Quality and Utilization in Healthy Kids programs in California

Michael R. Cousineau, Dr. PH.Gregory D. Stevens, Ph.D.Em Arpawong, MPHKyoko RiceTrevor Pickering, MA

Evaluating the Children’s Health Initiatives Multi-dimensional four year study of the

evolution of the CHIs in California Funded by the California Endowment and California

First5 Commission Augments several county-specific studies, Los

Angeles, San Mateo and Santa Clara

Evaluating the Children’s Health Initiatives

Multi-dimensional four year study of the evolution of the CHIs in California

Funded by the California Endowment and California First5 CommissionSupplements several county-specific studies, Los Angeles, San Mateo and Santa Clara

Evaluation Questions

How does the use of services and quality of care in Healthy Kids programs compare to Medi-Cal and Healthy Families?

What has been the impact of expansion on preventable hospitalizations in California?

What has been the impact on the safety net of clinics and hospitals?

CHIs now in 26 counties

82,000 children enrolled in Healthy Kids between 2001 and 2006

Estimated 150,000 to 200,000 enrolled in Medi-Cal and Healthy Families

Enrollments in Healthy Kids Program, 2003 to 2008

0

10,000

20,000

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Month and Year

Total En

rollm

en

t

0-5

6-18

Total

Financial Stability of Healthy Kids programs in CHIs in California, 2008

-0.4

-11.9

-15.5

-27.7

-66.1

-69.4

-171.1

-35.6

-$200 -$160 -$120 -$80 -$40 $0 $40Millions

Ages 6-18

Ages 0-5

Total

FY '10-'11

FY '09-'10

FY '08-'09

Evaluation Questions

How does the use of services and quality of care in Healthy Kids programs compare to Medi-Cal and Healthy Families?

What has been the impact of expansion on preventable hospitalizations in California?

What has been the impact on the safety net of clinics and hospitals?

HEDIS® Measures and Indicators

Specific criteria Administrative data review or in

combination with Chart review 12 month continuous enrollment Threshold (minimum) number of enrollees

*HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA)

Well Child Visits, 3-6 yearsHEDIS Well-Child Visits (ages 3-6 years): 2005, 2006, 2007

0102030405060708090

CCAH IEHP K-HN LAC PHP SFHP HPSJ SLO HPSM SBRHA SCFHP

County/Health Plan

% m

ee

tin

g c

rite

ria

2005 2006 2007

2006 Medi-Cal72.7%

2006 CHI average 57.3%

Notes: 1) Some data not shown because either plans were not required to report or there were < 30 eligible members that year 2) K-HN in 2007 includes the counties of Kern, Fresno, and Tulare

Immunization Combination 2

Notes: 1) Some data not shown because either plans were not required to report or there were < 30 eligible members that year 2) K-HN in 2007 includes the counties of Kern, Fresno, and Tulare

Immunizations (combination 2): 2005, 2006, 2007

0

20

40

60

80

100

CCAH IEHP K-HN LAC PHP SFHP HPSJ SLO HPSM SBRHA SCFHP

County/Health Plan

% m

ee

tin

g c

rite

ria

2005 2006 2007

2006 Medi-Cal76.6%

2006 CHI average 61.5%

Primary Care Visits, 12-24 months

Notes: 1) Some data not shown because either plans were not required to report or there were < 30 eligible members that year 2) K-HN in 2007 includes the counties of Kern, Fresno, and Tulare

Primary Care Visits (ages 12-24 months): 2005, 2006, 2007

0

20

40

60

80

100

CCAH IEHP K-HN LAC PHP SFHP HPSJ SLO HPSM SBRHA SCFHP

County/Health Plan

% m

ee

tin

g c

rite

ria

2005 2006 2007

2005 Healthy Families92.0%

2006 CHI average 84.3%

Primary Care Visits, 25 months-6 years

Notes: 1) Some data not shown because either plans were not required to report or there were < 30 eligible members that year 2) K-HN in 2007 includes the counties of Kern, Fresno, and Tulare

Primary Care Visits (ages 12 months-6 years): 2005, 2006, 2007

0

20

40

60

80

100

CCAH IEHP K-HN LAC PHP SFHP HPSJ SLO HPSM SBRHA SCFHP

County/Health Plan

% m

ee

tin

g c

rite

ria

2005 2006 2007

2005 Healthy Families87.0%

2006 CHI average 74.8%

Emergency Department Visits (trends)

Unadjusted, younger children (0-5) tended to have higher rates of ER use compared to older children

Noted differences but no specific pattern when comparing ER use among health plans and between health plan type

Multivariate regression analysis of CHI county data showed a statistically significant lower rate ED use in older children (p<0.05), and Health Insurance Program (Healthy Kids lower than Medi_Cal and HF (p<0.01).

Comparison within Counties

More investigation is needed to understand why there are differences across counties. Specifically:where member incentive programs are in placewho has implemented education on the use of

preventive carewhat impact could these be having on use of

care

Evaluation Questions

How does the use of services and quality of care in Healthy Kids programs compare to Medi-Cal and Healthy Families?

