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By Judith S. Palfrey, MD, FAAP

President, American Academy of Pediatrics

On Wednesday, I was honored to attend an event in DC unveiling the US Department of Health and Human Services' (HHS) Interim Final Rule on preventive services under health reform. To so many of us in the business of taking care of children, the achievement of passing the law last March was a time of historic celebration, and now, as one of the most significant pieces of the law takes shape, we realize just how much better off our children will be under health reform.

One of the earliest provisions of the Patient Protection and Affordable Care Act to take effect is Section 2713, which requires health plans to cover, at absolutely no out-of-pocket cost to families, preventive care services outlined in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Supported by the Health Resources and Services Administration, Bright Futures is the definitive standard of pediatric well-child and preventive care developed by an evidence-informed, active collaboration led by the American Academy of Pediatrics (AAP).

Perhaps the best-known aspect of Bright Futures is the schedule of "well-baby and well-child visits" it establishes--31 visits between birth and age 21 years (to pediatricians and other clinicians, it is also known as the "periodicity schedule"). The interim rule clearly states that all components of pediatric well-child visits--including physical exams, immunizations, hearing and vision screening, developmental and behavioral screening, and anticipatory guidance--in accordance with the Bright Futures periodicity schedule must be free of financial barriers, including co-pays and deductibles. Insurers may not exclude any of these services from coverage, and cost-sharing cannot be imposed on families.

This landmark investment in preventive services will eventually allow all families, regardless of income, the opportunity to visit their pediatrician regularly during their children's most critical years of development. Having coverage for the clinically appropriate well-child visits will allow pediatricians to identify and treat health problems in children before they start. This, in turn, should help bring down the prevalence of chronic conditions that place significant financial and physical strain on children and families.

The Academy will continue to work with HHS on the development of a Final Rule, and in the process, will continue to advocate for the following: all plans--including those retaining "grandfather status"--to cover Bright Futures services; Bright Futures to be appropriately integrated into other initiatives and standards, such as meaningful use and quality measures; and for insurance companies to eliminate cost-sharing while making up those dollars for pediatricians and other health care providers.

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

Editor's Note:  CCF's Dawn Horner also blogged about the preventive health services rule. 

The National Academy of State Health Policy (NASHP) is an independent academy of state health policymakers working together to identify emerging issues, develop policy solutions, and improve state health policy and practice. Recently, its executive committee identified ten aspects of health reform that states must get right in order to successfully implement federal health reform. Like the health reform law, the top ten list covers a broad range of objectives and responsibilities:

1) Be Strategic with Insurance Exchanges

2) Regulate the Commercial Health Insurance Market Effectively

3) Simplify and Integrate Eligibility Systems

4) Expand Provider and Health System Capacity

5) Attend to Benefit Design

6) Focus on the Dually Eligible

7) Use Your Data

8) Pursue Population Health Goals

9) Engage the Public in Policy Development and Implementation

10) Demand Quality and Efficiency from the Health Care System

With the dust settling on the passage of health reform, attention is shifting from the early provisions of the law such as coverage for young adults under their parent's plan and consumer-friendly insurance reforms including eliminating pre-existing exclusions for children, lifetime caps and rescissions of policies. Many states have launched formal or informal groups to begin the planning and decision-making process. According to the National Governors Association (NGA), at least a quarter of the states have formally launched commissions, task forces or advisory groups. The lack of consumer representation on these state structures is a bit disappointing given that engaging the public has been flagged as one of the top ten critical areas.

Two of my favorites among the top ten are simplifying and integrating eligibility systems and using data to analyze and improve your programs. Those of us working on children's coverage know how important these aspects of program administration are to the ultimate success of enrolling all eligible children and families. Both rely on well-designed, high-functioning technology based on simplified processes and streamlined procedures.

The NASHP brief puts it bluntly: "36 million Americans cannot be enrolled in Medicaid or the new exchanges by relying upon what, in most states, is a county-based eligibility platform designed around the cumbersome and intrusive processes of the welfare eligibility system." Touche`!

Effective systems are expensive and time-consuming to build and implement. There is an important role here for the federal government to assist states in system procurement, to standardize data reporting requirements and to require that systems meet data reporting standards as a condition of federal funding. We cannot hope to meet our coverage goals without data to analyze how well our programs are working and identify where improvements are needed. Public reporting of data on enrollment, retention, access to care, health outcomes and much more will be the best way for Americans to know when states are truly getting it right!!

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.