0
Children with Special Health Care Needsin California: Legislative BriefingApril 18, 2013David Alexander, MDPresident and C...
Service ProvidersVariable Access to Care Depending On:• The Condition You Have• Where You Live• How Much $$ You Have• The ...
Unified Payment System:Each Pays its ShareQualifying ConditionsUnified Access Rules: Yes or NoAn Enhanced System for Child...
Existing SystemUnified Payment System: Each Pays its ShareQualifying ConditionsUnified Access Rules: Yes or NoMedical Care...
Children with Special Health Care Needsin CaliforniaLegislative BriefingCalifornia State AssemblyApril 18, 2013www.lpfch-c...
Prevalence, Characteristics andExperiences of California’sChildren with Special Health NeedsCalifornia Legislative Briefin...
Why? Optimize health and wellbeing of California’s childrenHow can we optimize earlyand life-long health of children,yout...
“CSHCN are those who have or are at increased risk for a chronicphysical, developmental, behavioral, or emotional conditio...
Overall Prevalence andVariation by Race/Ethnicity% CSHCNData Source: 2011/12 National Survey of Children’s HealthNATIONWID...
Demographic Characteristicsof California’s CSHCNNon-CSHCN CSHCNCSHCN with ComplexHealth NeedsAge0-5 years 36.2% 18.8% 18.1...
Prevalence and Medical Expendituresfor CSHCN: By Complexity(For reference: Non-CSHCN average expenditures: $856).Prevalenc...
Expanding Our Reach:Importance of a Broad ViewDATA SOURCE: 2011/12 National Survey of Children’s Health (2011/12 NSCH).*Nu...
Positive and Protective HealthIndicators: By CSHCN StatusCaliforniaNon-CSHCNCaliforniaCSHCNProtective Home Environment(no ...
Health of the Family:Parental HealthParental Overall Health Status (Physical & Mental/Emotional) by CSHCN StatusCSHCN with...
Health Care Quality SummaryMeasure (All Children)AKTXCAMTAZNVNMCOIDORUTKSWYNESDILMNOKFLIANDMOGAALWAARWILANCPANYMSMITNKYINV...
31.7% 32.6%26.4%0%5%10%15%20%25%30%35%All Children Non-CSHCN CSHCNPrevalence of Meeting MinimumQuality Index Among Childre...
Developmental screening refers to a child (age 10 months-5 years) beingscreened for being at risk for developmental, behav...
Consistent and AdequateHealth Insurance60.6% 57.9% 59.1%0%10%20%30%40%50%60%NATIONWIDE TEXAS CALIFORNIACOMPONENTS OF CONSI...
Medical Home The American Academy of Pediatrics (AAP) description of a "medical home" listsseven defining components: acc...
Medical Home:Care Coordination (CC)DATA SOURCE: 2009/10 National Survey of Children with Special Health Care Needs56.0 52....
Shared Decision-MakingCSHCN whose families are partners in shared decision-making: California ranks last (51st) in the nat...
Transition to AdulthoodYouth with special health care needs who receive the servicesnecessary to make appropriate transiti...
Impact on the FamilyCSHCN whose conditions cause family members to cutback or stop working California ranks last (51st) i...
Health Insurance and WorkCSHCN whose family member(s) avoided changingjobs in order to maintain health insurance for child...
Comparing Prevalence and Utilization of Children who Qualify on CSHCN Screener, comparedto Affordable Care Act (ACA) Medic...
If you have any questions, feel free to contact us:The Child and Adolescent Health Measurement Initiativewww.cahmi.orgEmai...
CCS Medical Eligibility California Children’s Services offers assistance tochildren who have a health problem covered by ...
Children with Special Health Care Needsin CaliforniaLegislative BriefingCalifornia State AssemblyApril 18, 2013www.lpfch-c...
STATE PROGRAMS FORMEDICALLY COMPLEXCHILDREN:WHO IS COVERED? WHO ISN’T?Bernardette ArellanoDirector of Government Relations...
California Children’s HospitalAssociationCCHA has been providing leadership and advocacy on behalfof the eight independent...
Topics• Children’s Insurance Coverage• Insurance by California State Program• Covering Children with Special Healthcare Ne...
The Basics9 Million Children in California• Private Insurance: 3.05 million children• Public Insurance: 4.85 million child...
Sources of Coverage (California)
Covering Children with Special HealthCare Needs (CSHCN)64%28%8%58%37%6%Privately Insured Publicly Insured UninsuredCalifor...
Sources of Private HealthInsurance
Private Health InsuranceWhy is coverage sometimes inadequate?• Network and benefit variations between providers• Health in...
Public Health InsuranceProgramsWhat are the options for families?• There are 8 public health insurance programsfor childre...
CCS Program Overview• More than insurance: Diagnostic and treatmentservices, medical case management and physical andoccup...
CCS EligibilityFamily IncomeRequirementsAge and CitizenshipstatusReimbursement ModelCCS Only Under $40,000or out of pocket...
CCS Eligible Conditions**Problems that are physically disabling, or need to betreated with medicine, surgery, rehabilitati...
