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Remarks by:

Dick Merritt
Group Director,
Forum for State Health Policy Leadership
National Conference of State Legislatures

Lisa Simpson, MD
Deputy Director,
Agency for Healthcare Research and Quality
United States Department of Health and Human Services

Question and Answer Session

Dick Merritt:

Our final presenter will be Dr. Lisa Simpson who is the Deputy Director of AHRQ.

Dr. Lisa Simpson:

Good morning. It's a wonderful pleasure actually to be here this morning and to spend a couple of minutes telling you about some of the activities at the agency that are focused on child health. One of the reasons it's a particular pleasure for me is I get to see an old and dear colleague from Hawaii, Dennis Arrocoque, because I used to be the state MCH director in Hawaii and my passion for children hasn't ebbed at all but I get to play in a slightly different way, as well as broadly work with the agency to promote all of the programs that you've been hearing about this morning.

What I'd like to do is focus in on some of the activities that we are doing to try to bring to both sponsor research that helps folks like you and program mangers in the public and private sectors to understand and improve care for children, and I focus this morning my remarks on Medicaid and SCHIP, and also the tools that the agency has developed and made available for both program monitoring management and improvement. When I came to the agency there wasn't a discreet focus on children's health services and thanks to the work of a lot of dedicated folks we've been able to build that. I'm sure you've heard from all my colleagues, we've tried to shape this program to again, be very responsive to users needs and since so many children are cared for in public systems, whether it's Medicaid, SCHIP, state sponsored, state only programs, you all play a critical role in children's health in America.

The first example, and I've just picked some highlights; I also want to point out that there's a couple of handouts on the table; this is a children's health highlights, it gives a lot more details about specific findings and ongoing research that you might want to look at if this is of interest. I want to focus in on one sort of flagship initiative that we developed a few years ago and that's related to SCHIP. Obviously, you know this was established in 1997 and states had substantial flexibility in designing the programs, and so the agency pulled together public and private funders in 1998 to discuss what were the key research questions that we should be looking at so that we could learn from this new program. So at the end of a certain number of years we actually have an ongoing learning opportunity to keep improving and refining whether it's Medicaid, SCHIP look-alike, whatever you want to call them. So we developed the Child Health Insurance Research Initiative and this is a set of nine research grants cooperative agreements, which are cofunded by the agency, the Packard Foundation and HRSA. Like I said, it's a public/private partnership and we made them as cooperative agreements because as opposed to the traditional research model where you fund the investigators and they go study something and 3, 4 or 5 years later come back and tell you what they found, these investigators come together 3 times a year to share information and research strategies; to use, for example, the same way to measure quality for chronically ill kids across the states that they're studying so we can learn more generalizeable information for policy makers use.

In addition, we convened a policy makers users group so that these investigators over the time they were working still had to come together once a year with representatives of state legislators, state program managers and the private sector, to have an interaction of that. Well here's where we're going asking these questions. Well no, you know, mid-course correction. This is the point I'm interested in; here's what's happening real time in these programs that we are seeing in our state.

There was a special emphasis within this program; two areas of high concern: children's special health care needs who within the child community are the highest costers and the highest users of services, whether they come in through SSI or not or your Title V programs and minority children for whom we know we have significant disparities in access and quality.

I want to give you a few key findings. These are going to be published in this particular finding in Health Care Financing Review, this month, and there will be a policy brief generated from this so you can get sort of more detail. I'm just giving you a little highlight. These studies were in Florida, Kansas, New York and Oregon and they found that many children covered through the various states SCHIP programs did experience interruptions in coverage and that the state redetermination requirements were associated with large disenrollments and that the one state that had a passive reenrollment process resulted in more children experiencing uninterrupted coverage. So there's the numbers for you. On the left side you can see Florida had a 5% of children disenrolled at redetermination v 50% for Oregon.

