How the CHIPRA quality demonstration elevated children on State health policy agendas
Evaluation Highlight No. 4
Authors: Nicole Cafarella Lallemand, Elizabeth Richardson, Kelly Devers, and Lisa Simpson
The CHIPRA Quality Demonstration Grant Program
In February 2010, the Centers for Medicare & Medicaid Services (CMS) awarded 10 grants, funding 18 States, to improve the quality of health care for children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). Funded by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), the Quality Demonstration Grant Program aims to identify effective, replicable strategies for enhancing quality of health care for children. With funding from CMS, the Agency for Healthcare Research and Quality (AHRQ) is leading the national evaluation of these demonstrations.
The 18 demonstration States are implementing 51 projects in five general categories:
The demonstration began on February 22, 2010 and will conclude on February 21, 2015. The national evaluation of the grant program started on August 8, 2010 and will be completed by September 8, 2015.
This Evaluation Highlight is the fourth in a series that presents descriptive and analytic findings from the national evaluation of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Quality Demonstration Grant Program. Historically, it has been challenging for child health advocates and stakeholders to keep children and adolescents high on States’ policy agendas because of State budget constraints and competing priorities. However, the CHIPRA quality demonstration grants have provided a unique opportunity not only to advance child health quality in the short term, but also to link child health quality issues to broader Federal and State health reforms that increase the likelihood that demonstration grant activities will be amplified, sustained, and spread in the long term. In this Highlight, we give concrete examples of activities in five States—Maine, Maryland, Massachusetts, Vermont, and Oregon—and how they used their CHIPRA quality demonstration grants to elevate children’s health care issues on their States’ health policy agendas. Our analysis is based on work completed by the States during the first 2 years of their 5-year demonstration projects.
The experiences of these five CHIPRA quality demonstration States may be helpful to other States that are trying to focus attention and resources on child and adolescent health issues.
Key messages from these States include:
- States have aligned their efforts with—and used their CHIPRA quality demonstration project experiences to directly inform—broader Federal and State health reform initiatives.
- CHIPRA quality demonstration data can be used to obtain buy-in from policy officials, help raise awareness about pediatric health issues, and elevate considerations about how policies impact this population.
- Ongoing engagement with a range of public and private stakeholders has both elevated child and adolescent health considerations and informed ongoing activities related to health care payment reform and quality measurement and reporting.
In recent years, per capita Medicaid expenditures have grown faster for children than for adults (including the elderly). However, adults still make up a greater share of total Medicaid expenditures; as a result, they tend to attract the most attention for reform initiatives.1, 2 Though Federal- and State-specific health reforms are high on the policy agenda of most States, historically policymakers’ attention has been focused on either adults or specific costly subpopulations, such as the aged and disabled or those who are dually eligible for Medicaid and Medicare.3, 4, 5
The passage of the Affordable Care Act (ACA) has created an unprecedented opportunity to integrate child and adolescent health issues into the broader discussions on health care quality, workforce training, and systems transformation.6 As the most significant Federal investment in child health care quality,7 the CHIPRA quality demonstrations can contribute to some of these efforts to improve health care quality for children.
The purpose of this Highlight is to describe how States participating in the CHIPRA quality demonstration leverage and link the funding, attention, visibility, and knowledge gained through their demonstration projects to better address children’s health care within both existing and upcoming Federal and State reforms. It will draw on the specific examples of five States— Maine, Maryland, Massachusetts, Vermont, and Oregon—to illustrate how their demonstration grants are contributing to: 1) statewide delivery system reform initiatives such as medical homes, 2) health information technology (IT) development, 3) efforts to integrate behavioral and physical health, and 4) quality measurement and improvement efforts.
For this Evaluation Highlight, we draw from in-person, semi-structured interviews conducted in the summer of 2012, brief followup telephone discussions conducted with key demonstration staff in the spring of 2013, and semiannual progress reports that demonstration States submitted to CMS on August 1, 2012 and February 1, 2013.