What makes CCS so special?• High quality, specialized providers and care centersthat tailor care to the child’s unique hea...
Insuring CSHCN - looking ahead• Even with CCS available, almost one quarter (24.2%)of California CSHCN have conditions tha...
Bernardette ArellanoDirector of Government RelationsCalifornia Children’s Hospital AssociationBarellano@ccha.orgPhone: 916...
Children with Special Health Care Needsin CaliforniaLegislative BriefingCalifornia State AssemblyApril 18, 2013www.lpfch-c...
Children with Special Health CareNeeds in Medi-Cal and the CaliforniaHealth Benefits ExchangeMeg Comeau, MHADirector, The ...
Medicaid Matters to ALL Children...But it’s especially important tochildren with disabilities and specialhealth care needs...
Children with special health care needs(CSHCN) by insurance categorySOURCE: National Survey of Children with Special Healt...
Medi-Cal: An Overview• State/Federal Partnership– Jointly funded (50/50 split in CA)– State administered program with flex...
Covered ServicesMandatory Services• Inpatient and outpatient hospital• Physician services• Family planning services• Nursi...
Early Periodic Screening, Diagnosisand Treatment (EPSDT)• Applies to all Medicaid-enrolled children underage 21• Screening...
State Health Exchangesaka “the Marketplace”• Opening January 1, 2014 in each state• Choice of different individual and sma...
California Health Benefit Exchange:Covered California• State-based Exchange (one of 18)• Independent public entity within ...
Medi-Cal,Covered California and CSHCN• Approximately 500,000 children are expected tobe eligible for coverage under Covere...
For more information,please contact us at:The Catalyst CenterHealth and Disability Working GroupBoston University School o...
Children with Special Health Care Needsin CaliforniaLegislative BriefingCalifornia State AssemblyApril 18, 2013www.lpfch-c...
PRIVATE COVERAGE UNDER CALIFORNIA’S ACA:BENEFITS AND COST-SHARING REQUIREMENTS AFFECTINGCHILDREN AND ADOLESCENTS WITH SPEC...
Key Questions for Presentation1. How well does Kaiser’s benchmark plan meet the needs of children andadolescents with spec...
Funding and Approach• Funding: Packard Foundation for Children’s Health• Information Sources– Benefits: Kaiser’s benchmark...
Important Background• Kaiser’s small group HMO plan was selected as CA’sbenchmark plan• CA prohibits insurers from making ...
More Important Background• Kaiser’s benchmark plan did not cover habilitative services orpediatric dental and vision servi...
How well does Kaiser’s benchmark planmeet the needs of children and adolescentswith special needs?• Very well! Kaiser offe...
Are there particular services important tochildren with special needs that are limited orexcluded from the benchmark plan?...
What differences in out-of-pocket paymentswill families inplatinum, gold, silver, bronze, and catastrophicplans face?• Hug...
More cost-sharing differences• Deductible differences (per family)- Platinum and gold: NONE- Silver: $4,000 for certain me...
More differences• Copay or Coinsurance Amounts in Platinum versusBronze Plans– Ambulatory care (deductible in bronze appli...
More differences– Lab services (deductible applies in bronze) Lab tests: $20 vs 30% CT/PET scan/MRI: $150 vs 30%– Rehabi...
To what extent will families who qualify forcost-sharing subsidies be protected from highout-of-pocket costs?• Quite a bit...
More on subsidized cost-sharing inCA’s Silver PlanDeductibles (family)100% - 150% FPL: None150% - 200% FPL: $1,000 for med...
What pediatric-specific requirements were partof CA’s qualified health plan solicitation?• Introduction recognized CA’s hi...
What critical pediatric issues should policymakersconsider with implementation of new private coverageunder CA’s ACA?• Wor...
Critical Issues for Families and HealthCare Providers• Inform families who may qualify as disabled or medically frail or a...
Children with Special Health Care Needsin CaliforniaLegislative BriefingCalifornia State AssemblyApril 18, 2013www.lpfch-c...
Juno DuenasApril 18 , 2013of California
What Works Well
MCHB Core Performance Measures• Families partner in decision making at all levelsand are satisfied with the services they ...
What Works Well?Communitiesthatrecognize theparent as thecustomer andthe centralcarecoordinator
Families Partner In Decision MakingAt All Levels And Are Satisfied• Information AndEducation• At Risk Families• PlanningIm...
Coordinated Ongoing ComprehensiveCare Medical Home Define CareCoordination Access To PrimaryAnd Specialists Autonomy To...
Families Have Adequate PrivateAnd/Or Public Insurance• Clear Payment Policies• Payer Of First Resort• Clear Information Wh...
Children Are Screened Early AndContinuouslyScreenScreenScreen
Community-based services areorganized• Systems Issues Across At StateAnd Local Level• Community Based Information
Youth receive the services to maketransitions Infrastructure to develop andimplement transition plans Build capacity of ...
AccountabilityAssessmentEvaluationTable
THANK YOU!!!
THE TRANSFORMATION OFCHILD HEALTH IN CALIFORNIAWhy The CCS Program Has BecomeCrucial To All Children In CaliforniaPaul H W...
