Examines the outcomes and policy implications of CHIs and the Healthy Kids insurance program in the state

Chris Feifer

Gregory D. Stevens

Michael R. Cousineau

T. Em Arpawong

English

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  COVERING CALIFORNIA’S KIDS EVALUATION HTTP://COMMUNITYHEALTH.USC.EDU   August 2007  OUTCOMES FROM CHILDREN’S HEALTH INITIATIVES IN CALIFORNIA T. EM ARPAWONG, CHRIS FEIFER, GREGORY D. STEVENS AND MICHAEL R. COUSINEAU  Approximately one-third of uninsured children in California do not qualify for existing federal and state health insurance programs due to family income eligibility thresholds or undocumented immigration status.  Recognizing this as a gap in coverage, several California counties have formed coalitions known as Children’s Health Initiatives (CHIs) and designed locally-funded and operated health insurance programs known as Healthy Kids.  As of January 2007, Healthy Kids programs were in operation in 22 of California’s most populous counties, and have collectively covered more than 88,000 children. The earliest CHIs launched their Healthy Kids programs in 2001-2002 (beginning with Santa Clara and San Francisco), and these served as models for seven other counties to launch similar programs in late 2002 through 2004, three in 2005, and ten in 2006.i  As these programs spread from county to county, they were supported by an increasing number of organizations including a range of California philanthropies.  Two of these agencies—The California Endowment and First5 California—commissioned a multi-component evaluation to assess, in part, the contribution of the Healthy Kids programs to improving access to high quality health care for children.   This report highlights findings and recommendations from a broader report regarding the ongoing process of monitoring utilization and quality in Healthy Kids programs in California.  It summarizes the selection of utilization and quality indicators, and presents the first round of data provided by nine CHIs that were operational for the full 2005 calendar year.  The report also provides a snapshot of Healthy Kids program successes by comparing utilization and quality indicators for Healthy Kids programs to Medi-Cal and Healthy Families (California’s State Children’s Health Insurance Program (SCHIP)).    QUALITY INDICATORS Seven process indicators, listed in Table 1, were selected for the evaluation.  Six of the measures were based on HEDIS®ii technical specifications while the one on emergency department visits was a modified HEDIS® measure. These indicators were selected after conducting semi-structured interviews with 22 CHIs exploring their ability to collect and report various data elements.  We also conducted literature searches, and obtained input from funding agencies and other experts. Despite drawbacks to using process measures (e.g., need for calibration to determine what a percent change in measure means in terms of percent change in outcome) they provide an advantage over medical outcome measures for evaluation because the latter are prone to problems with reliability, validity, and bias.iii, iv   RESULTS All nine CHIs that were in operation for the entire 2005 calendar year submitted data for this analysis.  These CHIs collectively enrolled 80,542 children in Healthy Kids programs in: Kern, Los Angeles, Riverside, San Bernardino, San Francisco, San Joaquin, San Mateo, Santa Clara and Santa Cruz counties. The results for Riverside and San Bernardino counties were combined in the evaluation and labeled ‘Inland Empire’ because both CHIs are served by the same health plan, the Inland Empire Health Plan.   Table 1. Evaluation Indicators  Indicator Category Age Preferred reporting method Well-Child Visit in the Past Year Access & Utilization 3-6 years HEDIS hybrid  Well-Adolescent Visit in the Past Year Access & Utilization 12-21 years HEDIS hybrid Emergency Department Visits in the Past Year Access & Utilization 0-19 years project specific - administrative Primary Care Physician Visit in the Past Year Access & Utilization 1-19 years HEDIS administrative Dental Visit in the Past Year Access & Utilization 2-18 year HEDIS administrative Immunizations, Combination 2 Quality 0-2 years HEDIS hybrid Asthma Medication Quality 5-17 years HEDIS administrative  The development of this summary was supported by grants from The California Endowment and First 5 California.    Figure 2Healthy Kids, Primary Care Visits in 2005 by County: ages 25 months-6 years91.087.588.852.175.579.578.70 10 20 30 40 50 60 70 80 90 100Santa CruzSanta ClaraSan MateoSan JoaquinSan FranciscoLos AngelesKernInland EmpireCounties% with visitsHealthy Families average = 87National Medicaid average = 82Note: All rates reported using the administrative method* Rate (89.2%) w as calculated w ith different inclusion criteria. The eligible population defined as total # children w ho received Healthy Kids services in 2005 based on date of service rendered.  It w as not able to take into account any gaps in enrollment in 2005. *Figure 1 Healthy Kids Well-Check Visits in 2005, by County, ages 3-6 years51.569.960.569.952.666.70 10 20 30 40 50 60 70 80 90 100Santa CruzSanta ClaraSan MateoSan JoaquinSan FranciscoLos AngelesKern*Inland EmpireCounties% with visitHybridAdministrative70 = Medi-Cal averageHealthy Families average = 65NRNational Medicaid average = 62NR = Not Reported*Rate (32.3%) w as calculated w ith different inclusion criteria.  It w as not able to take into account any gaps in Healthy Kids enrollment in 2005. Comparing Healthy Kids to Medi-Cal and Healthy Families These CHI performance indicators were compared to similar aggregated performance from the California Healthy Families programv, Medi-Cal Managed Carevi, and/or national data for Medicaid.vii, viii    Access and Utilization Measures The Healthy Kids program is helping to fill a gap in coverage and demonstrating utilization similar to the state health insurance programs.  • Figure 1 shows that more than half of all children ages 3-6 years (range: 52.6-69.9%) who were enrolled in six county Healthy Kids programs for the entire year of 2005, received a Well-Child check.  This is close to the average rates for Medi-Cal (70%) and Healthy Families enrollees (65%).   • The percent of Adolescents ages 12-21 years who received a Well-Adolescent check for six CHIs range from 17.8 to 43.8%, close to the Medi-Cal (37%) and Healthy Families state averages (36%). • On average, 16% of children enrolled in Healthy Kids programs, ages 0-5 visited the emergency department (ED) while an average of 9% of adolescents ages 6-18 years, visited the ED.  Healthy Kids enrollees visited the ED less than children in both age groups who were enrolled in Medi-Cal (38% and 24%, respectively) and Healthy Families (27% and 18%, respectively) programs.  Access Measures Access measures are divided into age group strata that limit our ability to draw conclusions in counties with small numbers of insured members. • Eight of the nine CHIs had sufficient enrollment of children ages 25 months to 6 years, to examine access to primary care.  The rate of Primary Care Visits in 2005 among the different CHIs ranged from 52.1 to 91.0%.  Seven of those CHIs reported rates above 75% (Figure 2).  The Medi-Cal and Healthy Families averages for this age group were also high (82 and 87%, respectively). There is an urgent need for dental care access among vulnerable children, and Healthy Kids programs are helping to remedy this.   • In all age groups, CHIs reported rates of dental care use far above the national Medicaid averages (no comparisons available for Healthy Families). Between 26.9 to 52.6% of children ages 2-3 years enrolled in Healthy Kids had a dental visit.  The need for dental care visits can be expected to rise over the next several years as a dental check-up becomes an enrollment prerequisite for California elementary schools.   • Healthy Kids enrollees between 4-6 years of age had a dental visit at rates of 55.6 to 86.2%, compared to the national Medicaid average of 46% (Figure 3).    The development of this summary was supported by grants from The California Endowment and First 5 California.    Figure 3Healthy Kids, Dental Visits in 2005 by County: ages 4-6 years70.068.055.686.275.3IENRNR0 10 20 30 40 50 60 70 80 90 100Santa CruzSanta ClaraSan MateoSan JoaquinSan FranciscoLos AngelesKernInland EmpireCounties% w ith visits46 = National Medicaid averageNote: A ll rates reported using the administrative methodIE = Insufficient EligibilityNR = Not ReportedQuality Measures The small enrollment sizes of CHIs also affected their ability to report results for quality measures.  None of the CHIs could report rates for the asthma quality measure looking at appropriate prescribing.  Three CHIs did have sufficient populations under the age of two to report on Immunizations. Rates varied widely among those counties (59.3, 12.5, and 79.1%) and were generally lower than the Medi-Cal (65%) and Healthy Families (82%) state averages.  One reason for low utilization rates may be that children in Healthy Kids are frequently enrolled through the Child Health and Disability Prevention Program (CHDP) through which they may have received their required immunizations.   Limitations for Data Interpretation The results of this evaluation cannot be generalized to all enrollees as it does not capture the experiences of children who have not been continuously enrolled for the full year due to logistical reasons (e.g., child enrolls mid-year, family moves out of the county, parents do not keep up with enrollment paperwork, change in health plan contracts).  In addition, small counties did not have eligible populations large enough to report for many measures and newer programs did not accumulate an adequate sample to evaluate certain measures.  POLICY IMPLICATIONS Healthy Kids programs are helping to fill a gap by increasing access to care for vulnerable children across the state.  Healthy Kids enrollees demonstrate utilization of services at rates close to, and often better than, rates for state programs such as Healthy Families and Medi-Cal.  This reflects a considerable achievement of the CHIs, since the undocumented population that Healthy Kids programs serve has historically been cautious in seeking health care services for fears of deportation or public charge. However, reporting on a per county basis for individual program such as Healthy Kids is problematic for evaluation purposes as many counties are small and lack sufficient eligibility for reporting some measures and certain age strata within others.   In order to improve the state’s ability to assess the contribution of the Healthy Kids programs to improving children’s health care access, utilization, and outcomes, we recommend the synchronization or merging of ongoing quality monitoring efforts for all children in California supported by public funds.  The collaboration would help to achieve consistency in reporting, allow state-level comparisons, and reduce the administrative burden associated with responding to multiple quality monitoring efforts.                                                    i Stevens GD, Rice K, Cousineau MR. Chidlren’s Health Initiatives in California: the experiences of local coalitions pursuing universal coverage for children. Am J Public Health. 2007 Apr;97(4):738-43. ii HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).  HEDIS measures used by Medi-Cal Managed Care are audited by certified NCQA auditors. There was no audit for this Healthy Kids evaluation. iii McAuliffe WE. Measuring the quality of medical care: process versus outcome. Health & Society. 1979;57(1). iv Eddy DD. Performance Measurement: Problems and Solutions. Health Aff. July/August 1998;July/August:7-25. v Healthy Families. Health Plan Quality Measurement Report For Services Provided in 2005 December 20 2060. vi Delmarva Foundation. Report of the 2005 Performance Measures for Medi-Cal Managed Care Members. Sacramento, CA: California Department of Health Services, Medi-Cal Managed Care Division; August 2005. vii National Committee for Quality Assurance. HEDIS® 2005 Means, Percentiles & Ratios.   http://www.ncqa.org/Programs/hedis/audit/2005MPR.htm, 2007 viii National Committee for Quality Assurance. The State of Health Care Quality 2006.  1-84. Available at: http://www.ncqa.org/Communications/SOHC2006/SOHC_2006.pdf 

Covering California's Kids: Outcomes from Children's Health Initiatives in California

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Covering California's Kids: Outcomes from Children's Health Initiatives in California

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