SCHIP's Impact on Access and Quality: Findings from Karen VanLandeghem, Consultant, CHIRI™ Cindy...

SCHIP's Impact on Access and Quality: SCHIP's Impact on Access and Quality: Findings fromFindings from

Karen VanLandeghem, Consultant, CHIRI™

Cindy Brach, Agency for Healthcare Research and Quality

The Child Health Insurance The Child Health Insurance Research Initiative (CHIRI™)Research Initiative (CHIRI™)

9 studies of public child health insurance 9 studies of public child health insurance programs and health care delivery systems, programs and health care delivery systems, funded by AHRQ, the David and Lucile Packard funded by AHRQ, the David and Lucile Packard Foundation, and HRSA.Foundation, and HRSA.

Emphasis on vulnerable children, e.g., minority Emphasis on vulnerable children, e.g., minority children and children with special health care children and children with special health care needs.needs.

Role of policymakers: provide input into research Role of policymakers: provide input into research and products, disseminate products, implement and products, disseminate products, implement findings.findings.

Presentation OverviewPresentation Overview

CHIRI™ MethodsCHIRI™ Methods Who’s Enrolled in SCHIP: AL, FL, IN, KS, NYWho’s Enrolled in SCHIP: AL, FL, IN, KS, NY Implications of Enrollment FindingsImplications of Enrollment Findings Impact of SCHIP: FL, KS, NYImpact of SCHIP: FL, KS, NY Impact ConclusionsImpact Conclusions Areas for ImprovementAreas for Improvement CHIRICHIRI™™ Products Products AHRQ Findings on “What SCHIP Really AHRQ Findings on “What SCHIP Really

Costs”Costs”

MethodsMethods

Telephone surveys of new SCHIP enrolleesTelephone surveys of new SCHIP enrollees Longitudinal impact analysisLongitudinal impact analysis

– Shortly after enrollment to assess access and Shortly after enrollment to assess access and quality of care 12 months before SCHIP quality of care 12 months before SCHIP enrollmentenrollment

– 12 months later to assess access and quality of 12 months later to assess access and quality of care after 12 months of SCHIP enrollmentcare after 12 months of SCHIP enrollment

– In comparisons of sub-populations regression In comparisons of sub-populations regression techniques to control for other factors were usedtechniques to control for other factors were used

Who’s Enrolled in SCHIP?Who’s Enrolled in SCHIP?

Most Enrollees from Families with Most Enrollees from Families with Income Income ≤ ≤ 150% of FPL150% of FPL

*Adolescents Only

About One Third of SCHIP Enrollees About One Third of SCHIP Enrollees Are Are Adolescents Adolescents

28.529.934.2

38.6

0

10

20

30

40

50

AL IN* KS NY

Perc

ent

* CSHCN Only

A Significant Proportion of SCHIP A Significant Proportion of SCHIP Enrollees Were Black and HispanicEnrollees Were Black and Hispanic

*Adolescents Only CSHCN Only

- Hispanic

- Other- Black, Non-Hispanic

†

†

More CSHCN in SCHIP Than More CSHCN in SCHIP Than General PopulationGeneral Population

*Adolescents Only

- CSHCN in general population (Source: NCHS)

- CSHCN in SCHIP population

Implications of Enrollment FindingsImplications of Enrollment Findings

The unique needs of adolescents, minority The unique needs of adolescents, minority children, and CSHCN should be considered children, and CSHCN should be considered in health care services design and delivery, in health care services design and delivery, e.g., e.g.,

– Reproductive services and confidentialityReproductive services and confidentiality

– Language services and cultural competenceLanguage services and cultural competence

– Breadth of services for complicated conditionsBreadth of services for complicated conditions

What is SCHIP’s Impact?What is SCHIP’s Impact?

SCHIP Increased Percent of Children SCHIP Increased Percent of Children with a Regular Source of Carewith a Regular Source of Care

50

60

70

80

90

100

Before After Before After Before After Before After

% o

f ch

ild

ren

Florida

p=.00 p=.00 p=.00p=.44

Kansas New YorkNew York

AdolescentsAll Children

Adjusted estimates; p-values represent differencebefore vs. after within each state

Unmet Needs Decreases Under Unmet Needs Decreases Under SCHIP, But Still SubstantialSCHIP, But Still Substantial

0

10

20

30

40

50


% o

f ch

ild

ren

Florida

p=.00 p=.12 p=.00p=.00




SCHIP Increased Percent of Children with SCHIP Increased Percent of Children with Preventive Visit, But 20-30% Still Don’t Get VisitPreventive Visit, But 20-30% Still Don’t Get Visit