CHILD HEALTH IN THE UNITED STATESHAS BEEN TRANSFORMED• Sharp reduction in serious, acute diseases
CHILD HEALTH IN THE UNITED STATESHAS BEEN TRANSFORMED• Sharp reduction in serious, acute diseases• Concentration of illnes...
CHILD HEALTH IN THE UNITED STATESHAS BEEN TRANSFORMED• Sharp reduction in serious, acute diseases• Concentration of illnes...
HEALTH STATUS AND LIMITATIONSBY AGE, US 2005 WHILE ALMOST HALF OFTHE ELDERLY ARE LIMITEDBY THEIR CHRONICCONDITIONS, LESS ...
CHILD HEALTH CARE SYSTEM MUST BEDIFFERENT THAN THAT FOR ADULTS• IN GENERAL, HIGH QUALITY SERVICESASSOCIATED WITH EXTENSIVE...
CHILD HEALTH CARE SYSTEM MUST BEDIFFERENT THAN THAT FOR ADULTS• IN GENERAL, HIGH QUALITY SERVICESASSOCIATED WITH EXTENSIVE...
CHILD HEALTH CARE SYSTEM MUST BEDIFFERENT THAN THAT FOR ADULTS• IN GENERAL, HIGH QUALITY SERVICES ASSOCIATEDWITH EXTENSIVE...
REGIONAL SPECIALTYCARE CENTERCH CH CHPRIMARYCAREPRIMARYCARETO ENSURE HIGH QUALITY SERVICES FOR SERIOUSLY ILL CHILDREN,RARE...
THE IMPORTANCE OF THE CALIFORNIACHILDREN’S SERVICES PROGRAM• ARCHITECTURE FOR REGIONALIZED SPECIALTYCARE SERVICES IN CALIF...
THE IMPORTANCE OF THE CALIFORNIACHILDREN’S SERVICES PROGRAM• ARCHITECTURE FOR REGIONALIZED SPECIALTYCARE SERVICES IN CALIF...
CCS HAS BECOME MORE THANSAFETY NET PROGRAM• BECAUSE SERIOUS CONDITIONS ARE RARE INCHILDREN, PRIVATELY INSURED CHILDRENDEPE...
CCS HAS BECOME MORE THANSAFETY NET PROGRAM• BECAUSE SERIOUS CONDITIONS ARE RARE INCHILDREN, PRIVATELY INSURED CHILDRENDEPE...
A SMALL GROUP OFCHILDREN ACCOUNTFOR THE MAJORITYOF CCSEXPENDITURESEXPENDITURES IN CCS ONLY 10% OF CHILDRENACCOUNT FORAPPR...
CRITICAL CHALLENGES• PROTECT WHAT IS WORKING IN THE CCSPROGRAM – REGIONALIZED SPECIALTY CARE
CRITICAL CHALLENGES• PROTECT WHAT IS WORKING IN THE CCSPROGRAM – REGIONALIZED SPECIALTY CARE• EROSION OF CCS PROGRAM WILL ...
CRITICAL CHALLENGES• PROTECT WHAT IS WORKING IN THE CCSPROGRAM – REGIONALIZED SPECIALTY CARE• EROSION OF CCS PROGRAM WILL ...
Legislative Briefing: Children with Special Health Care Needs in California
Upcoming SlideShare
Loading in...5
×

Legislative Briefing: Children with Special Health Care Needs in California

1,319

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
1,319
On Slideshare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
9
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Consequences of childhood independent of specific disease; (2) Condition checklists impractical and unreliableIdentifying Children difficultDevelopingDependentDiagnosisWhat is the 4th D?
  • I included the dark blue lines for C-CSHCN, however, the data is not as compelling as I had hoped
  • For reference: Hispanic (32.4%), White NH (27.5%), Black (unreliable est), Other NH (22.2%)
  • CA ranks 34th in the nation on outcome #3
  • CA ranks 44th in the nation on overall medical homeCA ranks 46th in nation for receiving needed care coordinationCA ranks 44th in the nation for receiving family-centered careCA ranks 50th in the nation for No Problems Accessing Referrals
  • CA ranks 44th in the nation on overall medical homeCA ranks 46th in nation for receiving needed care coordinationCA ranks 44th in the nation for receiving family-centered careCA ranks 50th in the nation for No Problems Accessing Referrals
  • CA is one of only two states that perform significantly worse than the national average
  • CA ranks 36th in the nation on Transition to Adulthood
  • Nation: 25.0% California: 29.4%--Household income could be both a cause and result of cut back/stopped working--Complexity of health needs staggering
  • CA ranks 46th in the nation
  • When looking in 2008 MEPS, FOR ADULTS & CHILDREN identified by ACA criteria 49.7% female and 50.3% maleFOR CHILDREN identified by ACA criteria 27.0% female and 73.0% male
  • - The California Children’s Hospitals served over 1.5 million outpatient visits last year and on average, their patient population is over half medi-cal. - Some of the hospitals regularly have medi-cal patient populations above 70%. - All the Children’s hospitals are CCS tertiary care centers
  • In comparison to the United States, Children in California are less likely to have private insurance, more likely to have public insurance, and more likely to be uninsured.¾ of the uninsured children in California are actually eligible for Medi-Cal but are not enrolled
  • In comparison to the United States, Children in California are less likely to have private insurance, more likely to have public insurance, and more likely to be uninsured.¾ of the uninsured children in California are actually eligible for Medi-Cal but are not enrolledThis population (click) encompasses the following programs.
