Childrens Health Insurance Programs in New Hampshire: FollowUp Studies

1
Childrens Health Insurance Programs in New
HampshireFollow-Up Studies

• Presentation to the New Hampshire CHIS Users
  Group Meeting, December 9, 2008

2
Overview

• Purpose
• Prior Childrens Health Insurance Program (CHIP)
  annual report results suggested areas for more
  detailed study
• CHIP current reports under final review
• SFY2007 annual report
• Factors influencing payments PMPM
• Adolescents
• Geographical variations
• CHIP reports in progress and planned
• Mental health
• Application of Clinical Risk Grouping
• Children with no preventive visit
• Enrollment disenrollment
• SFY2008 annual report

3
Factors Influencing Payments per Member per
Month in NHChild Health Insurance Programs
4
Factors Influencing CHIP Payments PMPM

• Previous NH CHIS CHIP reporting indicate higher
  payments PMPM for low-income children enrolled
  in Medicaid compared with SCHIP or CHIS
  commercial
• For SFY2007 the Medicaid rate (242 PMPM) was
  significantly higher than SCHIP (128 PMPM) or
  CHIS commercial (120 PMPM)
• The degree of difference is unexpected since
  Medicaid typically reimburses at a lower rate per
  service
• Purpose of CHIP Payment PMPM Study
• To investigate in detail the causes of higher
  payment PMPM rates for children in Medicaid by
  eligibility group, diagnoses, category of
  service, outlier cases, FPL

Excludes severely disabled children in home care
5
Categories of Service Unique to Medicaid
Payments for private non-medical institutions,
school-based special education services, services
for the developmentally disabled, and services
provided through NH DCYF

• Clinic services (COS 25) determined to be
  school-based services - special education
• Day habilitation (COS 60) are day services for
  the developmentally disabled and home and
  community based care for the developmentally
  impaired (COS 65) are waiver services
• Crisis intervention (COS 72)
• Intensive home and community services (COS 73)
• Child health support services (COS 74)
• Home-based therapy (COS 76)
• Placement services (COS 77)
• ICF services for the mentally retarded (COS 102)
  are institutional services for the mentally
  retarded
• Private non-medical institution (COS 78) are
  residential institutional care for children
• Dental services (COS 45) are often not covered by
  CHIS commercial plans
• These special services accounted for 71.5
  million (37) of the 193.3 million in Medicaid
  payments for low-income children

6
Revised Payment Rates PMPM, SFY2007
After exclusion of dental, PNMI, school-based
special education services, services for the
developmentally disabled, services provided
through NH DCYF, newborns and infants (age 0-11
months), the payment rate in Medicaid (138
PMPM) was 8 percent higher than the rate in
SCHIP (128 PMPM) and 22 percent higher than CHIS
commercial (113 PMPM).
7
Other Findings Medicaid PMPM by Poverty Level
SCHIP children are enrolled at 185-300 of
Federal Poverty Level. Children enrolled in CHIS
commercial plans may be at any Federal Poverty
Level household income is not available in CHIS
commercial data. Federal Poverty Level (FPL) is
determined at enrollment by the adjusted income
and not the gross income of the household. An
FPL of 100 would indicate the child was living
at the FPL and 0 would indicate the child was
living in a household with no income after
adjustments for income disregards.
8
Summary of Factors Influencing Medicaid
Low-Income Payments PMPM

• The types of services that are typically not
  covered by CHIS commercial plans represent a
  large proportion of payments for low-income
  children enrolled in Medicaid
• After removing these services payment PMPM was
  1.2 times higher in Medicaid
• Payment rates for older children age 7-11 and
  12-18 and mental disorders account for most of
  the remaining difference between Medicaid and
  CHIS commercial
• Poverty level was associated with payment PMPM
  rates and children in the highest adjusted
  household income level within Medicaid had
  payment PMPM rates similar to SCHIP and CHIS
  commercial

