Child Health Performance Measurement

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1 MEMORANDUM TO: Susan Radke FROM: Margo Rosenbach, Anna Katz, and Sibyl Day DATE: 9/29/2006 SUBJECT: Continued Progress in Performance Measurement Reporting by SCHIP In recent years, CMS has focused increasing attention on the reporting of program performance measures within the Children s Health Insurance (SCHIP). The Government Performance and Results Act (GPRA) requires the Centers for Medicare & Medicaid Services (CMS) to submit a five-year strategic plan for SCHIP, and an annual performance plan that documents progress toward meeting its goals during the previous fiscal year. In addition, states are required by Title XXI and the SCHIP Final Rules to report on their progress toward their strategic objectives and performance goals, and submit an annual report to CMS. By collecting information from states each year, CMS can track program performance over time. CMS contracted with Mathematica Policy Research, Inc. (MPR) to analyze the child health performance measurement reported by states in their SCHIP annual reports in federal fiscal years (FFY) 2003, 2004, and CMS also contracted with MPR to provide technical assistance to states to improve the completeness and quality of their reporting. This memo updates our analysis of the FFY 2003, which was presented in an earlier report (Day et al. 2005). First, we discuss trends in reporting from FFY 2003 to FFY 2005, including the number of states reporting the child health measures across the three years. Next, we analyze the performance measurement, focusing on the reported in the FFY 2005 annual reports. We constructed SCHIP means, medians, and percentiles for each of the child health measures, and compared the SCHIP medians to Medicaid and commercial medians produced by the National Committee for Quality Assurance (NCQA). In summary, we observed an increase in the number of states reporting each of the four core child health performance measures from FFY 2003 to Moreover, the quality and consistency of state reporting has improved. As a result, we were able to compare the FFY 2005 SCHIP medians to the NCQA medians for Medicaid and commercial health plans. This analysis demonstrates that, for most measures, SCHIP performance is similar to performance in Medicaid and commercial health plans. As CMS and the states continue to develop their capacity to use SCHIP performance measurement for quality improvement efforts, they can set objectives for future SCHIP program performance. Setting these objectives is an important step toward greater accountability for improving access to, and quality of, services delivered to SCHIP enrollees. 1

2 OVERVIEW OF CHILD HEALTH PERFORMANCE MEASURES s are required to report on the four core child health performance measures in Section IIA of the annual report template. 1 The four measures are: 1. Well-child visits in the first 15 months of life 2. Well-child visits in the third, fourth, fifth, and sixth years of life 3. Use of appropriate medications for children with asthma 4. Children s access to primary care practitioners (PCPs) 2 These measures are based on the technical specifications provided by the Health Plan Employer Data and Information Set, known as HEDIS. 3 HEDIS provides a useful framework for defining and measuring performance in addition to allowing for comparison of SCHIP program performance to national or state benchmarks. However, states are not required to use HEDIS and may use a different methodology to report on program performance. s may also modify HEDIS specifications to accommodate they already collect. The goal is for states to select one methodology and continue using it across subsequent years, thus achieving consistency in reporting over time. METHODS FOR ANALYZING PERFORMANCE MEASUREMENT DATA To analyze the performance measurement for FFY 2003 to 2005, MPR downloaded the SCHIP annual reports from the CMS website and compiled the child health performance measurement reported by each state across the three years of annual reports. The compiled information includes the methodology used, source and year, a summary of the progress made by each state, and the state s reasons for not reporting on a particular measure, if 1 CMS convened the Performance Measurement Partnership Project (PMPP) in 2002, a collaborative effort between federal and state officials, to explore the development of a national set of performance measures for Medicaid and SCHIP. CMS contracted with the National Academy for Health Policy (NASHP) to facilitate the workgroup that would develop these measures. The group focused on well-established measures whose results could motivate agencies, providers, and health plans to improve the quality of care delivered to Medicaid and SCHIP enrollees. After receiving comments from Medicaid and SCHIP officials on an initial set of 19 measures, the PMPP recommended a core set of seven national performance measures consisting of the four child health measures discussed in this report, and three adult measures. CMS requested that states report available on these measures beginning in their FFY 2003 SCHIP annual reports. 2 In the FFY 2003 annual report, this measure was referred to as objectives related to use of preventative care. The title of the measure was changed beginning in the FFY 2004 report to make it consistent with the Health Plan Employer Data and Information Set (HEDIS) measure. 3 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). HEDIS is the most widely used set of performance measures in the managed care industry. 2

3 applicable. MPR staff spent considerable time formatting the information so that it was presented consistently across states. To measure trends in the completeness and quality reporting, MPR tracked three indicators over the three years: (1) the number of states that reported each of the four child health measures; (2) the number of measures reported by each state; and (3) the number of states reporting HEDIS or HEDIS-like for each measure. MPR staff considered a state as having reported a particular measure if it reported any type of rate in a given year, regardless of the method that was used. We considered a state as having reported using HEDIS or HEDIS-like methods if it self-reported that its rates were modeled after HEDIS. We also calculated SCHIP means, medians, and 25th and 75th percentiles for each measure, based on for states that used HEDIS or HEDIS-like approaches. This enabled us to compare SCHIP medians to NCQA HEDIS medians for Medicaid and commercial plans. IMPROVEMENTS IN STATE REPORTING OVER TIME Using the methods described above, MPR calculated the number of states reporting each child health measure, and the number of measures reported by each state (Table 1). As shown in Figure 1, substantial progress has been made in the number of states reporting the four measures. The largest increase occurred between FFY 2003 and One reason for this substantial increase is that CMS made improvements to the annual report template in FFY Another reason is that MPR provided technical assistance to individual states to help them improve their reporting. 5 The most dramatic increase occurred for the measure on the use of appropriate medications for children with asthma; the number of states reporting this measure more than doubled from FFY 2003 to The number of states reporting the children s access to PCPs measure also increased substantially, by almost 50 percent from FFY 2003 to The number of states reporting the two well-child measures increased by about one-third during this time period. Figure 2 shows the substantial increase in the number of measures reported by states in each of the three years. Whereas 8 states reported all four measures in FFY 2003, 30 states reported all four measures in FFY There was also a large reduction in the number of states reporting zero measures: 14 states did not report any measures in FFY 2003, while only 3 states did not report any measures in FFY To address the reporting variations MPR observed in the FFY 2003 annual reports, and to solicit more complete information from states, CMS revised Section II of the FFY 2004 annual report template. Revisions were made to both the structure and content of the annual report template. This revised template was also used in FFY MPR staff provided technical assistance through various strategies including a teleconference organized by NASHP in June 2004 and a subsequent one-hour group training session; one-on-one discussions with states at the NASHP annual meetings in 2004 and 2005; and individual phone calls in which we answered state-specific questions. Technical assistance was voluntary and was initiated by the states. 3