  • Medi-Cal, Healthy Families, Healthy Kids (County only), AIM/CalKids, Kaiser, and finally CCS (click).Of the 4.85 million children in public insurance programs, more than three quarters are in Medi-Cal.Medi-Cal’s share will increase in 2013 as kids in the Healthy Families program are transitioned into Medi-Cal.While children with special health care needs might be found in any of these state programs, the sickest, most medically complex children are in the CCS Program
  • The access to private insurance for CSHCN is good compared to the rest of the nation (on average) however, (click) 37.9% of even privately insured CSHCN reported inadequate coverage as defined by lacking access to the proper provider, insurance not covering the right benefits, or not providing access to the benefits at an affordable share of cost.Also, is the case in the rest of healthcare, private vs. public health coverage rates for low-income, minority, and disadvantaged populations reflect a different balance between access to public vs. private insurance coverage.
  • The Affordable Care Act will eliminate or substantially reduce some of the barriers to adequate coverage for privately insured CSHCN but the resource intensity of their care and shortage of pediatric subspecialists will continue to affect their access to high quality care.
  • Examples of other disability programs: California Regional Centers coordinate care for developmental disabilities – specifically Intellectual Disability,Cerebral Palsy, Epilepsy, Autism, or adisabling condition closely related to intellectual disability or requiring similar treatment.
  • For CCS/Healthy Families and CCS/Medi-Cal, children are currently carved out of managed care plans meaning that all care related to their CCS eligible condition is provided on a FFS basis and all other care is provided by the managed care plan.
  • 1. Research also shows that children with CCS coverage have better outcomes than similarly diagnosed children with only private insurance.2. For example: Standards for CCS designated tertiary care centers like the children’s hospitals run 30 pages long3. By design, the program is intended to serve low-income families. They may have other social service needs.
  • Comprehensive list of mandatory and optional services, with strict cost-sharing limitsnote the last item on the list of mandatory services – EPSDT. It’s vitally important to Medicaid enrolled-CSHCN so let’s talk about it in a little more detail....
  • “Age trumps pathway”so everything that you saw on the list of optional services is included for kids under EPSDT....however, there is no standardized federal definition of medical necessity – states have discretion in interpreting it. So variability between states in what’s considered medically necessary and covered and what isn’t.
  • I mentioned the Essential Health Benefits briefly in my description of Covered California – now that I’ve given you a taste of their context in the Exchange, let me turn now to the next speaker, Margaret MacManus, who will give you some more detailed information on the EHBs under Covered California and their importance to CSHCN.....
  • Notes can go here
  • MediCal FFS only.Among the high-cost kids (top 10%) in 2010 who were enrolled for all 4 years: 34% were also high cost in each of the 3 previous years;62% were high cost in the previous year (2009).
  • Transcript of "Legislative Briefing: Children with Special Health Care Needs in California "

    1. 1. Children with Special Health Care Needsin California: Legislative BriefingApril 18, 2013David Alexander, MDPresident and CEOLucile Packard Foundation for Children’s Healthwww.lpfch-cshcn.org
    2. 2. Service ProvidersVariable Access to Care Depending On:• The Condition You Have• Where You Live• How Much $$ You Have• The Insurance You Have• Your AgeVariable Quality StandardsMinimal Outcome MeasuresVariable Coordination of CareP R I N C I P L E S & S T A N D A R D SF R A G M E N T A T I O NSubspecialty-Driven Care; Treatment-driven, Not proactiveVariable Coordination of CareMedical Care and Family Support ServicesCommunityHospitalRegionalCenterFamilyResourceCenterSpecialtyPhysicianAdditional Variables: Conditions within Family • Culture • Pro-activeness of FamilyChildren’sHospitalPCPPharmacyParentCenterFederalMedicaidFederalTitle VFederalSCHIPCalChildren’sServices(CCS)FederalMedicare:(End Stage Renal Disease)PrivateInsurancePatient &FamilyM E D I C A L H O M E U N D E R F U N D E DI N C O N S I S T E N T A C C E S S & Q U A L I T YExisting System for Childrenwith Special Health Care Needs inCaliforniaPatient&FamilyFragmented Payment System:Each pays according to different guidelines.Eligible conditions overlap among some payors.RegionalCentersStateHealthyFamilies(SCHIP)PayorsVarying CoverageDepending On:• The Condition You Have• Where You Live• How Much $$ You Have• The Insurance You Have• Your AgeInadequate reimbursementDelivery system for children isunderfunded;Leads to shortage of providersF R A G M E N T A T I O N O F C O V E R A G EStateMediCalState58Counties
