1. SCHIP: Reauthorization, Increased Cost Sharing, and Quality Initiatives Betsy Shenkman Institute for Child Health Policy Department of Epidemiology and Health Policy Research University of Florida June 2006

2. Key Issues State policy changes and increased cost sharing Quality initiatives – Whats required? Whats novel?

3. Illustration of Policy Changes in Two States

5. Florida Title XXI Enrollment and Major Program Changes July 03: No Growth budget enacted Program over- enrolled, wait list started No Title XIX to Title XXI transfers Federal and state funding for Florida KidCare Outreach eliminated Apr. 04: Begin enrolling Title XXI Wait List Dec. 03: 6-month cancellation for premium non- payment No reinstatements for breaks in coverage Jan. 04: Only CMSN accepts Medicaid to Title XXI transfers (ended Mar. 04) Mar. 04: Legislation enacted wait list funded, other program changes July 04: New income documentation & access to employer health insurance requirements (delayed due to hurricanes) New enrollees accepted only during open enrollment Loss of Medicaid for over-income eligible to apply outside of open enrollment, 7/1/04 FY 04-05 Appropriated Avr. Monthly Caseload: 389,515 Fall 2004: Premium non-payment penalty reverts to 60 days Reinstatements allowed if in the data system before 3/12/04 Hurricane Relief Provisions: No disenrollments for failure to provide renewal documents or failure to pay premiums, credits for those who did pay (3 months) December 04: Open enrollment announced Disenrollments for renewal non- compliance and unpaid premiums implemented Legislature reduced income documentation requirements July 05: Year-round open enrollment reinstituted; application valid for 120 days FY 05-06 Appropriated Avr. Monthly Caseload: 388,862 Jan. 05: Open enrollment Jan. 1-30, 2005; applications processed, children enrolled (ongoing) Aug. 05: Back-to- School campaign, post cards 202,433 220,533 252,209 323,262 331,281 336,689 315,222 326,755 322,997 264,278 202,615

6. Cost Sharing Increased cost sharing in the form of increased premiums a large portion of the changes Important issue because of Deficit Reduction Act of 2005 so lessons to be learned for SCHIP and Medicaid

7. Florida Premium Changes Family Income PFPM Premium Amount Prior to July 2003 July 2003 September 2003 October 2003 Forward 101%-150% FPL $15$20$15 151%-200% FPL $15$20

8. Cost Sharing Using Florida data, accelerated failure time model (AFT) – enrollment length Opportunity to examine potential changes in behavior across time and with shifting premiums Followed 153,768 Title XXI children from July 1, 2002 to June 30, 2004 Included age, gender, and health status in our analyses

9. Time Time Ratio Jul-02Jul-03Oct-03 1 2 3 101-150% FPL 151-200% FPL Premium = $15 Premium = $20 Premium = $20 for 151-200% FPL Premium = $15 for 101-150% FPL Enrollment Length Ratios By Income and Premium Amount

10. Interaction of Premium Change and Health Status Children were classified into health status categories using the Clinical Risk Groups Interaction between premium and health status not significant for children with moderate chronic or major chronic conditions In the short-term enrollment duration decreased for children who were healthy, had significant acute or minor chronic conditions and were above 150% FPL and then increased but not back to baseline levels.

11. Quality of Care in SCHIP Annual CMS Report - Core quality measures Well child visits first 15 months of life Well child visits 3 rd, 4 th, 5 th, and 6 th years Appropriate medications for children with asthma Access to primary care practitioners

12. Quality of Care in SCHIP - Mathematica Study 2005 report based on SFY 2003 Reporting Core Measures reported 8 states use 4 measures 18 states use 3 measures 7 states use 2 measures 3 states use 1 measure 14 states use no measures

13. Quality of Care in SCHIP - Mathematica Study Most frequent – well child in 3 rd, 4 th, 5 th, 6 th years – 33 states (13% to 73% compliance) Least frequent – asthma medications – 15 states (52% to 70% compliance) Goal Re: Quality Improve consistency of reporting Report something Use performance data for quality improvement

14. Published Reports – Quality of Care in SCHIP Primary focus on access to care – usual source of care Continuity of care – continuity with usual provider Utilization of specific health services Usually parent report See increase in those with USC, greater continuity, increased reports of preventive care visits

15. Illustration: Texas Value- Based Purchasing Initiative Concept - buyers should hold providers of health care accountable for both cost and quality of care HEDIS core measures and Consumer Assessment of Health Plan Survey (CAHPS) results reported Additional adult measures used Reported in a quarterly chart book by plan, service delivery area, and overall Annual encounter data certification and validation performed

16. Illustration: Texas Value- Based Purchasing Initiative Established standards – usually average of Medicaid plans reporting to NCQA Validated calculations with the health plans Three year process to reach validation stage Plans submit goals to state health plan managers and report on strategies to improve performance SFY 2007 – 3 goals and measures; increase to 5-7 per year

17. Examples - Chart 17. HEDIS® Well-Child Visits in the 3rd, 4th, 5th, And 6th Years of Life-TANF

18. Illustration: Texas Value- Based Purchasing Initiative Health plan meetings and workgroups Meet with state plan managers on status Financial incentive 1% of premium at risk Unearned funds available to those plans that excel on selected measures Exceptional performance – additional 0.5% of available funds Liquidated damages and remedies

19. Outcomes? Even prior to implementation of value- based purchasing – seeing indicator improvement Some studies – modest to no performance increases

20. Pay for Performance CMS/Premier P4P demonstration Mostly private sector interest Interest in Medicare Some states P4P in Medicaid New York, Michigan, California, RI, NC, PA New York – 1% of premium and may increase to 3% of premium

21. Potential Obstacles Credibility of information Lack of dissemination Information not being used to initiate change Time, effort, and expertise No requirement

22. Summary Cost sharing changes, among others, have an impact on enrollment and access Little required in terms of quality measurement and little is known Some innovations with financial incentives but outcome uncertain