4 Table 1. Summary of FFY 2004 and 2005 Reporting by Child Health Measure Type Total Number of Measures Reported by FFY 2004 FFY 2005 Well-Child Visits, First 15 Months FFY 2004 FFY 2005 Well-Child Visits, 3 to 6 Years FFY 2004 FFY 2005 Use of Appropriate Asthma Medications FFY 2004 FFY 2005 Children s Access to Primary Care Practitioners FFY 2004 FFY 2005 Total Number of s Reporting Alabama S-SCHIP 4 4 X X X X X X X X Alaska M-SCHIP 2 2 X X X X Arizona S-SCHIP X X - - X X Arkansas COMBO 3 3 X X X X X X - - California COMBO X X - - X X 4 Colorado S-SCHIP X - X - X - X Connecticut S-SCHIP 3 3 X X X X - - X X Delaware COMBO X X District of Columbia M-SCHIP Florida COMBO 3 4 X X - X X X X X Georgia S-SCHIP X X X X X X Hawaii M-SCHIP 4 NR X NR X NR X NR X NR Idaho COMBO 2 2 X X X X Illinois COMBO 4 4 X X X X X X X X Indiana COMBO 3 4 X X X X - X X X Iowa COMBO X X X - X - X Kansas S-SCHIP 3 4 X X X X - X X X Kentucky COMBO 4 4 X X X X X X X X Louisiana M-SCHIP 4 4 X X X X X X X X Maine COMBO 4 4 X X X X X X X X Maryland COMBO 3 4 X X X X - X X X Massachusetts COMBO 4 4 X X X X X X X X Michigan COMBO 4 4 X X X X X X X X Minnesota COMBO Mississippi S-SCHIP X X X X X X X Missouri M-SCHIP 2 0 X - X Montana S-SCHIP 4 4 X X X X X X X X Nebraska M-SCHIP 2 3 X X X X - X - -

5 Table 1 (continued) Type Total Number of Measures Reported by FFY 2004 FFY 2005 Well-Child Visits, First 15 Months FFY 2004 FFY 2005 Well-Child Visits, 3 to 6 Years FFY 2004 FFY 2005 Use of Appropriate Asthma Medications FFY 2004 FFY 2005 Children s Access to Primary Care Practitioners Nevada S-SCHIP 3 4 X X X X - X X X New Hampshire COMBO 4 4 X X X X X X X X New Jersey COMBO 4 4 X X X X X X X X New Mexico M-SCHIP 4 4 X X X X X X X X New York COMBO 4 2 X - X - X X X X North Carolina S-SCHIP X X X X X X North Dakota COMBO X X X - X X X Ohio M-SCHIP 3 2 X X X X X Oklahoma M-SCHIP 3 4 X X X X - X X X Oregon S-SCHIP 3 3 X X X X - - X X Pennsylvania S-SCHIP 4 4 X X X X X X X X Rhode Island COMBO 4 4 X X X X X X X X FFY 2004 FFY South Carolina M-SCHIP 2 2 X X X X South Dakota COMBO 4 4 X X X X X X X X Texas S-SCHIP 4 4 X X X X X X X X Utah S-SCHIP 3 3 X X X X - - X X Vermont S-SCHIP X X Virginia COMBO 2 4 X X X X - X - X Washington S-SCHIP 4 4 X X X X X X X X West Virginia S-SCHIP 4 4 X X X X X X X X Wisconsin M-SCHIP 4 4 X X X X X X X X Wyoming S-SCHIP 4 4 X X X X X X X X Sources: FFY 2004 and 2005 Title XXI Annual Reports. NR = Hawaii did not submit an annual report in FFY 2005.

6 Figure 1. Number of s Reporting Four Child Health Measures: FFY 2003, 2004, and 2005 Number of states Well-child visits, first 15 months Well-child visits, 3-6 years Use of appropriate asthma medications Chlidren's access to PCPs FFY 2003 FFY 2004 FFY 2005 Source: Mathematica Policy Research, Inc. analysis of FFY 2003, 2004, and 2005 Title XXI Annual Reports. Notes: FFY 2003 and 2004 counts include 49 states and the District of Columbia. FFY 2005 counts include 48 states and the District of Columbia. Hawaii did not report in FFY Tennessee did not have a SCHIP program during the study period. Figure 2. Number of Child Health Measures Reported by s: FFY 2003, 2004, and 2005 Number of states Zero One Two Three Four FFY 2003 FFY 2004 FFY 2005 Source: Mathematica Policy Research, Inc. analysis of FFY 2003, 2004, and 2005 Title XXI Annual Reports. Notes: FFY 2003 and 2004 counts include 49 states and the District of Columbia. FFY 2005 counts include 48 states and the District of Columbia. Hawaii did not report in FFY Tennessee did not have a SCHIP program during the study period. 6