    3. 3. Unified Payment System:Each Pays its ShareQualifying ConditionsUnified Access Rules: Yes or NoAn Enhanced System for Childrenwith Special Health Care Needs inCaliforniaConsistentAccountabilityMedical Care and Family Support ServicesPatient&FamilyPrivateInsuranceFederal StateConsistent Guiding Principles& Quality StandardsCare CoordinationThrough an EffectiveMedical HomeE F F E C T I V E, F U N D E DM E D I C A L H O M EPayorsQualifying Conditions AreConsistent State-WideReimbursement is AdequateServiceProvidersConsistent Guiding Principles,Quality Standards, & QualifyingConditionsCoordinated CareEvidence-based CareDefined Outcome Measures
    4. 4. Existing SystemUnified Payment System: Each Pays its ShareQualifying ConditionsUnified Access Rules: Yes or NoMedical Care and Family Support ServicesPatient&FamilyPrivateInsuranceFederal StateConsistent Guiding Principles& Quality StandardsE F F E C T I V E, F U N D E D M E D I C A L H O M EEnhanced SystemPatient&FamilyFederalMedicaidFederalTitle VFederalSCHIPCal(CCS)FederalMedicarePrivateInsuranceStateM E D I C A L H O M E U N D E R F U N D E DI N C O N S I S T E N T A C C E S S & Q U A L I T YStateMediCalRegionalCenters58CountiesStateSCHIPMedical Care and Family Support ServicesF R A G M E N T A T I O N O F C O V E R A G EP R I N C I P L E S & S T A N D A R D SF R A G M E N T A T I O N
    5. 5. Children with Special Health Care Needsin CaliforniaLegislative BriefingCalifornia State AssemblyApril 18, 2013www.lpfch-cshcn.org
    6. 6. Prevalence, Characteristics andExperiences of California’sChildren with Special Health NeedsCalifornia Legislative BriefingApril 18, 2013Christina Bethell, PhD, MPH, MBAProfessor, OHSU School of MedicineDirector, The Child & Adolescent Health Measurement Initiative
    7. 7. Why? Optimize health and wellbeing of California’s childrenHow can we optimize earlyand life-long health of children,youth and families inCalifornia?What can we learn to informefforts to leverage, modify orrenew the current system ofcare in California?Why?
    8. 8. “CSHCN are those who have or are at increased risk for a chronicphysical, developmental, behavioral, or emotional condition and whoalso require health and related services of a type or amount beyondthat required by children generally” Current CSHCN –existing condition resulting in above routine needor type of health care and related services (5 item screener) At risk (examples) diagnosis, but no above routine need or use unclear chronicity, above routine need or use meets criteria for being “at risk” of developmental problems born premature or low birth weight but not yet CSHCN psychosocial risks strongly associated with health (e.g. AdverseChildhood Experiences, etc.)Who Are Children With SpecialHealth Care Needs (CSHCN)Why Not Define by Diagnoses?• Common DX errors, misses and miscoding• Significant within DX variation in needs• Significant across DX similarities• Multiple conditions is the norm• Needs naturally vary across time within any DX• Supposedly “non-serious” DX can be very seriousdepending on co-morbidities and psychosocialcontext
    9. 9. Overall Prevalence andVariation by Race/Ethnicity% CSHCNData Source: 2011/12 National Survey of Children’s HealthNATIONWIDE15.085.0Children age 0-17 years% CSHCN10.6 13.218.331.910.6010203040Overall Hispanic White, NH Black, NH Other, NHPrevalence of CSHCN by Race/Ethnicity inCaliforniaCALIFORNIA (1.4 Million)% CSHCN % CSHCN19.880.2Children 0-17 years% CSHCN
    10. 10. Demographic Characteristicsof California’s CSHCNNon-CSHCN CSHCNCSHCN with ComplexHealth NeedsAge0-5 years 36.2% 18.8% 18.1%6-11 years 32.0% 38.0% 38.8%12-17 years 31.8% 43.2% 43.1%SexMale 49.4% 58.1% 60.4%Female 50.6% 41.9% 39.6%Race/EthnicityHispanic 25.2% 17.4% 18.9%White, NH 51.5% 56.8% 55.9%Black, NH 12.8% 16.4% 16.0%Other, NH 10.5% 9.3% 9.2%HouseholdIncome Level0-99% FPL 22.2% 23.6% 27.5%100-199% FPL 21.5% 21.6% 22.4%200-399% FPL 28.3% 27.9% 26.7%400% or more 28.0% 26.9% 23.4%DATA SOURCE: 2011/12 National Survey of Children’s Health