50

60

70

80

90

100


% o

f ch

ild

ren

Florida

p=.02 p=.00 p=.09p=.06




Families More Satisfied with Families More Satisfied with Health Care Under SCHIPHealth Care Under SCHIP

5

6

7

8

9

10


Rat

ing

of

Car

e

Florida

p=.00 p=.00 p=.00p=.07




Most Black and Hispanic Children Most Black and Hispanic Children Share in SCHIP USC GainsShare in SCHIP USC Gains

Adjusted estimates

50

60

70

80

90

100


% o

f c

hild

ren

FloridaKansas New YorkNew York


BlackWhite Hispanic

SCHIP Increases Percentage Black Children SCHIP Increases Percentage Black Children with Preventive Visit, But Not Hispanic Childrenwith Preventive Visit, But Not Hispanic Children

Adjusted estimates

40

50

60

70

80

90

100


% o

f c

hild

ren



BlackWhite Hispanic

SCHIP Improved Rating of Health Care SCHIP Improved Rating of Health Care for Both CSHCN and Other Childrenfor Both CSHCN and Other Children

Adjusted estimates

5

5.5

6

6.5

7

7.5

8

8.5

9

9.5


Ra

tin

g



CSHCNNot CSHCN

SCHIP Reduces Percent of Children with SCHIP Reduces Percent of Children with Unmet Needs, But Almost 1/3 CSHCN Unmet Needs, But Almost 1/3 CSHCN

Had Unmet Needs After SCHIPHad Unmet Needs After SCHIP

Adjusted estimates

0

10

20

30

40

50

60


% o

f c

hild

ren



CSHCNNot CSHCN

SCHIP Eliminates Preventive Visit Disparities SCHIP Eliminates Preventive Visit Disparities Between Long-Term Uninsured and OthersBetween Long-Term Uninsured and Others

0

10

20

30

40

50

60

70

80

90

100


% o

f c

hild

ren



Insured atLeast Part-Year

UninsuredAll Year

SCHIP Increases Satisfaction for Both SCHIP Increases Satisfaction for Both Long-Term Uninsured and OthersLong-Term Uninsured and Others

7

7.5

8

8.5

9

9.5

10


Ra

tin

g



Insured atLeast Part-Year

UninsuredAll Year

NY SCHIP Reduces Unmet Need for Dental NY SCHIP Reduces Unmet Need for Dental Care; Overall Need for Dental Care RemainsCare; Overall Need for Dental Care Remains

010203040506070

Dental Care Need Unmet Need if HadNeed

Unmet Need AllKids

% c

hildr

en BeforeAfter

NY SCHIP Improves Quality of Care NY SCHIP Improves Quality of Care for Children with Asthmafor Children with Asthma

9

3

16

42 2

02468

101214161820

To USC To ED Medications

Before

After

Percent with Problems Getting Care or Meds if Asthma Attack Before and After Enrollment in New York SCHIP

p<.05

%

Yes

Some Measures of Quality Remain Suboptimal Some Measures of Quality Remain Suboptimal after SCHIP Enrollment*after SCHIP Enrollment*

8

24

58

2

38

69

0102030405060708090

100

Asthma Tune-upVisit

Preventive Med Action Plan

Before

After

Percent of Children with Moderate/Severe Asthma Who Had:

%

p = NS *Before and 1 Year After Enrollment in New York SCHIP

SCHIP Impact ConclusionsSCHIP Impact Conclusions

SCHIP improves access to and satisfaction SCHIP improves access to and satisfaction with care. with care.

““All boats rise with the tide” – SCHIP All boats rise with the tide” – SCHIP improvements are shared by members of improvements are shared by members of vulnerable populations, including vulnerable populations, including adolescents.adolescents.

SCHIP levels the playing field of the long-SCHIP levels the playing field of the long-term uninsured.term uninsured.

Targeting Areas for ImprovementTargeting Areas for Improvement Consider strategies to address remaining unmet needs of enrollees, Consider strategies to address remaining unmet needs of enrollees,

especially those with special health care needs.especially those with special health care needs.

– Conduct needs assessments, identifying CSHCN and ASHCN, and Conduct needs assessments, identifying CSHCN and ASHCN, and monitor.monitor.

– Risk-adjust capitation rates.Risk-adjust capitation rates.

– Collaborate with Title V MCH programs, primary care providers, and Collaborate with Title V MCH programs, primary care providers, and educational agencies.educational agencies.

Ensure SCHIP enrollees’ access to dental care benefit.Ensure SCHIP enrollees’ access to dental care benefit.