Another way to look at that data is here. If you look at 24 months and look back over the children's enrollment in SCHIP over those 24 months, you see that the blue bars are those children who are continuously enrolled and the yellow bars are those who are enrolled with at least one disenrollment and you can see again that for example in New York, while 53% of the kids are enrolled at 24 months during those 2 years, 27% have experienced a period of disenrollment, so that there is some turning on and off of the insurance. Again, what that means for each state is somewhat different because obviously the question is are they disenrolling to become uninsured; are they disenrolling in getting privately insured and I hope I'm interesting you in this because full results will be in that policy brief, but we're starting to get some results that help us understand what happens with these programs.

Another finding that's coming out of this set of studies looking in Alabama, Georgia and Florida; again looking at the utilization of dental care; we've all learned that dental care is a huge issue for publicly insured children and their lack of access and their utilization even when publicly insured is lower than privately insured. We do know that children's use of dental care is highest between 6 and 11 but in these public programs in these three states, these rates are still lower than the recommended levels. And then the question is well, is this really necessary care. What kind of care are these kids getting. It's really much needed services and significantly a large number of these children are getting emergency or restorative care. So we're not even looking at recommended, preventive services for children. These are really sort of more treatment dental care.

So those are a set of findings coming out of that one initiative. I want to turn now to just some other findings that the agency has sponsored to give you a flavor of the breadth of the kinds of research that we sponsor that's important to improving children's health care. The first finding here is Dr. Steve Berman in Colorado looked at, within the Medicaid program in Colorado, the use of expensive or third-line antibiotics for children with ear infections and he defined certain criteria that it was an uncomplicated ear infection and the clinical recommendations for those indications, you should use the generic and first line antibiotic which is cheaper and he found if all of the doctors and practitioners used the recommended cheaper antibiotic, you could save substantial dollars in the Medicaid program in Colorado. I don't remember the exact number but I think it was between $200,000 and $400,000 a year just in that program. Again, appropriate use of the right treatment, for the right child, at the right time can result in cost savings, as well as improved quality.

The second finding here is a more recent one that we sponsored that just came out last year that looked at the use of ear tubes for kids who have chronic ear infections and sort of glue ear. There's been a lot of practice after sort of long-term antibiotics, you send them surgeons and you get tubes inserted and the concern over these children with glue ears is they don't hear as well and their language development will be retarded. So Jack Paradise, a very well known investigator in this area, then looked at children's language outcomes at 3 years and found that whether the children had the tubes inserted or not, there was not a significant difference. So that again raises the question is this the appropriate use of this intervention and can quality be improved and cost reduced.

A final study here was looking at children who were hospitalized with respiratory illnesses and found that you could actually do more conservative treatment, i.e. keeping them out of hospital for certain indications and you'd reduce the use of hospital resources and related costs and again, maintain quality of care.

Then a final study I included here was done by Kieran Phipps and his colleagues I think in 1998 in California and looked at those high-risk pre-term babies were the big costers in hospital care. If you look at all children's health, the big costs come from those really sick babies who were born too small and too early and we all know that those babies need to be cared for in a tertiary quaternary NICU. But the question is does it make a difference if you go to a NICU that has a larger number of patients that sees a high volume of those patients because what's happened in the last 20 years in this country, particularly in the last 10, is a proliferation of these neo-natal intensive care units in states because of market share, competition, etc. And actually what Kieran Phipps found was that your mortality outcomes are better if you're in an NICU that sees more children. So this is a broader volume outcome relationship that we're seeing throughout adult and child health services and hospital, but this is one specific example that relates to mortality in pediatrics.

We have a host of other studies that we're sponsoring. Here's some of the current studies that are in our portfolio that again, I picked out because they're relevant to Medicaid because Medicaid pays for such a large number of births in this country, somewhere around 30%; mental health services are so huge for adolescents under your systems and the move to managed care. For example, newborn jaundice, with the discharges earlier, Mom's going home less than 24 hours, we've seen in the last 10 years an upswing in the number of kids with not just mild jaundice, that's not a problem, but actually severe jaundice and even the most severe with very high blood levels of what causes this that can cause permanent brain damage. So obviously there's a question about how can we better screen, diagnose and manage newborn jaundice so we avoid those very serious consequences and appropriately manage those who aren't going to become serious with the lowest intervention.