    11. 11. Prevalence and Medical Expendituresfor CSHCN: By Complexity(For reference: Non-CSHCN average expenditures: $856).Prevalence Data: 2011/12 National Survey of Children’s Health; Expenditures Data: 2008 MEPS$4003$4866$6755
    12. 12. Expanding Our Reach:Importance of a Broad ViewDATA SOURCE: 2011/12 National Survey of Children’s Health (2011/12 NSCH).*Number of conditions is based upon the list of 18 conditions included in the 2011/12 National Survey of Children’s Health, including ADD/ADHD,anxiety problems, asthma, autism/ASD, behavioral problems, brain injury or concussion, depression, developmental delay, diabetes, hearingproblems, intellectual disability, bone/joint/muscle problems, learning disability, epilepsy or seizure disorder, Tourette Syndrome, vision problems.**Almost half of children (47.9%) nationally have 1 or more Adverse Child/Family Experiences, with 44.3% of children in California.Nine Adverse Child/Family Experiences were included in the survey: (1) socioeconomic hardship, (2) divorce/separation of parent, (3) death ofparent, (4) parent served time in jail, (5) witness to domestic violence, (6) victim of neighborhood violence, (7) lived with someone who was mentallyill or suicidal, (8) lived with someone with alcohol/drug problem, (9) treated or judged unfairly due to race/ethnicity.Non-CSHCN;No named conditionsNon-CSHCN;1+ conditionsCSHCN;1+ conditionsOverall Health StatusExcellent/Very Good82.3% 73.2% 53.1%11+ Missed School Days (6-17) 2.2% 9.7% 22.5%High levels of parentingaggravation with child11.5% 16.3% 32.2%Nation CaliforniaChildren with Current Chronic Conditions andSpecial Health Care Needs (CSHC)19.8% 15.0%Non-CSHCN Who May Be At Risk for Special Health Care NeedsChronic Conditions (1+ of 18 conditions assessed) -but not CSHCN 8.1% 8.1%Met 1+ CSHCN Consequences (but not condition/duration CSHC criteria) 10.3% 10.3%Risk of Developmental Delay: Moderate or Severe (PEDS) (< age 6) 20.2% 20.2%Adverse Child and Family Experiences (2+ of 9 assessed) 15.5% 15.5%Born Premature 8.1% 8.1%Overweight/Obese: (age 10-17) 22.3% 23.3%Non-CSHCN: 1+ risk factors 39.0% 39.7%CSHCN + Non-CSHCN With 1+ Risk Factors 58.8% 54.7%
    13. 13. Positive and Protective HealthIndicators: By CSHCN StatusCaliforniaNon-CSHCNCaliforniaCSHCNProtective Home Environment(no smoking in home; share meals; limit TV…)28.7% 19.5%Neighborhood Safety & Support 56.8% 53.9%Factors that Promote School Success 63.3% 53.0%Resilience: Age 10 months-5 years 81.5% 63.0%Resilience: Age 6-17 years 68.0% 62.7%Met All Flourishing Components: (6-17) 51.7% 43.2%11+ Missed School Days (6-17) 3.0% 20.8%High Levels of Parenting Aggravation w/Child 12.0% 27.8%DATA SOURCE: 2011/12 National Survey of Children’s Health
    14. 14. Health of the Family:Parental HealthParental Overall Health Status (Physical & Mental/Emotional) by CSHCN StatusCSHCN with More Complex Needs are noted with dark blue dotted line.DATA SOURCE: 2011/12 National Survey of Children’s Health55.3%49.0%59.5% 57.9%0%10%20%30%40%50%60%70%Non-CSHCN CSHCNCaliforniaMothers Overall Health isExcellent/Very GoodFathers Overall Health isExcellent/Very Good
    15. 15. Health Care Quality SummaryMeasure (All Children)AKTXCAMTAZNVNMCOIDORUTKSWYNESDILMNOKFLIANDMOGAALWAARWILANCPANYMSMITNKYINVAOHSCMEWVVTNHMACTDENJDCMDRI!HIState RankingHigher=Better PerformanceSignificantly higher than U.S.Higher than U.S. but not significantLower than U.S. but not significantSignificantly lower than U.S.Statistical significance: p<.05Nationwide:39.0%California:31.7%(Ranks Lower 5)Health CareQuality:• Adequate HealthInsurance• PreventiveMedical Visit inPast Year• Has a MedicalHomeDATA SOURCE: 2011/12 National Survey of Children’s Health
    16. 16. 31.7% 32.6%26.4%0%5%10%15%20%25%30%35%All Children Non-CSHCN CSHCNPrevalence of Meeting MinimumQuality Index Among Children inCalifornia, by CSHCN StatusHealth Care Quality SummaryMeasure (CSHCN)DATA SOURCE: 2011/12 National Survey of Children’s Health18.2%34.2%0% 10% 20% 30% 40%CSHCN with PublicInsuranceCSHCN with PrivateInsurancePrevalence of MeetingMinimum Quality Index AmongCSHCN in California, byInsurance TypeDATA SOURCE: 2011/12 National Survey ofChildren’s Health