Participating States employed a range of strategies in their efforts to maximize the impact of their CHIPRA quality demonstration grants, reflecting the variation in existing resources, stakeholder relationships, and the progress of health reform efforts underway in each demonstration State. In addition to highlighting specific State approaches, we describe perceived short-term impacts of these efforts and strategies planned for the remainder of the demonstration that will keep or elevate child health on the State policy agenda and potentially lead to substantial, long-lasting changes.
Aligning CHIPRA Quality Demonstration Grants with Broader Health Reform Initiatives
Some States are linking their demonstration activities to existing statewide reform initiatives, particularly those related to patient-centered medical home (PCMH) implementation (see Figure 1). Oregon, for example, has used insights gained through its CHIPRA quality demonstration to inform the medical home standards used in the State’s Patient-Centered Primary Care Home (PCPCH) program—a statewide medical home initiative established in 2009.8 In the initial stages of the standards development process, most of the focus was on adults and their care needs. Those involved with the CHIPRA quality demonstration project were able to use the information and experiences gained through the demonstration to highlight the importance of making the standards child-relevant. When Oregon began the process of revising its medical home standards, the lessons learned through the CHIPRA quality demonstration grant shaped some of the changes made to the standards. For example, the referral criteria were expanded to incorporate other health and education services that the pediatric population can sometimes require, based on the experiences of the project’s Enhancing Child Health in Oregon (ECHO) Learning Collaborative.9
Figure 1. Alignment with Other Health Reform Initiatives
States are leveraging their CHIPRA quality demonstration experiences to:
Oregon leveraged its CHIPRA quality demonstration experience in negotiations surrounding the development of a statewide program for Coordinated Care Organizations (CCOs), which are community-based networks that contract with the State to provide integrated care for the Medicaid patient population, similar to ACOs.10 For example, the newly formed Oregon Health System Transformation Center, which will support CCOs through technical assistance and learning collaboratives, will sponsor a learning collaborative aimed at connecting child health providers with early education providers. The State’s experience in the CHIPRA quality demonstration informed that planning process.
“Patient-centered medical homes tend to wind up with a very adult chronic illness focus. And with [the CHIPRA] grant, we’ve been able to help make sure that the kids don’t get lost in the focus on adults.”
— Oregon CHIPRA team member, July 2012
In addition, Oregon’s experience with producing quality measure data using the Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP (Child Core Set).11
Some demonstration States also chose to link their efforts to existing health IT initiatives funded through the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act of 2009.12 For example, in addition to expanding its statewide medical home initiative to pediatric practices, Vermont also used CHIPRA quality demonstration funding to broaden its existing webbased clinical registry (known as DocSite) to include pediatric providers. DocSite was also expanded to include some of the Child Core Set of quality measures, as well as other pediatric performance measures selected by a diverse group of stakeholders in the State. Vermont also hired an additional practice facilitator to work exclusively with child-serving practices on a range of issues, including electronic health record (EHR) adoption, achievement of meaningful use, participation in and use of DocSite, and connection to the State’s health information exchange. Although this expansion to pediatrics was already on the State’s agenda, CHIPRA quality demonstration funding accelerated the timeline for implementation and allowed the State to provide additional technical support to participating practices. In addition, its direct support of child-serving practices helped foster provider buy-in to the State’s ongoing reform efforts.
“With the Blueprint for Health, every practice that signs up to become a Blueprint practice or a patient-centered medical home is assigned a facilitator.... We elected to have a specific pediatric facilitator which probably would not have been as high on the agenda without CHIPRA funding. She has made an extreme difference with the pediatric practices.”