The second study here for example is premature babies. Again, those very expensive babies in our systems are often born, if they're born too early, with weak lungs and we're sponsoring a major study that's happening in over half of the neo-natal intensive care units in this country through the Vermont Oxford Neo-natal network and they're looking at can you make sure that these babies get the drug they need at the right time so that you can prevent chronic lung disease. A lot of these babies end up, many of your states may sponsor NICU follow up programs where these are high-risk infant follow up programs. They may end up in your IDEA programs. So again, can we deliver care that we know is effective better so that we avoid complications?

Again looking at adolescent health services; obviously the National Institutes of Mental Health sponsors a lot of research on mental health but the slice of it that we focus on is on primary care. We know both in adults and children there's an under-diagnosis of mental health challenges and what can the primary care doc, whether family practice or pediatrician, do to both identify and manage these challenges in primary care before they get so severe that they require more expensive outpatient or inpatient services and then looking at practices around managed care for children with chronic conditions; again, the high cost children in the various systems.

Turning from some of the research findings I want to just run through and unfortunately as I was putting this slide together I realized gosh, that's a very Washington slide. It's all these abbreviations. But I'll try to explain them briefly and again, I'd love to answer any questions. We again, as part of looking at how we could be more responsive to users, we started working with federal Medicaid representatives and SCHIP representatives and Trish Riley and others, sort of hearing what do states need to improve quality to managed care for children and what came out of that was a sense that a toolbox that's on-line, web based that allows program managers quick access, sort of one-stop shopping to a menu of what's available in terms of these tools to improve quality would be helpful. So we developed a child health toolbox and as you see here it has access to the various caps or quality indicators, our national guideline clearing house in the future, a national quality measures clearing house. Again, evidence based, tested, reliable and available is more readily apparent to state program managers so that they can use it and we're just evaluating and updating that tool right now.

CAPS is another tool; this is going to be a test, a little survey. How many of you have ever heard of CAPS? Okay, we've got some work to do. We actually have I think over 24 states, I don't know if any of you are from those 24 states; Medicaid programs who are using this, this is the Consumer Assessment of Heath Plan Survey, and it's a tool that's used to survey Medicaid and persons in health plans experiences of care and then use that for program improvement. So it's nationally representative and very scientifically validated, we spent 5 years developing it, and it's also the requirement in the HEDIS program.

Turning to HCUP, the last two tools I want to mention is this is actually a federal/state partnership where we work now with 30 different states and your hospital associations to put together your hospital discharge data and create a set of tools off that both nationally and state specific so that you can use this data to look at quality and benchmarking and understand how hospital services are being delivered and looking at comparable states. It's a very rich program but there's one part of it that I just wanted to highlight. On our website you can go to HCUP.net which is sort of a user friendly, do it yourself, plug in some numbers, because you can actually pull down some simple analyses by plugging in what age group you want to look at; what diagnoses, etc. So for example, here's an output; hospital stays for children and you can put in which states you want. There's a national sample that's been weighted up to be nationally representative. So you can look at length of stay; that's LOS, charges, aggregate charges and deaths. So there's a lot of potential comparisons in various states like New York. Actually Hawaii is a partner and has been using this a lot. Using this to improve quality, we have a number of quality indicators that are built off this.

My final tool that I want to mention is a major survey that the agency sponsors called the Medical Expenditure Panel Survey. Now it's not big enough to have state specific estimates. I know that's always first question; can I get my state numbers out of it. Four states can get specific estimates and that's, as you can image, the large ones, California and New York, Illinois and I think Texas, but it provides national benchmarks for you to look at not just what care do children use, but how much does it cost and this is the only national survey that doesn't just rely on the parent's reports of what's happening. It actually goes to the medical provider and verifies what services were provided, how much it cost so you can find out how much is covered by which type of insurance, how much is paid out of pocket, etc. It also looks at employers and the employer sample is available for 40 states; what are employers offering, small employers, large employers, how much are premiums costing, etc. and trends in all the insurance offers. Here are just some highlights of findings; the expenses for children in Medicaid under age 18. As I mentioned the earlier finding, nationally 50% of kids don't use dental services and then a more recent finding which will just be released by the agency later this week is that when we ask parents using that CAPS survey about their experiences of care, we see not unexpectedly some variations by race, ethnicity but also by type of insurance that are pretty interesting because in the dimensions about did the doctor or provider explain enough for you to understand what to do with the care. Were you treated with respect and did you have enough time with your provider. In the insurance category, the publicly insured reported the most problems with answers to those three questions. Worse than the privately insured but also worse than the uninsured, which is a little counterintuitive so we're looking at those data a little bit more and that the differences on those three questions by race, ethnicity was not as marked. Again, we're trying to understand where did these disparities come from and how do we then use them to improve care.

