Brief and Pediatrics articles “Who’s Enrolled In SCHIP?” – CHIRI™ Issue Brief and Pediatrics articles “Improved Access and Quality of Care After Enrollment in the New York State Children’s Health Insurance Program (SCHIP)” Pediatrics May electronic issue “Improved Access and Quality of Care After Enrollment in the New York State Children’s Health Insurance Program (SCHIP)” Pediatrics May electronic issue – SCHIP impact on Medicaid physician participation and supply – Medicaid dental access – Consequences of States’ policies on disenrollment Using CHIRI findings? Please give us feedback at: Using CHIRI findings? Please give us feedback at:

What Does SCHIP Really Cost?

What is the Net Cost of SCHIP? The net cost of SCHIP may be only 1/3 of budgeted costs when considering certain factors. The net cost of SCHIP may be only 1/3 of budgeted costs when considering certain factors. Two primary factors in determining states’ net costs: Two primary factors in determining states’ net costs: – Costs associated with spend-down to Medicaid for medically-needy in the absence of SCHIP. – Costs associated with uncompensated care in the absence of SCHIP. Bottom-line: SCHIP costs states and feds significantly less than total budgetary cost. Bottom-line: SCHIP costs states and feds significantly less than total budgetary cost. StateFedTotal Budgetary Cost $282$596$878 Simulated Net Cost $ 97 $401$498 Selden and Hudson (2004) – Simulations of net costs using MEPS (2000)

For more information on SCHIP Net Costs Contact: Thomas Selden, Senior Economist, Center for Cost and Financing Studies, Agency for Healthcare Research and Quality