9
Adolescent Childrens Health Insurance Programs
Access, Prevention, Utilization and Payments
10
CHIP Adolescent Study

• The current annual NH CHIS report Childrens
  Health Insurance Programs in New Hampshire for
  SFY2007 indicated that while adolescent children
  had lower rates of preventive well-care visits,
  they had higher rates of utilization and payments
  compared with younger children
• The purpose of this study was to describe these
  differences in more detail by specific age,
  gender, and plan type and to elaborate on
  differences in disease status, utilization of
  services, and payments
• Adolescent children represent 1 in 5 NH Medicaid
  enrollees

11
Percent of Adolescents with Adolescent Well Care
Visits by Age, Gender, and Plan Type, SFY2007
Among 16,841 adolescent children continuously
enrolled in NH Medicaid, 8,680 did not receive a
well-care visit
National Committee Quality Assurance (NCQA) HEDIS
Adolescent Well Care (AWC) Measure. Medicaid
Managed Care43.6 Commercial Managed Care40.3
12
CHIP Adolescent Study Health Status

• Adolescent children enrolled in Medicaid had
  consistently higher prevalence rates of injury,
  infectious, nutritional, ear, eye, respiratory,
  digestive, genitourinary, skin, and mental health
  diseases and disorders compared with adolescent
  children enrolled in CHIS commercial

13
Adolescent Outpatient Emergency Department Visit
Rates per 1,000 Members for Selected
ConditionsAge, Gender, and Plan, SFY2007
Selected conditions which may be non-urgent or
for which an alternative setting of care
(office-clinic) may be more appropriate included
ICD-9-CM codes for Sore throat (strep),viral
infection (unspecified), anxiety (unspecified or
generalized), conjunctivitis (acute or
unspecified), external and middle ear infections
(acute or unspecified) upper respiratory
infections (acute or unspecified), bronchitis
(acute or unspecified) or cough, dermatitis and
rash joint pain, lower and unspecified back
pain, muscle and soft tissue limb pain, fatigue,
headache, abdominal pain
14
Adolescent Prevalence of Mental Health Disorder,
SFY2007
The mental health disorder prevalence rate for
adolescent children enrolled in Medicaid (31.5)
was higher than the prevalence rate for SCHIP
(27.5), and NH CHIS commercial (16.6). These
differences were consistent by individual year of
age and gender.
15
Psychotherapy Visits for Children with a Mental
Health Disorder. Rate per 1,000, SFY2007
For adolescent children with a mental health
disorder, the rate of psychotherapy visits in
Medicaid (7,100 per 1,000 members) was more than
double the rate in SCHIP (3,485 per 1,000) or
CHIS commercial (3,216 per 1,000)
16
Average Number of Days of Psychotropic Medication
for Children Using Psychotropic Medications,
SFY2007
Adolescent children enrolled in Medicaid who were
prescribed psychotropic medication averaged more
days of psychotropic medication use during the
year compared with children using psychotropic
medications enrolled in SCHIP or CHIS commercial.
The lower rates for SCHIP may be influenced by
the shorter average enrollment time for children
in SCHIP.
17
Geographical Variation Access, Utilization and
Payments in Children
18
CHIP Geographic Variations

• Other NH CHIS studies have demonstrated wide
  geographical variation in utilization rates
• The proportion of children residing in an area
  who are enrolled in Medicaid varies by
  geographical area
• NH CHIS assigns members to a Health Analysis
  Areas (HAA) based on their residence
• The purpose of this study was to describe
  variation in rates of preventive services and
  health care utilization by HAA for children in NH
• Medicaid, SCHIP, and CHIS Commercial rates for
  children (age lt19) standardized for
  age-differences between areas were compared
• Medicaid includes only low-income Medicaid
  children children with disabilities are excluded

19
Well-Child Preventive Visit by Health Analysis
AreaAge-Standardized Rate per 1,000
20
Outpatient Emergency Department Use for
Conditions Non-Urgent or Treatable in the Primary
Care SettingAge-Standardized Rates per 1,000
21
Other CHIP Studies in Progress or Planned

• Mental health
• Evaluate specialist visits, coexisting disorders,
  types and intensity of psychotropic medication
  use
• Risk-adjustment of plan comparisons
• 3M Clinical Risk Grouping (CRG) Software for
  Healthcare Reimbursement
• Children with no preventive visit
• Investigate characteristics and utilization
  patterns of children that did not receive a
  well-child visit
• Enrollment and disenrollment patterns