7 OVERVIEW OF DATA REPORTED IN FFY 2004 AND 2005 Table 2 provides additional insight into the status of state reporting, including the number that used HEDIS or HEDIS-like methodology versus another methodology, and the reasons states did not report. This table focuses on FFY 2004 and 2005, updating our earlier analysis of FFY 2003 (Day et al. 2005). Two main points are observed. First, among the states reporting in each year, the number using HEDIS or HEDIS-like methods increased substantially, especially for the asthma and access to PCPs measures. These increases are a direct result of the technical assistance provided to states, which clarified the definition of numerators and denominators for these measures. Second, the reasons for not reporting reveal Table 2. Summary of Reporting Status in FFY 2004 and 2005 Well-Child Visits, First 15 Months Well-Child Visits, 3-6 Years Use of Appropriate Medications for Asthma Children s Access to PCPs FFY 2004 Total number of states reporting Methodology HEDIS/HEDIS-like Other Total number of states not reporting Reasons for not reporting Small sample size Incomplete/unavailable Population not covered Plan to report in future Reason unknown FFY 2005 Total number of states reporting Methodology HEDIS/HEDIS-like Other Total number of states not reporting Reasons for not reporting Small sample size Incomplete/unavailable Population not covered Plan to report in future Reason unknown Source: Mathematica Policy Research, Inc. analysis of FFY 2004 and 2005 Title XXI Annual Reports. Note: FFY 2004 counts include 49 states and the District of Columbia. FFY 2005 counts include 48 states and the District of Columbia. Hawaii did not report in FFY Tennessee did not have a SCHIP program during the study period. 7

8 that additional states are likely to report in the future as become available, although for some states, the sample size is too small (less than 30 enrollees), precluding state reporting. For state-by-state details on reporting of child health measures, refer to Attachment A (FFY 2004) and Attachment B (FFY 2005). 6 ANALYSIS OF DATA REPORTED IN FFY 2005 As previously discussed, there has been an overall positive trend in the completeness and quality of state reporting in terms of the number of states reporting each measure and the number using HEDIS or HEDIS-like methods. The remainder of this memo focuses on the FFY 2005, not only because they are the most recent available, but also because they provide the most complete and consistent picture about SCHIP performance. This analysis is an important step toward using the for quality improvement efforts as it may enable CMS and the states to use their past performance as a guideline by which to set future performance objectives. SCHIP Means, Medians, and Percentiles for FFY 2005 To analyze SCHIP performance in FFY 2005, we followed the approach used by NCQA to report on health plan performance. We calculated the means, medians, and 25th and 75th percentiles for each measure, restricting the analysis to states that reported HEDIS or HEDISlike. Attachment C describes the decision rules that we used to select states for inclusion in the calculations. As shown in Table 3, the median SCHIP rates were highest for children receiving a PCP visit: 95 percent for ages 12 to 24 months, 87 percent for ages 25 months to 6 years, 87 percent for ages 7 to 11 years, and 85 percent for ages 12 to 19. This measure also had the least amount of variation that is, the tightest interquartile ranges across states. 7 The median rates for use of appropriate medications for children with asthma were also relatively high: 73 percent for ages 5 to 9 and 70 percent for ages 10 to 17. The lowest median rates were for the well-child visits for children ages 3 to 6 (55 percent), followed by the rates for well-child visits for children in the first 15 months of life, (41 percent with six or more visits). In addition, the interquartile ranges were large for the two well-child measures, demonstrating that the rates varied substantially across states. 6 The tables presented in the attachments document state reporting of the child health performance measures in FFY 2004 and They display the we extracted for all states that reported on each measure, including the source, performance year (which is the most recent year for which were available), and the rate (including numerator and denominator). However, due to reporting inconsistencies by states from one year to the next, such as the use of different methodologies and reporting on different population subsets, comparisons of these should be made with extreme caution. 7 The interquartile range is the difference between the 25th and 75th percentiles on a given measure. This range shows the spread among states in the rates reported at the first and third quartiles. For example, the interquartile range on the rate of children ages 12 to 24 months with a PCP visit was 3 points (97 minus 94). Similarly, the interquartile range on the rate of children ages 3 to 6 years with one or more well-child visits was 24 points (65 minus 41). 8

9 Table 3. Reporting of Child Health Measures in FFY 2005: Means, Medians, and Percentiles Measure Age Group Number of s Mean Median 25th Percentile 75th Percentile Well-Child Visits Percent with 6+ visits First 15 months Percent with 1+ visits 3-6 years Use of Asthma Medications Percent receiving 5-9 years appropriate medications years Access to PCPs Percent with a PCP visit months months-6 years years years Source: Mathematica Policy Research, Inc. analysis of FFY 2005 Title XXI Annual Reports. Note: These calculations are based on a subset of all states reporting HEDIS or HEDIS-like measures. See Attachment C for decision rules. Comparison of SCHIP Medians to NCQA Medicaid and Commercial Medians As CMS continues to shift its focus from quality measurement to quality improvement that is, using the to improve program performance it will be important to understand how the compare to external benchmarks. Benchmarks provide a point of reference for gauging progress and also can be used to set future performance objectives. To help inform CMS s quality improvement efforts, we compared the FFY 2005 SCHIP medians for each of the four child health performance measures to the 2005 medians produced by NCQA for Medicaid and commercial health plans. 8 These comparisons are presented in Figures 3 through 6. The most substantial variation was observed for the measure of well-child visits in the first 15 months of life. The median rate of children receiving 6 or more well-child visits in the first 8 The measures produced by NCQA include a subset of the total number of health plans in operation in the United s. The NCQA presented in this memo include health plans that (1) submitted HEDIS to NCQA for the specified reporting periods; (2) agreed to publicly report the they submitted; and (3) were in either the health maintenance organization (HMO), point-of-service (POS), or HMO/POS combined line of business. That is, fee-for-service, preferred provider organization, fully insured, and other plan types were not included in the (personal communication with Jennifer Benjamin, July 10, 2006). All health plans that have NCQA accreditation are required to publicly report HEDIS to NCQA. However, non-accredited plans may choose to: (1) submit to NCQA, and publicly report those ; (2) submit to NCQA, but not publicly report them; or (3) not submit any to NCQA. The majority of Medicaid and commercial health plans submitting to NCQA in 2005 chose to publicly report their. Specifically, of the 98 Medicaid plans submitting to NCQA, 95 chose to publicly report those. Of the 367 commercial plans submitting, 252 chose to publicly report (personal communication with Jennifer Benjamin, June 1, 2006). 9