So, if you have any additional questions, please feel free to e-mail me or Denise Dougherty, Dr. Dougherty is our senior advisor on child health and it's really thanks to her and many other colleagues that we've been able to put together this robust set of activities related to children's health. Thank you.

Question and Answer Session

On the first point, the dental care, the problem with the provider network is consistent I think across states. I hear it from everybody. That first set of research grants I mentioned the CHIRI initiative, Alabama and Georgia and I think also Florida are actually looking at that and particularly with rural providers in trying to see what kinds of strategies improve the participation in the provider network. We don't have results yet but they are specifically looking at that. It was an issue when I was in Hawaii 10 years ago; it remains an issue nationally.

On the second question of presumptive eligibility, the set of projects we're sponsoring are currently not looking at the issue of presumptive eligibility, sort of at conception or during prenatal care at all, but to the extent that the results I presented in terms of Florida at reenrollment, it's sort of a passive reenrollment unless you actively disenroll, you're passively reenrolled. It's sort of another take on presumptive and they're drilling down to find out more about the implications of that. But these are not the only studies looking at some of the questions. These are the ones we're sponsoring. There are a number of other studies or other analyses I should say that the Urban Institute and then Paul Ginsberg Shop with the community tracking study; I don't know if you've seen any of their work, are looking at some of these other issues because again, when we convened all the researchers sort of nationally in 1998, we wanted to make sure that we were working together across these research funding sources to try to answer these questions. So we sort of tried to make sure we were doing complementary work.

Thank you for that and you may end up hearing from us on this issue because one of the programs that we sponsor is the user liaison program where we make available sort of the latest best research on any one topic and also give state representatives an opportunity to sort of tell each other about these successes in their states. Dental care and how to deal with it may be one of the things that we'll do in the future.

One of the benefits of being in a research agency is that I can sort of defer on that question. I don't know about that Medicaid requirement but I would actually say that Secretary Thompson has been vociferous in his support of state flexibility on some of these issues as well as Dennis Smith. So on that specific issue I really don't know; I can't speak for them but I think that what we can do in our research, folks are actually looking at some of these perceptions of public programs and why parents make the choices that they do and the interaction between Medicaid and the SCHIP program. So I think we'll be able to produce some better information that helps the decision makers on those policies, you know, maybe look at those again.

That's great. We've actually heard from a number of states about simplification of application and joint and that does seem to have an important boost for eligible enrollment.

Very good question and one we keep striving to make our web site the most user friendly as possible. We're about to launch an improvement to the web site which I think speaks to your question a little bit and it's got another acronym, GOLD, for grants on line database. And you will be able to search by state, by topic area, by year. If you typed in like asthma and Medicaid, it just does a word search and pulls out all the active research that we're sponsoring that includes those two words. Now that tells you about active research so you at least know what we're funding and it tells you who is doing it etc., and you could e-mail us for more information if it's of interest.

In terms of research findings, the actual results, those are all over our web site right now but our goal more long term is that GOLD database would actually have results in it as well. So for right now where to find results on our web site is more driven by your content interest. You can just type the word you're looking for and see what comes up and it will be a mix of research findings, of on-going activities, press releases, etc. Then there's always the generic mailbox where you can just e-mail us. But we're always striving to try to make it more user friendly and if you do get on there and can't find what you need please just shoot off an e-mail and give us that feedback so we can keep improving.

END

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