Recently in CMS Category

You know those Old Westerns where the hero rides in at that last minute to save the day. That's what last week's "clawback" reduction announcement must have felt like to many states trying to maintain their Medicaid programs in the wake of increased need and reduced revenues caused by the recession. 

The trailer would go something like this: 

Charlie Homer
President and CEO, National Initiative for Children's Healthcare Quality

In this time of agonizing about broad health care reform, I take solace in celebrating the passage of CHIPRA (the Child Health Insurance Program Reauthorization Act) just over a year ago, and focusing on its productive implementation. CHIPRA not only expanded access to health insurance for children, but--as the regular readers of this blog know--included groundbreaking activities to strengthen the QUALITY of care that children who are insured through CHIP or Medicaid receive.  These activities included substantial grants to states for demonstration projects (announced just yesterday) funding for an electronic health record that meets the specific needs of children, and two sequential activities around the measurement of quality of children's health care.

The first measurement activity mandated by the CHIPRA legislation was the creation of a "core" measurement set. The legislation called for a tight deadline, mandated the scope of the measures, and specified an inclusive process for selecting the measures. Last summer, the Agency for Healthcare Research and Quality (AHRQ) conducted a thoughtful, broadly inclusive process to create that core measurement set.

The process that AHRQ used is well described on their website. The panel included leaders of state Medicaid and CHIP programs, consumers, pediatricians and family physicians, dentists, and public health professionals. AHRQ contracted with experts to produce background information, too. The committee used a formal consensus process, voting on the validity, feasibility and importance of the measures. It then prioritized measures to make sure the set was balanced (e.g., acute, preventive and chronic care, inpatient and outpatient, and oral health). They recommended 25 measures that were subsequently reviewed by AHRQ's National Advisory Committee and ultimately the Secretary of Health and Human Services. This recommended measurement set is now out for public comment, with responses due by March 1st.

This set includes 13 measures of preventive care, 5 for management of children with acute conditions, 9 of care for children with chronic conditions, 1 of patient experience and 1 of availability. 

• Most of the preventive measures are relatively simple, emphasizing counting encounters (e.g., number of well child visits, frequency of prenatal care, and number receiving preventive dental care) rather than focusing on the content of the preventive care itself. Preventive content is addressed in assuring documentation of BMI (happily consistent with the current emphasis by the White House on obesity prevention), using standard tools for developmental screening, immunizations, and Chlamydia screening. 

• Acute care measures address appropriate use of antibiotics, catheter associated blood stream infections in intensive care inpatient settings (the only inpatient measure), counts of those EPSDT eligible children who receive dental treatment and counts of emergency departments visits in a population (presumably an outcome measure assessing prevention and integration of care more than quality of acute care itself). 

• The most common chronic conditions in childhood are addressed through a simple outcome measure for asthma (number of children over one year old with one or more asthma related emergency room visits), follow up for children on a medication for ADHD, follow up after mental illness hospitalization, and assessment of hemoglobin A1C for children with diabetes. 

• Rounding out the set, the list includes the CAHPS Health Plan survey including supplemental items for Medicaid and Children with Chronic Conditions and an indicator of access to primary care practitioners.

One can quibble with some of the measures (e.g., the inclusion of children under two in the asthma measure given the difficulty of diagnosis, the accuracy of coding, and effectiveness of treatment in that age group) and lament the generally low bar the measures establish (e.g., counts of visits receiving more emphasis than content). I also believe the committee could have recommended the measurement of the "medical home" through the use of the CAHPS survey rather than defer this measurement to the future.  

Congress recognized that any initial measurement set would be inadequate and specified that CMS create a program to develop new measures to address gaps in the core measurement set. Indeed, this week, AHRQ is convening a panel to recommend criteria for the measures under this new program. The committee highlighted gaps in their measurement set, specifically highlighting the need for better measures of mental health and substance abuse service, inpatient and specialty care, duration of enrollment and coverage, medical home, and other means of care integration, and availability of services. We at the National Initiative for Children's Healthcare Quality--working with the National Quality Forum--recently convened an expert group that identified additional gap areas such as care coordination, broader indicators of population health, and special topics such as pediatric palliative care. We anticipate the Secretary will be seeking public comment on which topics the new program should address.

