1. Quality and Utilization in Healthy Kids programs in California Michael R. Cousineau, Dr. PH. Gregory D. Stevens, Ph.D. Em Arpawong, MPH Kyoko Rice Trevor Pickering, MA

2. 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

3. 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 Supplements several county-specific studies, Los Angeles, San Mateo and Santa Clara

4. 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?

5. 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

6. Enrollments in Healthy Kids Program, 2003 to 2008

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

8. 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?

9. 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)

10. Well Child Visits, 3-6 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

11. 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

12. 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

13. 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

14. 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).

15. Comparison within Counties More investigation is needed to understand why there are differences across counties. Specifically:  where member incentive programs are in place  who has implemented education on the use of preventive care  what impact could these be having on use of care

16. 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?

17. 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)

18. 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.

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

20. Trends in ACS Hospitalizations

21. ACSC Hospitalization observed rates per 10,000 Children in CHI counties before and after Implementation TotalHigh IncomeLow Income CountyPre-CHIPost CHI* Pre-CHIPost CHI* Pre-CHIPost CHI* Kern13.309.4313.1310.5813.508.84 Los Angeles14.4911.6713.318.9215.3713.87 Riverside15.7912.4915.1811.3316.3913.95 San Bernardino17.5913.7516.2610.8518.6116.52 San Francisco11.5511.0110.2611.9514.139.53 San Joaquin16.3213.9215.0810.5918.1417.70 San Mateo7.457.167.216.538.519.14 Santa Clara10.6710.1110.509.5911.2311.34 Santa Cruz9.589.958.997.9810.6413.67

22. 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 14.0 16.0 18.0 20.0 Pre-CHIPost-CHIPre-CHIPost-CHI Preventable Hospitalizations per 10,000 Children Higher-IncomeLower-Income

23. 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

24. 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?

25. Impact on the Safety Net A case study of Los Angeles County Comparing indigent care visits before and after implementation of Healthy Kids

26. CHART 1. Monthly Enrollment in Los Angeles Healthy Kids by Age Group, Children Ages 0-18 Source: 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,.

27. 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

28. 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.