10 15 months of life was substantially lower for Medicaid and SCHIP than for commercial plans (41 percent for SCHIP; 46 percent for Medicaid; 71 percent for commercial plans, as shown in Figure 3). A potential reason for this difference is that infants covered by commercial plans tend to have greater continuity of coverage than infants in either SCHIP or Medicaid programs. This difference could also be an artifact of how the denominators for the measures were constructed. Based on HEDIS specifications, the commercial and Medicaid medians required infants to have continuous coverage for 12 months to be included in the rates. In contrast, states varied in their definition of the denominator for the SCHIP measure, and in some cases may not have required infants to have continuous coverage in order to be included in the rate. In general, measures that lack a continuous coverage criterion would lead to lower estimates of utilization than measures requiring continuous coverage, because infants with shorter lengths of enrollment would generally have fewer visits (at least as captured in claims/encounter ). These benchmark comparisons provide an important context for understanding performance within the SCHIP program, and raise questions about the extent to which the low rates are a function of variations in access and utilization, or rather are an artifact of the. The median SCHIP rate for children ages 3 to 6 years receiving one or more well-child visits (55 percent) was about ten points lower than the Medicaid and commercial medians (64 percent and 65 percent, respectively), as displayed in Figure 4. Again, it is unclear whether the lower SCHIP rate is a function of variation in practice patterns, barriers to care, or an artifact of the. The pattern was slightly different for the measure on use of appropriate medications for children with asthma (Figure 5). In general, the SCHIP medians were similar to the commercial medians, whereas the Medicaid medians were lower. The median rates exhibited a 10-point difference across programs for children ages 5 to 9 and a 6-point difference for children ages 10 to 17. The children s access to PCPs measure showed the most similarity across programs, with two to five points separating the medians across the three programs (see Figure 6). Although the median rates were high across the board, the highest rates were for children ages 12 to 24 months, while the lowest rates were for children ages 12 to19 years. Overall, these results suggest that quality improvement efforts might vary according to the type of utilization under consideration. For the children s access to PCPs measure, for example, the SCHIP medians were similar to those for Medicaid and commercial health plans, indicating that these rates do not vary substantially based on the type of health coverage a child receives. One potential explanation for the similarity is that the plans and providers do not vary their practices according to type of coverage. Alternatively, aggregate may not be sensitive enough to capture individual-level variations in access and utilization that may occur within 10

11 Figure 3. Well-child Visits, First 15 Months: Comparison of Median SCHIP, Medicaid, and Commercial Rates Median percent with 6+ visits SCHIP (n=20 states) Medicaid HEDIS Commercial HEDIS Source: Mathematica Policy Research, Inc. analysis of FFY 2005 Title XXI Annual Reports, and NCQA HEDIS 2005 Percentiles. Figure 4. Well-child Visits, 3-6 Years: Comparison of Median SCHIP, Medicaid, and Commercial Rates Median percent with 1+ visits SCHIP (n=36 states) Medicaid HEDIS Commercial HEDIS Source: Mathematica Policy Research, Inc. analysis of FFY 2005 Title XXI Annual Reports, and NCQA HEDIS 2005 Percentiles. 11

12 Figure 5. Use of Appropriate Asthma Medications: Comparison of Median SCHIP, Medicaid, and Commercial Rates Median percent receiving appropriate medications Ages 5-9 Ages SCHIP (n=19 states) Medicaid HEDIS Commercial HEDIS Source: Mathematica Policy Research, Inc. analysis of FFY 2005 Title XXI Annual Reports, and NCQA HEDIS 2005 Percentiles. Figure 6. Children s Access to PCPs: Comparison of Median SCHIP, Medicaid, and Commercial Rates Median percent with a PCP visit months 25 mo. - 6 years 7-11 years years SCHIP (n=20 states) Medicaid HEDIS Commercial HEDIS Source: Mathematica Policy Research, Inc. analysis of FFY 2005 Title XXI Annual Reports, and NCQA HEDIS 2005 Percentiles. 12

13 these populations. 9 The lack of substantial variation by type of program (at the median) implies that quality improvement efforts might be more cost-effective if they were focused at the population level in other words, exploring ways to increase access for all children, as opposed to concentrating efforts on increasing access for one particular program. For other measures, where there is more substantial variation across programs especially the well-child measures some of the variation may be a function of how the measures were constructed. Understanding the source of variation will be key to identifying the future direction for SCHIP quality improvement efforts. CAVEATS OF SCHIP PERFORMANCE MEASUREMENT DATA AND COMPARISONS TO NCQA HEDIS MEDIANS While these provide useful insight into performance measurement in SCHIP, and can be used by CMS to further inform its quality improvement efforts, there are several important caveats to interpreting the results. This section discusses the caveats that apply to the SCHIP means, medians, and percentiles that we constructed, as well as to the comparisons between the SCHIP medians and the NCQA HEDIS medians. Caveats of the SCHIP Means, Medians, and Percentiles The first and foremost caveat concerns the national representativeness of the SCHIP summary statistics. To calculate the FFY 2005 SCHIP means, medians, and percentiles, MPR used a set of decision rules and criteria to determine which states to include in the calculations (see Attachment C). Many states did not meet the inclusion criteria and were therefore excluded from the calculations. Consequently, although the SCHIP median rates provide a useful overview of program performance in 2005, they cannot be considered representative of SCHIP at the national level. The second caveat is that state methods varied along many dimensions. For example, several states included traditional Medicaid as well as SCHIP children in their numerators and denominators for all or some of their rates. In addition, states varied in the collection year they used for constructing the SCHIP HEDIS or HEDIS-like measures. Some states reported rates from 2003, whereas others reported rates from 2004; some states constructed rates based on collected during the calendar year whereas others used the federal fiscal year. s that obtained HEDIS from their managed care organizations also varied in the way they calculated statewide rates, and some provided more detail on the methodology used than others (for example, some states reported individual HMO averages, while others reported one statewide rate averaged across their HMOs). To the extent that states are consistent in their 9 The NCQA HEDIS 2005 percentiles reflect that were collected during calendar year We chose this year as the comparison because it aligned most closely with the reporting year that most states used in the FFY 2005 annual reports. However, the NCQA percentiles do not change much over time, and therefore provide a fairly stable comparison even if the year does not correspond exactly to the year for which SCHIP programs reported. 13