    17. 17. Developmental screening refers to a child (age 10 months-5 years) beingscreened for being at risk for developmental, behavioral and social delaysusing a parent-reported standardized screening tool during a health carevisit.Key OpportunityDevelopmental ScreeningDATA SOURCE: 2011/12 National Survey of Children’s Health01020304050Overall Overall Non-CSHCN CSHCN PublicInsurancePrivateInsuranceNationwide California30.8 28.5 27.141.827.7 29.4
    18. 18. Consistent and AdequateHealth Insurance60.6% 57.9% 59.1%0%10%20%30%40%50%60%NATIONWIDE TEXAS CALIFORNIACOMPONENTS OF CONSISTENT ANDADEQUATE HEALTH INSURANCE1. CSHCN who are currently insured 96.5%2. CSHCN who have consistently had insurancefor past year91.7%3. CSHCN with adequate health insurance 62.8%3a. CSHCN’s health insurance offerbenefits or cover services that meethis/her needs83.0%3b. CSHCN’s health insurance allowhim/her to see the health care providershe/she needs86.4%3c. CSHCN’s health insurance premiumsor costs reasonable71.2%DATA SOURCE: 2009/10 National Survey of Children with Special Health Care Needs
    19. 19. Medical Home The American Academy of Pediatrics (AAP) description of a "medical home" listsseven defining components: accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective.43.056.0 64.676.638.352.7 61.2 66.1020406080100Prevalence of Medical Home Overall andSubcomponents, Nationwide vs CaliforniaNationCaliforniaDATA SOURCE: 2009/10 National Survey of Children with Special Health Care NeedsCalifornia State Ranking onMedical Home Overall andSubcomponentsOverall Medical Home 44thCare Coordination 46thFamily-Centered Care 44thProblems AccessingNeeded Referrals50th54.2%29.2%0102030405060Less Complex HealthNeedsMore Complex HealthNeedsPrevalence of Medical Home inCalifornia, by Complexity of Health CareNeeds70% of CACSHCN
    20. 20. Medical Home:Care Coordination (CC)DATA SOURCE: 2009/10 National Survey of Children with Special Health Care Needs56.0 52.7 45.870.1020406080Overall Overall More ComplexHealth NeedsLess ComplexHealth NeedsNationwide CaliforniaReceipt of Effective Care Coordination whenNeeded, California and Nation, by Complexity of HealthNeeds and Insurance TypeCSHCN ReceivingCare CoordinationMoreComplexCSHCNLessComplexCSHCN% CSHCN 2+ services(qualify for CC items)83.7% 59.5%% 2+ getting any CC help 22.2% 19.5%% very satisfied with doctor-doctor communication 44.8% 33.1%% very satisfied with doctor-school communication 52.8% 21.8%Summary Measure: % who received effective carecoordination, when needed45.8% 70.1%
    21. 21. Shared Decision-MakingCSHCN whose families are partners in shared decision-making: California ranks last (51st) in the nationDATA SOURCE: 2009/10 National Survey of Children with Special Health Care Needs69.957.301020304050607080Less Complex Health Needs More Complex Health NeedsCaliforniaPrevalence of Shared Decision-Making for Nation vsCalifornia, by Complexity of Health Care Needs
    22. 22. Transition to AdulthoodYouth with special health care needs who receive the servicesnecessary to make appropriate transitions to adult health care, workand independence -- CSHCN age 12-17 years onlyDATA SOURCE: 2009/10 National Survey of Children with Special Health Care Needs40.0 37.449.330.20102030405060Overall Overall LessComplexHealth NeedsMoreComplexHealth NeedsNationwide CaliforniaPrevalence of Youth Transition toAdulthood, California vs Nation, byComplexity of Health Care NeedsComponents of Youth Transition inCalifornia:Anticipatory Guidance: Over half ofadolescents (58.4%) did not get all neededanticipatory guidance• Discuss shift to adult health care providers• Discuss changing health needs as youthbecomes an adult• Discuss health insurance as youth becomes anadultSelf-Management Skills: Almost ¾ ofadolescents have doctors who encourageself management skills (73.7%)• Older youth are more likely to beencouraged (12-14: 65.4%; 15-17: 81.2%)
    23. 23. Impact on the FamilyCSHCN whose conditions cause family members to cutback or stop working California ranks last (51st) in the nationDATA SOURCE: 2009/10 National Survey of Children with Special Health Care Needs29.445.637.728.319.47.441.4010203040500-99% FPL 100-199% FPL 200-399% FPL 400% FPL ormoreLess ComplexHealth NeedsMore ComplexHealth NeedsCaliforniaOverallHousehold Income Level Complexity of Health NeedsPrevalence of CSHCN whose conditions cause family members to cut backand/or stop working in CALIFORNIA, by Household Income and Complexity ofHealth NeedsFPL refers to Federal Poverty Level, as defined by the Federal Registerissued by the Department of Health and Human Services.