— Vermont CHIPRA team members, May 2013
Leveraging CHIPRA Activities to Obtain Buy-in From Policymakers
Obtaining—and sustaining—buy-in from State policymakers is also an important part of ensuring that the work being done under the CHIPRA quality demonstration grant has a meaningful impact on the State’s broader health reform process. Even in cases where policymakers are supportive of project goals, they must weigh these goals against the reality of limited State resources and the demands of multiple, sometimes competing priorities. Demonstration staff have pursued a range of strategies to ensure that child and adolescent health issues remain a priority. One such strategy includes effectively leveraging data and analysis collected through the CHIPRA quality demonstration to support efforts to educate policymakers and other stakeholders. Maryland, for example, is working to improve quality and reduce the costs of care for youth with serious behavioral health issues through the expansion of care management entities. Project team members used data generated through the CHIPRA quality demonstration to support the broader redesign of the State’s mental health crisis response and stabilization system. In May 2013, the CHIPRA Crisis Response and Redesign Workgroup produced a report that used behavioral health claims data to identify gaps in the availability of crisis response tools throughout the State and make recommendations for system redesign. Preliminary highlights from the proposed redesign plans were disseminated during this year’s Children’s Mental Health Policy Day in Annapolis, and the Governor’s supplemental budget (released in April 2013) allocated approximately $3 million to expand the State’s crisis response system for both children and adults.13 The workgroup is continuing its efforts by analyzing emergency department and psychiatric utilization and costs in Maryland.
“With any large system change, there is a need to pull data, look at where trends are, organize policy, establish State plan amendments, draft regulations, bring along community members, and support community dialogue including families and youth. CHIPRA has been responsible for providing that overarching framework support to allow that large system change to happen.”
— Maryland CHIPRA team member, May 2013
Elevating Child and Adolescent Health Issues Through Ongoing Engagement
Regular engagement with stakeholders— not just State policymakers, but also provider associations, private-sector payers and insurance plans, and patient representatives—is another key strategy in elevating child and adolescent health issues on the State and national policy agendas. These efforts can help broaden support for demonstration activities, as well as provide a mechanism for demonstration staff to obtain feedback on their activities.
Demonstration staff in Maine engaged stakeholders on two fronts. First, they assembled a committee of providers from around the State to develop a master list of 52 pediatric quality measures. This list—which is regularly revisited and updated through stakeholder feedback—includes the Child Core Set measures, as well as additional measures that providers identified as important for driving quality improvement. Some of the Child Core Set measures were also broken into two or three separate measures in order to make them actionable at the practicelevel. The master list has informed several other initiatives in the State. For example, Maine included four measures from the Child Core Set among the quality measures it will report as part of its Health Homes program,14 which will expand the State’s existing multipayer PCMH pilot and target Medicaid beneficiaries with multiple chronic and behavioral health conditions. In addition, demonstration staff members have used the list to engage with a State coalition of public and private employers, hospitals, health plans, and provider associations. Through this engagement, the coalition has adopted child measures related to immunizations and asthma as part of its public reporting system, which is also used by some payers—including the State employee health plan—to design tiered health benefits and provider incentives.
While some States furthered the child health policy agenda as an unintended positive benefit of their CHIPRA quality demonstration projects, in Massachusetts it was an explicit goal. As part of its demonstration grant, Massachusetts established the statewide Massachusetts Child Health Quality Coalition, consisting of providers, health plans, hospitals, families, consumer advocacy organizations, public health entities, quality improvement experts, and State agencies. The coalition has spent time working with various State entities, including the State’s Medicaid program, its Department of Mental Health, and the Center for Health Information and Analysis to connect them with the pediatric expertise and consumer/ family perspective found in the coalition’s membership. For example, during the early stages of developing a new Primary Care Payment Reform (PCPR) initiative within Medicaid, Medicaid program staff met with coalition members to discuss issues from the pediatric perspective and developed an ongoing dialogue. These coalition meetings helped Medicaid staff consider the unique needs of children and adolescents when developing PCPR’s payment and delivery model and quality measures. Specifically, the coalition helped the State balance the different components of PCPR’s financial model (e.g., shared savings, bundled payments, and quality measure incentive payments) to better fit pediatric primary care. As a result of discussions between Medicaid staff and coalition members, the State Medicaid agency also included pediatric-focused quality measures, such as body mass index (BMI) and adolescent well-visits in PCPR.
Our State interview respondents reported that the presence of a federally funded, major statewide demonstration sends a broad signal about the importance of improving quality of care for children and adolescents, granting these issues greater legitimacy and more attention within the State than ever before. This renewed attention is reflected in the way that child and adolescent health needs are being incorporated into a range of broader reform activities.