14 methods from year to year, analysis of state-level trends will not be affected. However, such variation may affect the comparability of for purposes of national analyses, including comparisons to NCQA HEDIS medians. A third caveat concerns limitations of measuring change from year to year. Some states reported the identical in the FFY 2005 report that they reported in FFY While we included such in our calculations for FFY 2005, any future analyses that looks at changes in rates over time should take this into account, because such repeat reporting could bias the results towards no change. In response, CMS is revising the FFY 2006 annual report template to enable states to note that the same are being reported in more than one year. Caveats of Comparing SCHIP Medians to NCQA HEDIS Medians While we have compared the SCHIP medians to the NCQA HEDIS to provide a context for developing SCHIP quality improvement initiatives, there are several significant caveats to using these. First, the NCQA medians are not meant to be used as benchmarks per se. Instead, NCQA has indicated that they are meant primarily for checking reasonability in the audit process (NCQA 2004b; NCQA 2005). Second, the NCQA measures do not include all Medicaid and commercial plans in their measures, only those that submitted to NCQA and agreed to the being publicly reported (personal communication with Jennifer Benjamin, June 1, 2006). Finally, the NCQA HEDIS are audited, whereas the SCHIP performance measurement are not. DISCUSSION This analysis shows that state reporting of the SCHIP performance measurement from FFY 2003 to 2005 has improved, with an increase in both the number of states reporting and the number of measures reported by each state. These improvements in reporting likely have resulted from the enhancements CMS made to the annual report template and from the technical assistance MPR has provided to states. This analysis has stretched the use of the SCHIP performance measurement by comparing the SCHIP medians to external benchmarks from the NCQA HEDIS reports. For one of the measures, access to PCPs, the median rates were quite similar across programs, suggesting that quality improvement efforts might be more cost-effective at the population level rather than the program level. For the two well-child measures, in contrast, the SCHIP rates were markedly different from the commercial rates, in particular, suggesting that further exploration of the sources of the variation is required. It is unclear whether the variation across programs is a function of limitations, provider practice patterns, or barriers to care. Nevertheless, from a quality improvement standpoint, this comparison provides a context for interpreting the, and suggests an initial approach to focus efforts to improve quality of care for SCHIP enrollees. Although this analysis did not assess trends in the SCHIP rates over time, future efforts beginning with the FFY 2006 SCHIP annual reports will involve setting performance objectives to promote quality improvement. Not only will this effort require states to critically 14

15 evaluate their methods of reporting from year to year to ensure consistency in their, but also, it may generate a discussion about the level of improvement that is realistic to expect each year. Informal tracking of the NCQA HEDIS medians suggests that few rates change from year to year. It may be that these particular measures are not sensitive enough to show changes in practice that result in better quality of care. Alternatively, the lack of variation in these measures could simply be a reflection of how hard it is to change practice, both over time and across programs. As more states report on the four core child health performance measures, the SCHIP program will have an increased capacity to engage in discussions about how to improve the quality of care for children in SCHIP. CMS and states will also be better positioned to engage in broader discussions about improving the quality of care for children nationally, irrespective of their insurance coverage. REFERENCES Committee on Practice and Ambulatory Medicine, American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care. Pediatrics, vol. 105, no. 3, 2000, pp Day, Sibyl, Anna Katz, and Margo Rosenbach. Improving Performance Measurement in the Children s Health Insurance. Cambridge, MA: Mathematica Policy Research, Inc., July National Committee for Quality Assurance (NCQA). HEDIS Health Plan Employer Data and Information Set. Vol. 2, Technical specifications. Washington (DC): National Committee for Quality Assurance (NCQA); 2004a. National Committee for Quality Assurance (NCQA). Commercial and Medicaid HEDIS 2004 Means, Percentiles and Ratios. Available at [ 2004MPR]; 2004b. National Committee for Quality Assurance (NCQA). Commercial and Medicaid HEDIS 2005 Means, Percentiles and Ratios. Available at [ 2005MPR];

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17 ATTACHMENT A FFY 2004 DETAILED TABLES

18

19 Table A.1. Well-Child Visits in the First 15 Months, FFY 2004 Type Data Source Performance Year Percentage of Children Receiving Well-Child Visits: Rate(s) Reported Reported Using HEDIS or HEDIS -like Methodology (n=26) Alabama S-SCHIP Claims visits - 18% (49/271) 1 visit - 2% (5/271) 2 visits - 7% (20/271) 3 visits - 9% (25/271) 4 visits - 17% (46/271) 5 visits - 20% (53/271) 6+ visits - 27% (73/271) Arkansas COMBO Claims SFY visits - 6% 1 visit - 7% 2 visits - 11% 3 visits - 9% 4 visits - 10% 5 visits - 11% 6+ visits - 46% Hawaii M-SCHIP Health plans HEDIS reports SFY % (1,981/3,764) with 6+ visits Kansas S-SCHIP Claims visits - 5% 1 visit - 1% 2 visits - 7% 3 visits - 9% 4 visits - 15% 5 visits - 24% 6+ visits - 38% Kentucky COMBO HEDIS 2004 Data Submission Tool visits - 0% (0/164) 1 visit - 1% (1/164) 2 visits - 1% (2/164) 3 visits - 2% (3/164) 4 visits - 4% (7/164) 5 visits - 10% (17/164) 6+ visits - 82% (134/164) Louisiana M-SCHIP Claims FFY % (39,782/41,696) a Maine COMBO Claims and eligibility FFY visits - 1% (3/265) 1 visit - 2% (4/265) 2 visits - 3% (8/265) 3 visits - 4% (11/265) 4 visits - 10% (26/265) 5 visits - 18% (49/265) 6+ visits - 62% (164/265) Maryland COMBO MCOs HEDIS reports CY % with 5+ visits b Massachusetts COMBO Claims, encounter, and medical record Michigan COMBO Facility, pharmacy, and professional claims % with 6+ visits FY % (109/183) with 1+ visits Montana S-SCHIP Claims FFY visits - 11% (5/45) 1 visit - 7% (3/45) 2 visits - 4% (2/45) 3 visits - 13% (6/45) 4 visits - 22% (10/45) 5 visits - 29% (13/45) 6+ visits - 13% (6/45) Nevada S-SCHIP Claims % (87/190) with 6+ visits New Jersey COMBO HMOs HEDIS rates % with 6+ visits b New Mexico M-SCHIP HEDIS 2004 Data Submission Tool % (1,397/4,116) with 6+ visits