Address areas where suboptimal quality remains in spite of SCHIP (e.g., Address areas where suboptimal quality remains in spite of SCHIP (e.g., Tune-up visits and preventive meds for enrollees with severe asthma).Tune-up visits and preventive meds for enrollees with severe asthma).

Collect data to assess SCHIP’s effectiveness in providing quality health Collect data to assess SCHIP’s effectiveness in providing quality health care to diverse populations.care to diverse populations.

Targeting Areas for Targeting Areas for Improvement (continued)Improvement (continued)

Implement strategies to increase the proportion of Implement strategies to increase the proportion of children that receives a preventive visit.children that receives a preventive visit.

– Educate parents.Educate parents.

– Provide incentives to providers.Provide incentives to providers.

– Assess adequacy of health plans’ pediatric and family Assess adequacy of health plans’ pediatric and family physician network.physician network.

– Collaborate with public health, primary care providers, Collaborate with public health, primary care providers, and others to promote preventive care use.and others to promote preventive care use.

What Role Does SCHIP Play in the What Role Does SCHIP Play in the Patchwork Insurance System for Patchwork Insurance System for

Children?Children?

ConclusionsConclusions

Children who disenrolled around active Children who disenrolled around active recertification (NY and KS) were much more likely recertification (NY and KS) were much more likely to become uninsured.to become uninsured.

Pre-SCHIP insurance is a predictor of post-SCHIP Pre-SCHIP insurance is a predictor of post-SCHIP insurance.insurance.

CSHCN could be at greater risk of losing CSHCN could be at greater risk of losing insurance.insurance.

Disenroll more quickly (especially around recertification).Disenroll more quickly (especially around recertification). More likely to become uninsured after SCHIP. More likely to become uninsured after SCHIP.

ConclusionsConclusions

Little evidence that unmet needs affect Little evidence that unmet needs affect enrollment and disenrollment decisions.enrollment and disenrollment decisions.

Some evidence that health care use prior to Some evidence that health care use prior to enrollment predicts insurance status following enrollment predicts insurance status following SCHIP disenrollment. SCHIP disenrollment.

Examples of Examples of CHIRICHIRI™™ Products Products

““Who’s Enrolled In SCHIP?” – CHIRIWho’s Enrolled In SCHIP?” – CHIRI™™ Issue Brief Issue Brief and and PediatricsPediatrics articles articles

““Improved Access and Quality of Care After Improved Access and Quality of Care After Enrollment in the New York State Children’s Health Enrollment in the New York State Children’s Health Insurance Program (SCHIP)” Insurance Program (SCHIP)” PediatricsPediatrics May May electronic issueelectronic issue

www.ahrq.gov/chiri/www.ahrq.gov/chiri/– SCHIP impact on Medicaid physician participation and SCHIP impact on Medicaid physician participation and

supplysupply– Medicaid dental accessMedicaid dental access– Consequences of States’ policies on disenrollmentConsequences of States’ policies on disenrollment

Using CHIRI findings? Please give us feedback at: Using CHIRI findings? Please give us feedback at: [email protected] [email protected]

http://www.ahrq.gov/chiri/

What Does SCHIP Really Cost?What Does SCHIP Really Cost?

What is the Net Cost of SCHIP?What is the Net Cost of SCHIP?

The net cost of SCHIP may be only 1/3 of budgeted costs when considering The net cost of SCHIP may be only 1/3 of budgeted costs when considering certain factors.certain factors.

Two primary factors in determining states’ net costs: Two primary factors in determining states’ net costs: – Costs associated with spend-down to Medicaid for medically-needy in the Costs associated with spend-down to Medicaid for medically-needy in the

absence of SCHIP.absence of SCHIP.– Costs associated with uncompensated care in the absence of SCHIP.Costs associated with uncompensated care in the absence of SCHIP.

Bottom-line: SCHIP costs states and feds significantly less than total Bottom-line: SCHIP costs states and feds significantly less than total budgetary cost.budgetary cost.

StateState FedFed TotalTotal

Budgetary CostBudgetary Cost $282$282 $596$596 $878$878

Simulated Net CostSimulated Net Cost $ 97$ 97 $401$401 $498$498

Selden and Hudson (2004) – Simulations of net costs using MEPS (2000)

For more information on For more information on SCHIP Net CostsSCHIP Net Costs

Contact:Contact:Thomas Selden, Senior Economist, Thomas Selden, Senior Economist,

Center for Cost and Financing Studies, Center for Cost and Financing Studies, Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality

[email protected]@ahrq.gov

mailto:[email protected]

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