But, overall, for now, rather than critique the current set, it is far more important to commend the committee, AHRQ, CMS, and the Secretary for moving quickly, transparently and yet rigorously to assemble a thoughtful and credible measurement set. We should also urge HHS to move on to establishing effective mechanisms for collecting and reporting these data across all types of care provided in Medicaid and CHIP programs (e.g., fee-for-service and primary care case management as well as managed care), for encouraging universal, standardized reporting (not required under CHIPRA), and for assisting states and delivery organizations in using these data to improve care.

The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

Donna Cohen Ross

Outreach Director, Center on Budget and Policy Priorities

One year ago last Thursday, President Obama signed the Children's Health Insurance Program Reauthorization Act (CHIPRA) into law.  The President's words that day reinvigorated a nationwide effort to ensure that children have the health coverage they need.

We have made significant strides since then, as CMS details in a new report. Despite grim budget conditions, states have expanded coverage, streamlined enrollment procedures, and stepped up outreach efforts.  And, when the weak economy generated increased need, Medicaid and CHIP rose to the challenge, covering 2.6 million previously uninsured children last year.

My memory of last year's bill-signing got me thinking about two incredible people who exemplify the challenge that lies before us:  Greg Secrest and Ann Walker, both from Martinsville, a once-robust manufacturing town in southern Virginia.  Greg used to work for a furniture manufacturer, but was laid off when the company moved overseas.  Without health insurance or a job, Greg found help at Project Connect (a program funded by the Virginia Health Care Foundation and Anthem Blue Cross Blue Shield Foundation), where Ann, an outreach advocate, helped dispel his skepticism about CHIP and signed up his two sons. 

Invited to the White House CHIPRA signing ceremony last year, the entire Secrest family traveled to Washington to join the President and other distinguished guests.  President Obama mentioned the Secrest family in his remarks saying:  "Let's give Americans the support they need to weather this crisis... In the end, that's really all that folks like the Secrests are looking for -- the chance to work hard and to have that hard work translate into a good life for their kids." 

I called Ann and Greg last week for an update. Ann is still working hard to help unemployed families find the help they need.  "Anywhere there's a door," says Ann, "I'm still sticking my toe in. I'm a nagger.  I'm a stalker." 

Greg gives Ann high praise: "If I could give Ms. Walker a medal, I would. She gave me peace of mind.  Because of her, I have health insurance for my children and I don't have to worry when my kids go out to play."  That had been a motivating force -- Greg's 16-year-old had wanted to play football and join ROTC, but his parents worried about what would happen if he got injured and didn't have health insurance.

Martinsville has the state's highest unemployment rate, at over 20 percent. With many more companies downsizing or shutting their doors, Ann keeps sticking her toes in where she has to -- Stanley Furniture, Stuart Flooring, CP Films, even Food Lion.  She has been invited by the local Virginia Employment Commission to be a part of the "rapid response team" that visits firms laying off workers to give them swift access to information about applying for available benefits.  As Ann points out, the VEC visit may be her first, but it's rarely her last.  It may take awhile to reassure parents that Medicaid and CHIP aren't "handouts" -- they were designed to help people get through tough times like these. 

Greg Secrest is now a full-time community college student with his eye on a business degree.  His wife, Rileen, found a part-time job keeping the books for a biodiesel company.  CHIP coverage has helped enormously.  During the year, a football injury sent one son to the doctor.  Sinus medicine for the other would have set the family back $50 or $60 if it hadn't been for insurance.  The Secrests have renewed CHIP coverage for their boys, although they needed Ann once again to troubleshoot when the paperwork they submitted got lost. 

To build on last year's progress, on CHIPRA's anniversary, Secretary Sebelius issued a new challenge: Cover the remaining 5 million uninsured children who are eligible for Medicaid and CHIP in the next five years.  To do that, we'll need many more Ann Walkers, with their unrelenting spirit and willingness to stick their toes in lots of doors -- but they're going to need more help from us as well.  We need to redouble our efforts to reduce the paperwork barriers that keep eligible children from getting and keeping coverage.  We need to acknowledge, as Secretary Sebelius did, that Recovery Act funds have been instrumental in bolstering state finances and protecting Medicaid from cuts.  Convincing Congress to renew that support is absolutely critical.  