20 Table A.1 (continued) Type Data Source Performance Year Percentage of Children Receiving Well-Child Visits: Rate(s) Reported New York COMBO QARR % (1,460/1,848* ) with 5+ visits c Ohio M-SCHIP Claims and encounter SFY % (1,285/3,198) with 6+ visits Oklahoma M-SCHIP Claims and encounter % with 6+ visits (PCCM) 19% with 6+ visits (FFS) Oregon S-SCHIP Eligibility, claims, and encounter NR 86% (550/637) d Pennsylvania S-SCHIP MCO (one of seven MCOs reporting) % (25/36) with 6+ visits Rhode Island COMBO HEDIS Data Submission Tool % (1,295/1,545) with 5+ visits South Dakota COMBO Claims FFY visits - 5% (11/212) 1 visit - 8% (17/212) 2 visits - 8% (18/212) 3 visits - 8% (18/212) 4 visits - 13% (28/212) 5 visits - 11% (24/212) 6+ visits - 46% (96/212) Texas S-SCHIP Enrollment, claims, and encounter 12/1/02-11/30/03 0 visits - 12% (77/652) 1 visit - 12% (75/652) 2 visits - 9% (60/652 ) 3 visits - 12% (78/652) 4 visits - 20% (130/652) 5 visits - 23% (153/652) 6+ visits - 12% (79/652) Utah S-SCHIP HEDIS % with 5+ visits Virginia COMBO Claims % with 6+ visits Washington S-SCHIP Claims and medical record 2004 wide mean: 40% e wide median: 40% e West Virginia S-SCHIP Claims and eligibility % (13/15) a Type Data Source Performance Year Rate(s) Reported Reported Using Other Methodology (n=12) Alaska M-SCHIP Claims and EPSDT FFY 2003 Number of children through age 2 who received well-child (EPSDT) exams: 2,244 Screening ratio f for children through age 2: near 100% Participation ratio g for children through age 2: near 64% Connecticut S-SCHIP MCOs reports SFY 2004 Percentage of screens expected that were received by children <12 months old: 79% (377/475) Florida COMBO Claims SFY 2004 Percentage of children age 15 months or younger who received a well-child visit: 48% Idaho COMBO EPSDT FFY 2003 Screening ratio f for children ages 0-36 months: 55% (38,570/70,261) Illinois COMBO Claims and encounter FFY 2003 Participant ratio g for children ages 1-2: 70% (2,420/3,436) 2

21 Table A.1 (continued) Type Data Source Performance Year Rate(s) Reported Indiana COMBO Claims SFY 2004 Percentage of children ages 6-12 months with well-child visits: 59% Percentage of children age 1 with well-child visits: 47% Missouri M-SCHIP EPSDT FFY 2003 Participant ratio g for children less than age 1: 90% (35,736/39,590) Nebraska M-SCHIP EPSDT SFY 2004 Screening ratio f for children less than age 1: 100% (3,374/3,195) Screening ratio f for children ages 1-2: 100% (3,551/3,342) New Hampshire COMBO Claims and encounter SFY 2003 Percentage of children age 1 who received the expected number of visits: 11% (1/9) Percentage of children age 1 who received the minimum number of visits: 22% (2/9) Percentage of children age 2 who received the expected number of visits: 61% (81/132) Percentage of children age 2 who received the minimum number of visits: 75% (99/132) South Carolina M-SCHIP EPSDT SFY Number of children ages 1-2 receiving recommended screenings: 2,676 Wisconsin M-SCHIP Encounter 2003 Percentage of children ages 1-2 receiving at least one non-healthcheck ambulatory child care encounter: 98% Wyoming S-SCHIP Claims FFY 2004 Number of enrollees ages 15 months and younger: 62 Number of well-child visits: 78 Source: Notes: Original analysis of FFY 2004 Title XXI Annual Reports by Mathematica Policy Research, Inc. All percentages have been rounded to whole numbers. Numerators and denominators are shown if reported in the state annual reports. M-SCHIP denotes that the state operates a Medicaid expansion program; S-SCHIP denotes that the state operates a separate child health program; COMBO denotes that the state operates both an M-SCHIP and an S-SCHIP program. NR = Not Reported; CY = Calendar Year; SFY = Fiscal Year; FFY = Federal Fiscal Year; FY = Fiscal Year; HMO = Health Maintenance Organization; MCO = Managed Care Organization; EPSDT = Early and Periodic Screening, Diagnosis, and Treatment; QARR = Quality Assurance Reporting Requirements; PCCM = Primary Care Case Management; FFS = Fee For Service. a Number of visits not reported. b Unweighted average of individual MCO rates; numerators and denominators not reported. c Rate includes adjustment for length of plan enrollment. d Numerator and denominator not defined. e Rates not defined. f Screening ratio indicates the percent of initial and periodic screening services received, as required by the state s periodicity schedule, adjusted by the proportion of the year for which the children are eligible. g Participant ratio indicates the percent of children eligible for EPSDT who received any initial and periodic screening services during the year. 3

