SCHIP: Reauthorization, Increased Cost Sharing, and

Quality Initiatives

Betsy ShenkmanInstitute for Child Health Policy

Department of Epidemiology and Health Policy Research

University of FloridaJune 2006

Key Issues

State policy changes and increased cost sharing

Quality initiatives – What’s required? What’s novel?

Illustration of Policy Changes in Two States

Texas Title XXI Enrollment and Major Program Changes

507,259488,690

458,166

416,302

359,734340,101

326,557310,981

294,189

0

100,000

200,000

300,000

400,000

500,000

600,000S

ep

-03

Oct

-03

No

v-0

3

De

c-0

3

Jan

-04

Fe

b-0

4

Ma

r-0

4

Ap

r-0

4

Ma

y-0

4

Jun

-04

Jul-

04

Au

g-0

4

Se

p-0

4

Oct

-04

No

v-0

4

De

c-0

4

Jan

-05

Fe

b-0

5

Ma

r-0

5

Ap

r-0

5

Ma

y-0

5

Jun

-05

Jul-

05

Au

g-0

5

Se

p-0

5

Oct

-05

No

v-0

5

De

c-0

5

Jan

-06

Fe

b-0

6

Ma

r-0

6

Ap

r-0

6

Enrollment

Sept, 2003

( Enrol lment 507,259):

• Benefi ts eliminated for hospice, skilled nursing, dental, tobacco cessation, vision &

chiropractic services

• Benefi ts reduced for inpatient & outpatient mental health

Oct, 2003

(Enrol lment 488,690):

• Continuous eligibility reduced f rom 12 to 6 months

• 90 day waiting period before coverage implemented

• Exceptions to waiting period: decertifi ed f rom Medicaid & deemed CHIP eligibile, newborns & other children added to current enrollee account, children

disenrolled for failure to renew but whose parents complete the renewal within a specifi ed time period

Nov, 2003

(Enrol lment 458,166):

• Premium enrollment fees

implemented:

o 100%-150% FPL - $15 per

family per month

o 151%-185% FPL - $20 per

family per month

o 186%-200% FPL - $25 per

family per month

• Copayment changes

implemented:

o Offi ce visit - $3-$7,

depending on income

o Inpatient – Increase f rom $0

to $10 for families less than

100% FPL

• Cost sharing cap increases

• Earned income disregards

eliminated

J an, 2004

(Enrol lment

416,302):

• Disenrollment of families

for failure to pay monthly

premiums suspended

Aug, 2004

(Enrol lment 359,734):

• Asset test implemented for

families with incomes at or

above 150% FPL

Nov, 2004

(Enrol lment 340,101) :

• Collection of premiums at renewal

suspended

Sept, 2005

(Enrol lment 326,557):

• September 2003 benefi ts

restored & mental health

benefi ts increased

Feb, 2006

(Enrol lment 310,981):

• Cost sharing rules changed to the

following per 6 months enrollment

per family:

o 133%-150% FPL - $25

o 151%-185% FPL - $35

o 186%-200% FPL - $50

Apr , 2006

(Enrol lment 294,189):

• Dental benefi t restored with

benefi t tiers

Florida Title XXI Enrollment and Major Program Changes

July 03:

• “No Growth”budget enacted

• Program over-enrolled, wait list started

• No Title XIX toTitle 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

180,000

200,000

220,000

240,000

260,000

280,000

300,000

320,000

340,000

Jul-02 Oct-02 Jan-03 Apr-03 Jul-03 Oct-03 Jan-04 Apr-04 Jul-04 Oct-04 Jan-05 Apr-05 Jul-05 Oct-05

202,433

220,533

252,209

323,262

331,281

336,689

315,222

326,755322,997

264,278

202,615

Cost Sharing

Increased cost sharing in the form of increased premiums a large portion of the changes

Important issue because of Deficit Reduction Act of 2005 so lessons to be learned for SCHIP and Medicaid

Florida Premium Changes

Family Income

PFPM Premium Amount

Prior to July2003

July 2003September 2003

October 2003 Forward

101%-150% FPL

$15 $20 $15

151%-200% FPL

$15 $20 $20

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

Time

Time Ratio

Jul-02 Jul-03 Oct-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

Interaction of Premium Change and Health Status Children were classified into health status

categories using the Clinical Risk Groups Interaction between premium and health

status not significant for children with moderate chronic or major chronic conditions

In the short-term enrollment duration decreased for children who were healthy, had significant acute or minor chronic conditions and were above 150% FPL and then increased but not back to baseline levels.

Quality of Care in SCHIP

Annual CMS Report - Core quality measures Well child visits first 15 months of life Well child visits 3rd, 4th, 5th, and 6th

years Appropriate medications for children

with asthma Access to primary care practitioners

Quality of Care in SCHIP -Mathematica Study

2005 report based on SFY 2003 Reporting

Core Measures reported 8 states use 4 measures 18 states use 3 measures 7 states use 2 measures 3 states use 1 measure 14 states use no measures

Quality of Care in SCHIP -Mathematica Study

Most frequent – well child in 3rd, 4th, 5th, 6th years – 33 states (13% to 73% compliance)

Least frequent – asthma medications – 15 states (52% to 70% compliance)

Goal Re: Quality Improve consistency of reporting Report something Use performance data for quality improvement

Published Reports – Quality of Care in SCHIP Primary focus on access to care – usual

source of care Continuity of care – continuity with

usual provider Utilization of specific health services Usually parent report See increase in those with USC, greater

continuity, increased reports of preventive care visits

Illustration: Texas Value-Based Purchasing Initiative Concept - buyers should hold providers of

health care accountable for both cost and quality of care

HEDIS core measures and Consumer Assessment of Health Plan Survey (CAHPS) results reported

Additional adult measures used Reported in a quarterly chart book by plan,

service delivery area, and overall Annual encounter data certification and

validation performed

Illustration: Texas Value-Based Purchasing Initiative Established standards – usually average of

Medicaid plans reporting to NCQA Validated calculations with the health plans Three year process to reach validation

stage Plans submit goals to state health plan

managers and report on strategies to improve performance

SFY 2007 – 3 goals and measures; increase to 5-7 per year

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

STAR MCOs - March 1, 2004 to February 28, 2005 TANF Enrollees in Age Group = 95,060

Reference: TANF STAR Table PI-2

68.61%

63.48% 62.90%

68.45%66.29%66.56%

60.68% 59.86%

0%

10%

20%

30%

40%

50%

60%

70%

Plan A Plan B Plan C Plan D Plan E Plan F Plan G Plan H

MCO Percent STAR MCO Mean = 65.27% HEDIS 2004 Mean = 59.90%

Illustration: Texas Value-Based Purchasing Initiative Health plan meetings and workgroups Meet with state plan managers on status Financial incentive

1% of premium at risk Unearned funds available to those plans that

excel on selected measures Exceptional performance – additional 0.5%

of available funds Liquidated damages and remedies

Outcomes?

Even prior to implementation of value-based purchasing – seeing indicator improvement

Some studies – modest to no performance increases

Pay for Performance

CMS/Premier P4P demonstration Mostly private sector interest Interest in Medicare Some states P4P in Medicaid

New York, Michigan, California, RI, NC, PA

New York – 1% of premium and may increase to 3% of premium

Potential Obstacles

Credibility of information Lack of dissemination Information not being used to

initiate change Time, effort, and expertise No requirement

Summary

Cost sharing changes, among others, have an impact on enrollment and access

Little required in terms of quality measurement and little is known

Some innovations with financial incentives but outcome uncertain