Sheila Hoag

CHIP and Medicaid: Evolving to Meet the Needs of Children.

OBJECTIVE To examine the evolution of Childrens Health Insurance Program (CHIP) and Medicaid programs after passage of the Childrens Health Insurance Program Reauthorization Act of 2009 (CHIPRA), focusing on policies affecting eligibility, enrollment, renewal, benefits, access to care, cost sharing, and preparation for health care reform. METHODS Case studies were conducted in 10 states during 2012-which included key informant interviews and consumer focus groups-and a national survey of state CHIP program administrators was conducted in early 2013. RESULTS Despite the recession that persisted during much of the study period, many states expanded childrens coverage by raising upper income eligibility limits or by covering new groups made eligible by CHIPRA. Simplifying rules and procedures for enrollment and renewal continued to be a major priority for CHIP and Medicaid, and CHIPRA played a direct role in spurring innovation. CHIPRAs outreach grants played an important role in supporting and supplementing state outreach efforts. Important legacies of CHIPRA are the laws mandatory requirements for comprehensive dental benefits coverage and mental health parity for all types of CHIP programs. Although most states already offered generous coverage of these benefits, the mandate may have protected them from cuts during the economic downturn. Federal Maintenance of Effort rules were a crucial protection for CHIP, especially during the recession when state budget shortfalls could have led to program cuts. CONCLUSIONS Passage of the Affordable Care Act has raised questions surrounding the future role of CHIP in a reformed health care system. A growing number of stakeholders have recommended a 2-year extension of federal CHIP funding to allow complex transition issues to be resolved.

Spotlight on Express Lane Eligibility (ELE): A Tool to Improve Enrollment and Renewal

OBJECTIVE We examine a new simplification policy, Express Lane Eligibility (ELE), introduced by the Childrens Health Insurance Program Reauthorization Act of 2009 (CHIPRA), to understand ELEs effects on enrollment, renewal, and administrative costs. METHODS Beginning in January 2012 and lasting through June 2013, we conducted 2 rounds of phone interviews with 38 state administrators and staff in 8 states that implemented ELE in Medicaid, Childrens Health Insurance Program (CHIP), or both; we also conducted case studies in these same states, resulting in 136 in-person interviews. We collected administrative data on enrollments and renewals processed through ELE methods from the 8 states. RESULTS ELE was adopted in different ways; the method of adoption influenced how many children were served and administrative savings. Automatic ELE processes, which enable states to use eligibility findings from partner agencies to automatically enroll or renew children, serve the most children and generate, on average,

Association Between Extending CareFirst’s Medical Home Program to Medicare Patients and Quality of Care, Utilization, and Spending

1 million annually in administrative savings. Given the size of renewal caseloads and the recurring nature of renewal, using ELE for renewals holds substantial promise for administrative savings and keeping children covered. CONCLUSIONS Automatic ELE processes are a best practice for using ELE. However, because Congress has not yet made ELE a permanent policy option, states are discouraged from adopting this more efficient method of eligibility determination and redeterminations. Making ELE permanent would support states that have already adopted the policy; in addition, ELE could support the transition of children to Medicaid or exchanges should CHIP not be funded after September 30, 2015.

Evolution of Medicaid managed care systems and eligibility expansions.

Importance CareFirst, the largest commercial insurer in the mid-Atlantic Region of the United States, runs a medical home program focusing on financial incentives for primary care practices and care coordination for high-risk patients. From 2013 to 2015, CareFirst extended the program to Medicare fee-for-service (FFS) beneficiaries in participating practices. If the model extension improved quality while reducing spending, the Centers for Medicare and Medicaid Services could expand the program to Medicare beneficiaries broadly. Objective To test whether extending CareFirst’s program to Medicare FFS patients improves care processes and reduces hospitalizations, emergency department visits, and spending. Design, Setting, and Participants This difference-in-differences analysis compared outcomes for roughly 35 000 Medicare FFS patients attributed to 52 intervention practices (grouped by CareFirst into 14 “medical panels”) to outcomes for 69 000 Medicare patients attributed to 42 matched comparison panels during a 1-year baseline period and 2.5-year intervention at Maryland primary care practices. Main Outcomes and Measures Hospitalizations (all-cause and ambulatory-care sensitive), emergency department visits, Medicare Part A and B spending, and 3 quality-of-care process measures: ambulatory care within 14 days of a hospital stay, cholesterol testing for those with ischemic vascular disease, and a composite measure for those with diabetes. Interventions CareFirst hired nurses who worked with patients’ usual primary care practitioners to coordinate care for 3656 high-risk Medicare patients. CareFirst paid panels rewards for meeting cost and quality targets for their Medicare patients and advised panels on how to meet these targets based on analyses of claims data. Results On average, each of the 14 intervention panels had 9.3 primary care practitioners and was attributed 2202 Medicare FFS patients in the baseline period. The panels’ attributed Medicare patients were, on average, 73.8 years old, 59.2% female, and 85.1% white. The extension of CareFirst’s program to Medicare patients was not statistically associated with improvements in any outcomes, either for the full Medicare population or for a high-risk subgroup in which impacts were expected to be largest. For the full population, the difference-in-differences estimates were 1.4 hospitalizations per 1000 patients per quarter (P = .54; 90% CI, −2.1 to 5.0), −2.5 outpatient ED visits per 1000 patients per quarter (P = .26; 90% CI, −6.2 to 1.1), and −

Perils of Pioneering: Monitoring Medicaid Managed Care

1 per patient per month in Medicare Part A and B spending (P = .98; 90% CI, −

Children's Health Insurance Program: An Evaluation 1997-2010

40 to

Federally Qualified Health Centers: Surviving Medicaid Managed Care, but Not Thriving

39). For hospitalizations and Medicare spending, the 90% CIs did not span CareFirsts expected impacts. Hospitalizations for the intervention group declined by 10% from baseline year to the final 18 months of the intervention, but this was matched by similar declines in the comparison group. Conclusion and Relevance The extension of CareFirst’s program to Medicare did not measurably improve quality-of-care processes or reduce service use or spending for Medicare patients. Further program refinement and testing would be needed to support scaling the program more broadly to Medicare patients.