22 Table A.2. Well-Child Visits in the 3 rd, 4 th, 5 th, and 6 th Years of Life, FFY 2004 Type Data Source Performance Year Percentage of Children Receiving Well- Child Visits: Rate(s) Reported Reported Using HEDIS or HEDIS -like Methodology (n=34) Alabama S-SCHIP Claims FY % (1,522/4,972) with 1+ visits Arizona S-SCHIP Claims and encounter CYE % (2,574/4,530) with 1+ visits Arkansas COMBO Claims SFY % with 1+ visits California COMBO Claims % with 1+ visits Georgia S-SCHIP Claims CY % (12,770/36,785) with 1+ visits Hawaii M-SCHIP Health plans HEDIS reports SFY % (9,414/16,160) with 1+ visits Indiana COMBO Claims SFY years old: 26% with 1+ visits 4 years old: 22% with 1+ visits 5 years old: 18% with 1+ visits Iowa COMBO Encounter and enrollment files SFY % (357/1,301) with 1+ visits Kansas S-SCHIP Claims % with 1+ visits Kentucky COMBO HEDIS 2004 Data Submission Tool % (750/1,219) with 1+ visits Louisiana M-SCHIP Claims FFY % (80,165/137,658) with 1+ visits Maine COMBO Claims and eligibility FFY % (1,291/2,113) with 1+ visits Maryland COMBO MCOs HEDIS reports CY % with 1+ visits a Massachusetts COMBO Claims, encounter, and medical record % with 1+ visits Michigan COMBO Facility, pharmacy, and professional claims FY % (1,842/3,651) with 1+ visits Mississippi S-SCHIP Claims CY % (1,262/5,536) with 1+ visits Montana S-SCHIP Claims FFY % (322/1,110) with 1+ visits Nevada S-SCHIP Claims, encounter, and membership % (1,366/1,951) with 1+ visits New Jersey COMBO HMOs HEDIS reports % with 1+ visits a New Mexico M-SCHIP HEDIS 2004 Data Submission Tool % (8,581/18,104) with 1+ visits New York COMBO QARR % (21,149/27,195*1.0158) with 1+ visits b North Carolina S-SCHIP Claims % (3,814/6,872) with 1+ visits North Dakota COMBO Claims % (126/126) with 1+ visits Ohio M-SCHIP Claims and encounter SFY % with 1+ visits Oklahoma M-SCHIP Claims and encounter % with 1+ visits (PCCM) 40% with 1+ visits (FFS) Oregon S-SCHIP Eligibility, claims, and encounter NR 38% (1,148/3,061) c Pennsylvania S-SCHIP MCO (five out of seven MCOs reporting) % (2,584/4,141) with 1+ visits Rhode Island COMBO HEDIS Data Submission Tool % (4,241/5,853) with 1+ visits South Dakota COMBO Claims FFY % (124/460) with 1+ visits Texas S-SCHIP Enrollment, claims, and encounter 12/1/02 11/30/03 48% (29,150/60,742) with 1+ visits Utah S-SCHIP HEDIS % with 1+ visits Virginia COMBO Claims % with 1+ visits Washington S-SCHIP Claims and medical record 2004 wide mean: 51% with 1+ visits d wide median: 54% with 1+ visits d West Virginia S-SCHIP Claims and eligibility % (529/830) with 1+ visits 4

23 Table A.2 (Continued) Type Data Source Performance Year Rate(s) Reported Reported Using Other Methodology (n=10) Alaska M-SCHIP EPSDT FFY 2003 Number of children ages 3 to 5 who received well-child (EPSDT) exams: 1,329 Screening ratio e for children ages 3 to 5: near 80% Participant ratio f for children ages 3 to 5: near 69% Connecticut S-SCHIP MCOs reports SFY 2004 Participant ratio f for children ages 3 to 5: 76% (1,956/2,564) Idaho COMBO EPSDT FFY 2003 Screening ratio e for children ages 4 to 6: 29% (6,673/22,692) Illinois COMBO Claims and encounter FFY 2003 Participant ratio f for children ages 3 to 5: 78% (3,609/24,619) Missouri M-SCHIP EPSDT FFY 2003 Participant ratio f for children ages 3 to 5: 56% (54,498/98,036) Nebraska M-SCHIP EPSDT SFY 2004 Screening ratio e for children ages 3 to 5: 74% (1,652/2,231) Screening ratio e for children ages 6 to 9: 38% (910/2,395) New Hampshire COMBO Claims and encounter SFY 2003 Percentage of children with the expected number of visits: 62% (358/581) g South Carolina M-SCHIP EPSDT SFY Number of children ages 3 to 5 who received recommended screenings: 1,454 Wisconsin M-SCHIP Encounter 2003 Percentage of enrollees ages 3 to 5 with 1+ visits: 93% Wyoming S-SCHIP Claims FFY 2004 Number of children age 3 enrolled: 91 Number of well-child visits: 21 Number of children age 4 enrolled: 90 Number of well-child visits: 14 Number of children age 5 enrolled: 101 Number of well-child visits: 30 Number of children age 6 enrolled: 167 Number of well-child visits: 19 Source: Notes: Original analysis of FFY 2004 Title XXI Annual Reports by Mathematica Policy Research, Inc. All percentages have been rounded to whole numbers. Numerators and denominators are shown if reported in the state annual reports. M-SCHIP denotes that the state operates a Medicaid expansion program; S-SCHIP denotes that the state operates a separate child health program; COMBO denotes that the state operates both an M-SCHIP and an S-SCHIP program. CY = Calendar Year; FFY = Federal Fiscal Year; SFY = Fiscal Year; FY = Fiscal Year; CYE = Calendar Year End; NR = Not Reported; HMO = Health Maintenance Organization; MCO = Managed Care Organization; EPSDT = Early and Periodic Screening, Diagnosis, and Treatment; QARR = Quality Assurance Reporting Requirements; PCCM = Primary Care Case Management. a Unweighted average of individual MCO scores; numerators and denominators not reported. b Rate includes adjustment for length of plan enrollment. c Numerator and denominator not defined. d Rates not defined. e Screening ratio indicates the percent of initial and periodic screening services received, as required by the state s periodicity schedule, adjusted by the proportion of the year for which the children are eligible. f Participant ratio indicates the percent of children eligible for EPSDT who received any initial and periodic screening services during the year. g Ages not specified. 5

