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AHRQ National Advisory Council on Healthcare Research and Quality Subcommittee on Children’s Healthcare Quality Measures for Medicaid and CHIP Progress Report to AHRQ National Advisory Council, July 24, 2009

Jeffrey Schiff, MD, MBA, Co-Chair

Rita Mangione-Smith, MD, MPH, Co-Chair

Potential Impact of Core Measures Identification Work: 45% of America’s Children under Age 19

Sources: AHRQ, based on: Coverage estimates: Based on 2008 national participant and spending data derived from CMS and U.S. Census Current Population Survey data sources, reported by the National Center on Children in Poverty, http://www.nccp.org/profiles/index_32.html. CHIP estimates are for number of children in separate SCHIP programs. Medicaid estimates include children in Medicaid SCHIP programs. Coverage estimates reflect Medicaid and CHIP enrollees whether or not they received health care services. Total number of children under 19 interpolated from U.S. Census Bureau figures for number of children 17 and under (73.9 million) and children 19 and under (83 million).

Privately insured, 31.8 million,

41% of population

Uninsured, 11 million,

14% of population

CHIP, 5.3 million, 7% of population

Medicaid, 29.9 million,

38% of population

Medicaid

CHIP

Uninsured

Privately insured

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Public Law 111-3 Title IV- Strengthening Quality of Care and Health Outcomes Section 401 Child Health Quality

Improvement Activities for Children Enrolled in Medicaid or CHIP

Section 1139A Child Health Quality Measures By January 1, 2010, the Secretary shall identify

and publish for general comment an initial, recommended core set of child health quality measures for use by ….

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Public Law 111-3 Title IV (continued)Initial core set that includes (but is not limited to):

1. Presence and duration of health insurance

2. Availability and effectiveness of Preventive services Services for acute conditions Services to promote healthy birth, prevent and treat

premature birth, detect the presence or risk of conditions that could adversely affect growth and development

Treatments to correct and ameliorate the effects of chronic physical and mental conditions

(continued)

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Public Law 111-3 Title IV (continued)Initial core set (continued)

3. Availability of care Ambulatory Inpatient

4.Taken together – Used to estimate the overall national quality of health care for children

Including children with special health care needs and comparing disparate populations

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Public Law 111-3 (continued)

1. Encourage voluntary and standardized reporting

2. Particular attention to techniques that Ensure the timeliness and accuracy of provider reporting Encourage provider compliance Encourage successful quality improvement strategies, and Improve efficiency in data collection using HIT

3. Valid, reliable, and evidence-based

4. Allow families and health care providers to understand the quality of care

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Subcommittee on Children’s Healthcare Quality Measures for Medicaid and CHIP ProgramsMembership includes Two NAC members CHIP director Title V director Two Medicaid Medical Directors Organizational members

American Academy of Pediatrics, American Board of Pediatrics, American Academy of Family Physicians, March of Dimes, National Academy for State Health Policy, National Association of Children’s Hospitals and Related Institutions, National Association of State Medicaid Directors, National Association of Pediatric Nurse Practitioners

Individuals with expertise in dental care, mental health and chemical dependency, community health centers, children with special health needs, disparities, quality measurement

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Goals of the First Meeting

Reach consensus on the scope of the core measurement set

Reach consensus on definitions for evaluation criteria: Validity Feasibility Importance

Identify a preliminary core set of quality measures that meet these criteria

Establish the group process for arriving at the final recommended core set of quality measures by September 30, 2009

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Conceptual Framework – Guiding Determination of the Scope for Core Measurement Set Grounded → Intermediate → Aspirational Measures Measures Measures

Lean towards recommending more grounded measures Grounded:10-25, currently feasible, many already in place Intermediate category: number to be determined, good

specifications, some States already using them Aspirational: needed measures to fill in the gaps

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Scope for Core Measurement Set1. Must be realistic about staffing/funding needs for

pulling/analyzing/reporting available data

2. Comprehensive effort to find good measures for all service categories, duration of enrollment, and other aspects of care required by the legislation; however, if no good measures currently exist for a given aspect of care, a measure will not be recommended for the core set

3. Include measures not currently used by Medicaid/CHIP e.g. State and national measurement efforts

4. Choose measures that are actionable There should be clear steps a State can take to improve on

performance – the measure should inform what these steps need to be

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Consensus on Criteria Definitions Validity

Measures must be supported by scientific evidence or, where evidence is insufficient, by expert consensus

Measures must support a link between: Structure and outcomes of care Structure and processes of care Processes and outcomes of care