Finally, we can't forget that it's not just children who need coverage. Greg Secrest didn't mince words when he said, "We as a country need good health reform."  Despite his family's trials, Greg remains an optimist.  "There's a light at the end of the tunnel; we just have to go a little further to see it. It will get better.  I want my kids to know that." 

As we ended our phone call, Greg said he especially wanted to thank everyone who worked for health coverage.  I just want to thank Ann and Greg for sharing their stories of perseverance with all of us.  

The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

(Editor's Note:  Ann Walker is pictured above helping families access affordable health coverage for their children.  She is one of the many hard-working outreach workers helping families secure coverage for their uninsured children.)   

 

While there hasn't been much good news coming out of Washington lately on the health care front, the President's newly released FY 2011 budget offers some positive developments.

Most notably, the budget proposes $25.5 billion to extend the temporary FMAP increase for another six months, through June 2011. The FMAP increase and its accompanying maintenance of effort provision, which was included in last year's stimulus bill (ARRA), has been an incredibly important way to help states maintain their Medicaid programs during an economic downturn. Set to expire at the end of the calendar year (which is right in the middle of states' fiscal year), the Administration's proposed extension would provide critical relief to cash-strapped states. Since the budget extends the recovery act provision, states would still need to maintain Medicaid eligibility and enrollment/renewal procedures to receive the increased FMAP.

The budget also assumes savings from health reform, signifying the President's continued commitment to passing a bill. Using the average of the savings estimated under the House and Senate bills, the budget projects roughly $150 billion in savings over 10 years. 

The budget also proposes:

 * Extending, through the end of 2010, the COBRA health insurance premium assistance program established under the recovery act (set to expire at the end of this month).

* Providing an additional $290 million for community health care centers, $110 million for continuing investments in health IT, and an increase of $250 million for Medicare, Medicaid, and CHIP fraud and abuse initiatives.

* Allocating funding to strengthen rural health care, expand Indian health services, increase wellness and prevention activities, and conduct research on the comparative effectiveness of medical options.

* Establishing Medicaid and Medicare demonstration projects to coordinate care and lower costs for seniors and those with chronic conditions.

Also of note is a 229% increase in state Medicaid performance bonus payments. This change reflects the Administration's expectation that states will continue to enroll more children in Medicaid, resulting in an increase from $73 million in FY 2010 to $240 million in FY 2011 in payments made to states.

The President proposed a couple of measures that could impact programs for low-income families moving forward. This includes a 3-year non-security discretionary spending freeze (although Medicaid, CHIP, and most health programs were excluded) and the creation of a bi-partisan fiscal committee, which is charged with, among other things, addressing the growth of entitlement spending.

Expect to hear more from us in the coming months as Congress begins its work to have a final budget signed by the President by October 1.

Each celebration of a new year brings a renewed sense of optimism and 2010 offers tremendous promise in mitigating the chilling impact of the citizenship documentation requirement imposed by the 2005 Deficit Reduction Act (DRA) on Medicaid. The citizenship documentation requirement not only made it more difficult for eligible citizens to enroll in Medicaid but states have also spent millions of dollars in administrative costs to comply with the regulation. The title of a study by the Government Accountability Office says it well: "States Reported that Citizenship Documentation Requirement Resulted in Enrollment Declines for Eligible Citizens and Posed Administrative Burdens." 

It is indeed fitting - with the holidays focused on children and giving -  that HHS Secretary Kathleen Sebelius awarded more than $72 million in bonus payments last week to nine states for their success in enrolling low-income children in Medicaid. Like little kids during the holidays, we have awaited the announcement of these performance bonuses with excitement and gleeful anticipation. Drum roll, please.....Alaska, Illinois, Louisiana, Michigan, New Jersey, New Mexico, Oregon and Washington earned bonuses ranging from $1.5 to $9.1 million but Alabama is the big winner earning more than half ($39 million) of the total award.

The performance bonus  is one of the new tools and options created through the Children's Health Insurance Reauthorization Act  (CHIPRA). It give states a financial incentive to meet specific Medicaid enrollment targets if they also adopt at least 5 of 8 enrollment and retention simplification strategies such as 12-month continuous eligibility and streamlined administrative renewals.  