24 Table A.3. Use of Appropriate Medications for Children with Asthma, FFY 2004 Percentage of Children Receiving Appropriate Medications for Asthma: Rate(s) Reported Type Data Source Performance Year Children 5 to 9 years old Children 10 to 17 years old Combined rate for children 5 to 17 years old Reported Using HEDIS or HEDIS -like Methodology (n=26) Alabama S-SCHIP Claims FY % (239/322) 71% (491/691) 72% (730/1,013) Arkansas COMBO Claims SFY % 73% 75% Florida COMBO Claims and encounter % 53% NR Georgia S-SCHIP Claims CY % (1,546/2,201) 69% (1,449/2,112) 69% (2,995/4,313) Hawaii M-SCHIP Health plans HEDIS reports SFY % (651/1,228) 54% (560/1,041) NR Illinois COMBO Claims CY 2003 NR NR 64% a Kentucky COMBO HEDIS 2004 Data Submission Tool % (81/98) 71% (94/132) 76% (175/230) Louisiana M-SCHIP Claims CY 2003 NR NR 61% (9,922/16,321) b Maine COMBO Claims and eligibility Massachusetts COMBO Claims and encounter Michigan COMBO Facility, pharmacy, and professional claims 10/1/03-9/30/04 61% (14/23) 73% (29/40) 67% (42/63) % 66% NR 2003 NR NR 69% (207/302) a Mississippi S-SCHIP Claims % (145/195) 73% (220/303) 73% (365/498) Montana S-SCHIP Claims FFY 2004 NR NR 54% (90/166) a New Hampshire COMBO Claims and encounter SFY 2003 NR NR 88% (94/107) b New Jersey COMBO Focused study SFY 2003 NR NR 76% c New Mexico M-SCHIP HEDIS 2004 Data Submission Tool 2003 NR NR 68% (2,458/3,623) New York COMBO QARR 2003 NR NR 71% (3,707/5,258) d North Carolina S-SCHIP Membership and claims Ohio M-SCHIP Claims and encounter Pennsylvania S-SCHIP MCO (five out of seven MCOs reporting) % (336/427) 74% (592/806) 75% (928/1,233) SFY 2003 NR NR 32% (33,358/105,741) 2004 NR NR 73% (1,378/1,899) 6

25 Table A.3 (continued) Percentage of Children Receiving Appropriate Medications for Asthma: Rate(s) Reported Type Data Source Rhode Island COMBO HEDIS Data Submission Tool Performance Year Children 5 to 9 years old Children 10 to 17 years old Combined rate for children 5 to 17 years old 2003 NR NR 70% (1,053/1,514) a South Dakota COMBO Claims FFY % (17/21) 83% (20/24) 82% (37/45) Texas S-SCHIP Enrollment, claims, and encounter, including pharmacy 12/1/02 to 11/30/03 72% (2,313/3,203) 72% (2,893/4,037) 72% (5,206/7,240) Washington S-SCHIP Claims and medical record West Virginia S-SCHIP Claims and eligibility 2004 wide mean: 62% e wide median: 61% e wide mean: 61% e wide median: 62% e % (105/115) 84% (223/265) f 86% (328/380) d NR Wyoming S-SCHIP Claims FFY % (13/14) 85% (23/27) 88% (36/41) Type Data Source Performance Year Rate(s) Reported Reported Using Other Measure (n=1) Wisconsin M-SCHIP Encounter 2003 Percentage of enrollees ages 0 to 20 with diagnosis of asthma: 5% Percentage of enrollees ages 0 to 20 that had inpatient stays: 3% Percentage of enrollees ages 0 to 20 that had emergency visits: 17% Source: Notes: Original analysis of FFY 2004 Title XXI Annual Reports by Mathematica Policy Research, Inc. All percentages have been rounded to whole numbers. Numerators and denominators are shown if reported in the state annual reports. M-SCHIP denotes that the state operates a Medicaid expansion program; S-SCHIP denotes that the state operates a separate child health program; COMBO denotes that the state operates both an M-SCHIP and an S-SCHIP program. CY = Calendar Year; FFY = Federal Fiscal Year; SFY = Fiscal Year; FY = Fiscal Year; NR = Not Reported; MCO = Managed Care Organization; QARR = Quality Assurance Reporting Requirements. a Ages not specified. b Children under age 19. c Children ages 5 to 20. d Children ages 5 to 18. e Rates not defined. f Children ages 10 to 18. 7

26 Table A.4. Children s Access to Primary Care Practitioners, FFY 2004 Type Data Source Performance Year Percentage of Children Who Had 1+ Visits with a Primary Care Practitioner (PCP): Rate(s) Reported Ages 12 to 24 Months Ages 25 Months to 6 Years Ages 7 to 11 Years Ages 12 to 19 Years Rate(s) Reported for Other Age Groups Reported Using HEDIS or HEDIS -like Methodology for Access to Primary Care Practitioners (n=29) Alabama S-SCHIP Claims FY % (390/445) 78% (4,556/5,828) 81% (6,545/8,036) 78% (10,549/13,584) Arizona S-SCHIP Claims and encounter FFY % 87% 74% 74% a California COMBO Health plans CY % 83% 83% Florida COMBO Claims and encounter CY 2003 NR NR NR NR 85% b Georgia S-SCHIP Claims CY % (1,082/1,136) 88% (37,586/42,598) 84% (24,296/28,883) Hawaii M-SCHIP Health plans HEDIS reports SFY % (4,907/5,149) 86% (17,434/20,265) 88% (11,981/13,629) 87% (14,340/16,418) 8 Kansas S-SCHIP Claims % (546/564) 90% (3,609/4,028) 93% (3,437/3,708) Kentucky COMBO HEDIS 2004 Data Submission Tool % (215/218) 90% (1,263/1,397) 91% (1,405/1,550) 90% (1,627/1,802) Louisiana M-SCHIP Claims % (39,782/137,658) 85.91% (147,166/171,296) 86% (113,570/131,803) 85% (143,407/168,690) Maine COMBO Claims and eligibility Maryland COMBO MCOs HEDIS reports Massachusetts COMBO Claims and encounter Michigan COMBO Facility, pharmacy, and professional claims FFY % (377/382) 83% (1,679/2,018) 82% (2,846/3,467) 81% a (4,284/5,308) CY % c 84% c 82% c 82% c % 92% 96% 94% FY % (682/726) 90% (3,275/3,651) 92% (2,121/2,309) 89% (2,575/2,883)

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