What has been the impact of expansion on preventable hospitalizations in California?

What has been the impact on the safety net of clinics and hospitals?

Measuring the Impact of Coverage Expansion Ambulatory Care Sensitive Conditions (ACSC) are conditions for

which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease.

Did the expansion of health insurance for children reduce Hospitalizations for ACSC among children in CHI counties?

Data Source: Discharge Summaries- Office of Statewide Health Planning and Development (OSHPD)

Analysis: Preventable Hospitalizations

Did the ACSC hospitalization rate decline in the period after CHI was implemented?

Based on analyses of hospital discharge data available from OSHPD from 2000 to 2005.

Analyses limited to 9 CHIs that were operational at least 6 months by the end of 2005.

Ambulatory Care Sensitive (Preventable) Hospitalizations (ACSC)

Asthma23%

Diabetes3%

Gastroenteritis & Dehydration

27%

Perforated Appendix

8%

Urinary Tract Infection

10%

Bacterial Pneumonia

28%

Iron Deficiency Anemia

<1%

Between 2000 and 2005, there were about 333,000 preventable hospitalizations statewide (6.2% of all hospitalizations) for 0-18 years. Source AHRQ,2006

Trends in ACS Hospitalizations

8

10

12

14

16

18

20

2000 2001 2002 2003 2004 2005

Ra

te p

er

10

,00

0

Low Income

High Income

ACSC Hospitalization observed rates per 10,000 Children in CHI counties before and after Implementation

                       

Total High Income Low Income

County Pre-CHI Post CHI*   Pre-CHI Post CHI*   Pre-CHI Post CHI*  

Kern 13.30 9.43 13.13 10.58 13.50 8.84

Los Angeles 14.49 11.67 13.31 8.92 15.37 13.87

Riverside 15.79 12.49 15.18 11.33 16.39 13.95

San Bernardino 17.59 13.75 16.26 10.85 18.61 16.52

San Francisco 11.55 11.01 10.26 11.95 14.13 9.53

San Joaquin 16.32 13.92 15.08 10.59 18.14 17.70

San Mateo 7.45 7.16 7.21 6.53 8.51 9.14

Santa Clara 10.67 10.11 10.50 9.59 11.23 11.34

Santa Cruz 9.58 9.95 8.99 7.98 10.64 13.67

                         

 

Observed CHI Effect (adjusted)

**Note: adjusted for time trends, county differences, age, and gender.

12.1 12.0

14.1

10.6

0.0

2.0

4.0

6.0

8.0

10.0

12.0

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16.0

18.0

20.0

Pre-CHI Post-CHI Pre-CHI Post-CHI

Pre

ven

tab

le H

osp

italizati

on

s p

er

10

,00

0 C

hild

ren

Higher-Income Lower-Income

Policy Implications

Applying $7,000* cost factor CHIs have already saved $44 Million or $7 Million per year since they began.

If CHIs had been implemented statewide in all counties since 2000, prevented another 24,300 hospitalizations over the six-year period, saving an estimated $24 Million per year

Evaluation Questions How does the use of services and quality

of care in Healthy Kids programs compare to Medi-Cal and Healthy Families?

What has been the impact of expansion on preventable hospitalizations in California?

What has been the impact on the safety net of clinics and hospitals?

Impact on the Safety Net

A case study of Los Angeles County Comparing indigent care visits before and

after implementation of Healthy Kids

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

Jul

Aug

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2003 2004 2004 2004 2004 2004 2005 2005 2005 2005 2006 2006 2006 2006 2007 2007

Total enrollees (0-5) Total enrollees (6-18) Total enrollees (0-18)

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

FY 2003-04 FY 2004-05 FY 2005-06 FY 2006-07

To

ta

l V

isit

s

PPP Visits DHS Visits

CHART 1. Monthly Enrollment in Los Angeles Healthy Kids by Age Group, Children Ages 0-18Source: L.A. Care Health Plan.

CHART 2. DHS and Private Public Partnership (PPP), Total Visits Age 0-18, 2003-2007 Source: LAC DHS Enterprise Data Repository,

.

Conclusions Healthy Kids programs are approaching and

in some time exceeding the performance of the same plans in Medi-Cal and Healthy Families

Healthy Kids have reduced un necessary hospitalizations while improving access to primary care

Reduced demands on the safety net while reducing uncompensated care

References

Gregory Stevens, Kyoko Rice and Michael R. Cousineau, Children’s Health Initiatives in California, American Journal of Public Health, 2007; 97(4):738–743

Michael R Cousineau, Gregory Stevens and Trevor Pickering, Preventable Hospitalizations Among Children in California Counties after Child Health Insurance Expansion Initiatives, Medical Care, 2008; 46,142-147.

AHRQ Quality Indicators: Pediatric Quality Indicators Overview. Rockville, MD: Agency for Healthcare Research and Quality; February 2006.