States qualifying for the bonus receive payments equal to 15% of the annual cost of Medicaid services for the number of children enrolled above the target enrollment. To meet the target, a state's average monthly Medicaid enrollment for children in federal fiscal year 2009 (FFY 09) had to be approximately 8% above the average enrollment in FFY 07 with adjustments for any change (positive or negative) in the child population.

The significantly larger award was granted to Alabama because it was the only state to qualify for the higher "tier 2" bonus level. A state qualifies for the tier 2 bonus if the average number of enrollees exceeds the base (tier 1) enrollment target by 10%. At the tier 2 level, states receive a bonus equal to a joyful 62.5% of their share of Medicaid costs for the average number of children enrolled above the tier 2 target. For Alabama, this reduces the state's share of Medicaid for children enrolled above the tier 2 target to less than 9%.

In announcing the awards, the Center for Medicaid and State Operations within CMS issued a State Official Letter (SHO) explaining the performance bonus calculations and describing the eight enrollment and retention strategies. This was the tenth in a series of SHO letters, which provide guidance to the states in implementing the provisions of CHIPRA. The public announcement of the bonuses also coincided with the re-launch of "Insure Kids Now" as a more robust website focused on Medicaid and CHIP including state specific program information.

We send our congratulations to the State Medicaid and CHIP agencies in the nine performance bonus states for a job well done and our wishes to all for a holiday season filled with warmth and laughter.

I was thrilled to see two very capable public servants, Vikki Wachino and Barb Coulter Edwards, agree to return to public service as part of the Center for Medicaid and State Operations team. Both were appointed to their positions earlier this week by CMSO Director Cindy Mann.

Vikki will serve as the Director of the Family and Children's Health Programs Group, which oversees the children and family aspects of the Medicaid program as well as CHIP.  She is a nationally recognized expert on health coverage issues with particular expertise in Medicaid and Children's Health Insurance Program (CHIP) policy.  Vikki served as the lead consultant on CCF's Strengthening Medicaid project where we worked together on, among other things, a series of issue briefs designed to identify constructive ways to improve the Medicaid program. Her in depth knowledge, commitment to beneficiaries, and dedication to her work will be extraordinary assets to CMS as it continues to implement CHIPRA, works to strengthen the EPSDT benefit for kids in Medicaid, and, should something pass, plays a key role in implementing health insurance reform changes.

Barb will serve as the Director of the Disabled and Elderly Health Programs Group.  Barb is the former Ohio State Medicaid Director and is also a nationally recognized expert in Medicaid policy, including managed care, cost containment, long-term care, and State and federal health care reform. Barb also spent six months as the Interim Director of the National Association of State Medicaid Directors.  In the small world category, Barb actually co-authored a paper with Vikki for our Strengthening Medicaid series program management in Medicaid so the two of them will be ready to hit the ground running as a team!! 

Vikki and Barb will be invaluable to CMSO as it faces the many challenges and opportunities that lie ahead.  We applaud their return to public service and look forward to working with them.

As we all follow the twists and turns of health care reform in Congress, it's easy to forget that the critical children's health legislation that's already been passed this year--CHIPRA--is well on its way to being implemented.  CMS Medicaid and State Operations Director Cindy Mann (CCF's former fearless leader) took the time this week to update child health advocates on recent CMS actions and guidance on CHIPRA.  She highlighted that $10 million in outreach grants to tribal groups will soon be distributed.  She also passed on news that new guidance will soon be released on a variety of topics and was able to share several updates on issues raised by the new law:

• On dental coverage for kids:
• Dental provider lists are now available for each state at www.insurekidsnow.gov, but it sounds like there will be efforts to improve the quality and accessibility of these lists in the months ahead.  
• No state has submitted a plan amendment to alter its dental coverage in response to CHIPRA, but CMS has been talking individually to states. CMS also clarified that states won't be deemed out of compliance with the new dental benefits until it has officially promulgated regulations.
• The children of state employees can't be eligible for a CHIP-financed dental wrap-around, just as they are not eligible for CHIP itself.
• On the new option to drop the 5-year waiting period for lawfully residing immigrant kids and pregnant women in Medicaid and CHIP:
• The new option applies to children and pregnant women "lawfully residing" in the U.S., which is a broader category than the "qualified aliens" which the 5-year waiting period referenced. CMS is working with other agencies to develop an accurate definition.
• Eighteen states have plan amendments pending to exercise the new option; one state has been approved to date.  (Most of these states already use their own money to cover lawfully residing immigrant kids and pregnant women during the 5-year waiting period, but might have rolled back in the absence of the new federal help.)
• No "skipping" over Medicaid - states can't decide to cover lawfully residing immigrant kids and pregnant women in CHIP, but continue to impose the 5-year bar in Medicaid. 
• If a state does lift the 5-year bar in Medicaid, the good news is that it can secure the enhanced CHIP matching rate for the cost of covering these kids in Medicaid through the end of the 5-year period.
  