The measure must represent an aspect of care that is under the control of health care providers and systems

The measure should truly assess what it purports to measure

Measures supported by evidence from unpublished data should be considered for inclusion

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Consensus on Criteria Definitions Feasibility

The data necessary to score the measure must be available to State Medicaid and CHIP programs Administrative data, medical records data, survey

data

Detailed specifications must be available for the measure that allow for reliable and unbiased scoring of the measure across States and institutions

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Consensus on Criteria Definitions Importance

The measure should be actionable Cost of the condition to the Nation should be substantial Health care systems are clearly accountable for the quality

problem assessed by the measure The extent of the quality problem should be substantial There should be documented variation in performance on

the measure The measure should be representative of a class of quality

problems: “sentinel measure” of quality of care provided for preventive care, mental health care, or dental care, etc.

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Consensus on Criteria Definitions Importance

The measure assesses an aspect of health care where there are known disparities

The core set should represent a balanced portfolio of measures and be consistent with the intent of the legislation

Improving on performance for the core set of measures should have the potential to transform care for our Nation’s children

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Consensus on Criteria Definitions Transparency

For all measures recommended for inclusion in the core set: The level of scientific evidence supporting the measure

will be reported Example: U.S. Preventive Services Task Force grades A,

B, C, or I; Level I, II, III The level of expected burden for obtaining the data

needed to score the measure will be reported Low, moderate, high

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Pre-Work Process Completed by Sub-Committee Members Delphi process to assess validity and

feasibility of measures in use by State Medicaid and CHIP programs Round 1 completed prior to meeting Measures scored on a 9-point scale

7-9 – Measure is definitely valid and feasible 4-6 – Measure has uncertain validity and feasibility 1-3 – Measure is not valid or feasible

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Meeting July 22, 2009: Discussion of Delphi Round 1 Results Controversial measures

Validity or feasibility ratings with substantial disagreement among subcommittee members were discussed

Round 2 Delphi process for these controversial measures after meeting deliberations

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Meeting July 23, 2009: Assessing Measure Importance Evaluated importance for measures with passing validity and

feasibility in Round 1 Validity score of 7-9 Feasibility score of 4-6

Delphi process to assess importance 9-point scale

7-9: Measure of clear importance 4-6: Level of importance uncertain 1-3: Measure does not meet importance criteria

Measures with an importance score of 4 or higher on the 9-point Delphi scale were retained in the preliminary set of core measures

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Measures Having Passing Scores for Validity, Feasibility, and Importance Preventive Care Measures

Frequency of ongoing prenatal care Smoking cessation and prevention Chlamydia screening Immunizations for 2-year olds Adolescent immunization Influenza vaccination Well child care visit (WCV) rates - first 15 months WCV Rates- 3, 4, 5, 6-year olds Adolescent WCV - overall Hearing screening Vision screening

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Measures having passing scores for Validity, Feasibility, and Importance Dental Care Measures

Comprehensive periodic oral health exams Annual dental visit

Acute Care Measures Upper respiratory infection- Appropriate treatment Pharyngitis- Appropriate testing

Chronic Care Measures Asthma- Appropriate medications for people with

asthma

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Measures Having Passing Scores for Validity, Feasibility, and Importance Mental Health Care Measures

Attention-Deficit/Hyperactivity Disorder (ADHD) care - Initiation phase ADHD Care - Continuation and maintenance phase Followup after hospitalization for mental illness Depression management

Family Experiences with Care Measures Healthcare Effectiveness Data and Information Set (HEDIS), Consumer

Assessment of Healthcare Providers and Systems (CAHPS) For healthy children For children with special health care needs

Access and Utilization Measures Access to primary care practitioners, by age and total Utilization of ambulatory services

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Additional Measures in Use Proposed During Meeting Identify evidence supporting measure Identify who is currently using the measure Obtain specifications for the measure Delphi process for new measures to assess

Validity Feasibility Importance

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Selection of Measures Recommended for Inclusion in the Final Core Set September 2009 meeting:

Further discuss and rate importance for preliminary core set and new measures identified as valid and feasible

Arrive at the most parsimonious set of measures that when assessed together will provide valid estimates of the overall national quality of health care for children insured by Medicaid and CHIP

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Our View of the Opportunity Presented by the Legislation

Long-term focus on health care quality for children beyond CHIP

Opportunity to bring together efforts of disparate organizations/parts of government to create focus and move the child health quality agenda forward

Need support from the NAC to build the bridge toward our aspirational long-term vision of being able to rigorously and comprehensively assess and improve on health care quality for the Nation’s children