The States featured in this brief provide specific examples of how the CHIPRA quality demonstration is being leveraged to:
- Inform broader health reform activities, including provider payment and delivery system reforms.
- Raise awareness among policy officials about the importance of considering the impact of specific Federal and State reform efforts on children and adolescents, using data generated through the demonstration.
- Create opportunities for the child and adolescent health community and other knowledgeable stakeholders to collaborate and work more effectively on incorporating the needs of children and adolescents into the development of new quality measures and payment and delivery system reforms.
The strategies adopted by these States, and their specific near-term impacts, are to a certain extent unique, as they reflect the context in each State. However, the common thread running throughout these efforts is represented by the new connections being formed among State officials, policymakers, providers, staff of various reform initiatives and demonstrations, and other key stakeholders.
The early experiences of the demonstration States highlighted here suggest some promising practices and lessons that other States may want to bear in mind as they look for ways to effectively address child and adolescent health issues:
- Convening and facilitating regular, ongoing dialogue among policymakers and diverse child health stakeholders, including respected child health experts, to engage a broad base of constituencies. Such ongoing dialogue can provide a vehicle for policymakers to obtain input on policies that may affect child health, and it can help to increase buy-in for adapting those policies to meet the health needs of children and adolescents.
- Building on related reform efforts can help to facilitate dialogue and problem-solving among stakeholders who may not typically work together. This is particularly relevant to the child and adolescent population, where the public health and civic sectors also provide essential services and complement the health care system.4
- Elevating child and adolescent health issues on State policy agendas requires an ongoing process rather than a single intervention. Demonstration States are already beginning to identify sources of support to sustain stakeholder coalition and quality efforts after the CHIPRA quality demonstration grant ends in 2015.
Additional information about the national evaluation and the CHIPRA Quality Demonstration Grant Program is available at http://www.ahrq.gov/policymakers/chipra/demoeval/.
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The national evaluation of the CHIPRA Quality Demonstration Grant Program and the Evaluation Highlights are supported by a contract (HHSA29020090002191) from AHRQ to Mathematica Policy Research and its partners, the Urban Institute and AcademyHealth. Special thanks are due to Cindy Brach at AHRQ, Karen Llanos and Elizabeth Hill at CMS, State demonstration staff, and our evaluation team colleagues for their careful review and helpful comments. We particularly appreciate the help received from demonstration staff and providers in the States featured in this Highlight and the time they spent answering our questions during site visits. The observations contained in this document represent the views of the authors and do not necessarily reflect the opinions or perspectives of any State or Federal agency.
1. Truffer CJ, Klemm JD, Wolfe CJ, et al. Report to Congress: 2012 actuarial report on the financial outlook for Medicaid. Baltimore, MD: U.S. Centers for Medicare & Medicaid Services, Office of the Actuary. 2012. Available at: http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Financing-and-Reimbursement/Downloads/medicaid-actuarial-report-2012.pdf
10. CCOs were established in a 2011 State law. For more information on Oregon’s CCOs, see: Stecker, EC. The Oregon ACO experiment – bold design, challenging execution. N Engl J Med 2013;368(11):982- 985.
11. US Department of Health and Human Services, Centers for Medicare & Medicaid Services. CHIPRA initial core set of children’s health care quality measures. Available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/CHIPRA-Initial-Core-Set-of-Childrens-Health-Care-Quality-Measures.html.
12. Gold MR, McLaughlin CG, Devers KJ, et al. Obtaining providers’ ‘buy-in’ and establishing effective means of information exchange will be critical to HITECH’s success. Health Aff 2012;31(3):514-526.
13. State of Maryland, Office of the Governor. Supplemental budget no. 1– fiscal year 2014; April 1, 2013. Available at: http://dbm.maryland.gov/agencies/operbudget/Documents/2014/SupplementalBudget.pdf.
14. For more information on Health Homes, see: U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Health homes. Available at: http://www.medicaid.gov/Medicaid-CHIPProgram-Information/By-Topics/Long-Term-Services-and-Support/Integrating-Care/Health-Homes/Health-Homes.html.