• On citizenship documentation
• CMS is moving quickly to test Social Security Number matching with the Social Security Administration and expects to have a matching system ready by January 1 for states that choose to use this option to document applicants' citizenship.
• On performance bonuses
• CMS is currently evaluating 18 states' applications for performance bonus funds; states may continue to apply.  The awards are expected to be announced by mid-December.
  

An enthusiastic crowd of more than 500 gathered in Chicago last week for the National Children's Health Insurance Summit hosted by the Centers for Medicaid and Medicare (CMS). Attendees included CHIPRA outreach grantees, individuals from community-based and provider organizations, national and state experts, and officials from federal and state government. The purpose of the event was to reinvigorate outreach efforts and share best enrollment and retention practices in Medicaid and CHIP.

HHS Secretary Kathleen Sebelius and CMS Medicaid Director Cindy Mann kicked off the event by articulating the Administration's commitment to covering children and challenging attendees to find and enroll the estimated 5 million of the 8 million uninsured children who are eligible but not enrolled Medicaid and CHIP.

CMS released the latest in a series of state health official letters providing guidance on CHIPRA implementation. This seventh letter focuses on the new mandatory dental provisions for separate CHIP programs, as well as the option these states have to provide a stand-alone dental plan to children who are insured or underinsured but would otherwise qualify for CHIP. Both provisions are effective October 1, 2009. These provisions do not impact states that provide CHIP coverage through a Medicaid expansion program.

The addition of dental standards is considered one of the victories in CHIPRA since receiving dental care is without a doubt critical to the healthy development of children. With tooth decay as the most prevalent childhood infectious disease, the omission of mandated dental coverage in CHIP has been a significant oversight.

Although all states provided some level of dental services in CHIP there were often service or dollar limitations. Now states must provide "coverage of dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions." States have two options for providing this coverage:

• States can translate this requirement into a defined set of benefits that includes medically necessary services within specific categories. This may prove a bit tricky as the burden is on states to demonstrate that their package meets the intent of the statute.

• Alternatively, states can provide benefits equal to one of three benchmark plans: either the dental coverage in the most popular federal or state employee plan, or the state commercial plan with the highest non-Medicaid enrollment. Note that there is no option for proving actuarial equivalence (as there is for CHIP medical benefits).
  

Regardless of the option chosen, the cost-sharing requirements must meet CHIP rules. States cannot impose cost-sharing for preventive and diagnostic services and the cost-sharing for both medical and dental services can be no more than 5% of family income.  

States also now have the option to provide a stand-alone dental plan for children who are income-eligible for CHIP but who have private medical coverage that has limited or no dental benefits. States that elect to offer this coverage must offer the same (and not more favorable) dental benefit plan as is provided to CHIP enrollees. For children with some dental coverage, this plan can serve as a "wrap," filling in gaps as a secondary payer to their private coverage. In order to offer a stand-alone plan, states must not maintain a waiting list or set a numerical limitation on the number of children enrolled in CHIP. In addition, the 5% cost-sharing cap on total medical and dental services also applies, which may represent a challenge since the state may not have access to information about a family's cost-sharing in their private insurance. As such, this may present a sizeable administrative barrier.

Despite the recent guidance, some questions remain. For example, must cost-sharing above any aggregate or maximum cap on benefits (as are common in commercial plans) be counted toward the 5% maximum cost-sharing? While the provisions are effective October 1, 2009, are states with pre-existing managed care plans required to modify their current contracts to come into compliance immediately or at contract renewal? As is common with federal policy, we continue to peel back the multiple layers of intepretation in search of definitive answers states need to fulfill the promise of CHIPRA.