    24. 24. Health Insurance and WorkCSHCN whose family member(s) avoided changingjobs in order to maintain health insurance for childDATA SOURCE: 2009/10 National Survey of Children with Special Health Care Needs17.722.017.424.5051015202530Overall Overall Less ComplexHealth NeedsMore ComplexHealth NeedsNationwide CaliforniaFamily member(s) avoided changing jobs due tohealth insurance coverage, California vsNation, by Complexity of Health Care NeedsCaliforniaranks 46thin thenation onthismeasure
    25. 25. Comparing Prevalence and Utilization of Children who Qualify on CSHCN Screener, comparedto Affordable Care Act (ACA) Medical Home Section 2703 Condition List*. Average totalhealthcare expenditures and average number of office-based healthcare visits in past year.Data Source: 2008 Medical Expenditures Panel Survey (2008 MEPS)The Importance of SelectingIncentives Carefully: Medical Home$3,822 $4,003$2,509$5,947$3,060$0$1,000$2,000$3,000$4,000$5,000$6,000$7,000Meets ACA Criteria(US Prev: 6.2%)Meets ComplexCSHCN Criteria(US Prev: 10.4%)Meets ACA Criteria;Non-CSHCN/LessComplex(US Prev: 2.3%)Meets ACA Criteria;Complex CSHCN(US Prev: 4.1%)Does not meet ACACriteria; ComplexCSHCN(US Prev: 6.7%)Office Visits:8.6Office Visits: 7.6Office Visits: 5.2Office Visits:10.5Office Visits: 5.7*ACA Medical Home Section 2703 outlined diagnosis-based criteria for eligibility. This included having (1) One serious mental illness,and/or (2) Two conditions on the list (asthma, diabetes, heart disease, and being overweight). HIV/AIDS is optional upon CMSapproval at state-level. (Public Law 111-148, Section 2703. March 23, 2010. Available at http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf)73.0%27.0%0255075100Proportion of Children Meeting ACACriteria, by GenderFemaleMale
    26. 26. If you have any questions, feel free to contact us:The Child and Adolescent Health Measurement Initiativewww.cahmi.orgEmail: cahmi@ohsu.eduFor more data on Children with Special Health CareNeeds, visit:National Data Resource Center (DRC) for Child and Adolescent Healthwww.childhealthdata.orgLike us on Facebook:Follow us on Twitter: @childhealthdataQuestions or Further Information
    27. 27. CCS Medical Eligibility California Children’s Services offers assistance tochildren who have a health problem covered by CCS(and meet additional criteria related to household income): Infectious Diseases Neoplasms Endocrine, Nutritional, and Metabolic Diseases, and Immune Disorders Diseases of Blood and Blood-Forming Organs Mental Disorders and Mental Retardation Diseases of the Nervous System Diseases of the Eye Diseases of the Ear and Mastoid Diseases of the Circulatory System Diseases of the Respiratory System Diseases of the Digestive System Diseases of the Genitourinary System Diseases of the Skin and Subcutaneous Tissues Diseases of the Musculoskeletal System and Connective Tissue Congenital Anomalies Perinatal Morbidity and Mortality Accidents, Poisonings, Violence, and Immunization ReactionsIt is important to considerwhether the diagnostic-based approach iscapturing the childrenthat could benefit mostfrom services.• Capturing children withless complex health careneeds• Missing children withmore complex healthneeds without thespecific diagnoses
    28. 28. Children with Special Health Care Needsin CaliforniaLegislative BriefingCalifornia State AssemblyApril 18, 2013www.lpfch-cshcn.org
    29. 29. STATE PROGRAMS FORMEDICALLY COMPLEXCHILDREN:WHO IS COVERED? WHO ISN’T?Bernardette ArellanoDirector of Government RelationsCalifornia Children’s Hospital Association
    30. 30. California Children’s HospitalAssociationCCHA has been providing leadership and advocacy on behalfof the eight independent children’s hospitals in California for morethan 20 years. We are driven by the ideal that every child requiresaccess to the high quality, cost-effective primary, preventive andspecialty health care services available at children’s hospitals.
    31. 31. Topics• Children’s Insurance Coverage• Insurance by California State Program• Covering Children with Special Healthcare Needs(CSHCN)• Private Health Insurance• California Children’s Services Program (CCS)• CSHCN
    32. 32. The Basics9 Million Children in California• Private Insurance: 3.05 million children• Public Insurance: 4.85 million children• Uninsured: 1.1 million children1.4 Million Children in California have special healthcare needs
    33. 33. Sources of Coverage (California)
    34. 34. Covering Children with Special HealthCare Needs (CSHCN)64%28%8%58%37%6%Privately Insured Publicly Insured UninsuredCalifornia United States*Lucile Packard Foundation for Children’s Health, “Children with Special Health Care Needs: A Profile of Key Issues in California (2010)”37.9% of privatelyinsured CSHCNreportedinadequatecoverage in 2010Private Insurance vs. Public Insurance
    35. 35. Sources of Private HealthInsurance
    36. 36. Private Health InsuranceWhy is coverage sometimes inadequate?• Network and benefit variations between providers• Health insurance products tend to primarily focuson adults.• Information about the coverage may not beavailable when the parent(s) select a plan.• Parent(s) may select a health plan before theyhave/adopt a child, opting for a more restrictive butless expensive plan.• Employer sponsored health plan might not coverdependents.
    37. 37. Public Health InsuranceProgramsWhat are the options for families?• There are 8 public health insurance programsfor children in California, all with differenteligibility requirements.• Less medically complex children can accessservices through standard governmentinsurance products and with support fromother programs available to treat theirconditions.• The sickest, most medically complex childrenare covered by the California Children’sServices program.- Medi-Cal- Healthy Families- California Children’s Services- Kaiser Permanente Child HealthPlan- Child Health and DisabilityPrevention (CHDP)- CalKids (County only)- Healthy Kids (County only)- Access for Infants and Mothers(AIM)
    38. 38. CCS Program Overview• More than insurance: Diagnostic and treatmentservices, medical case management and physical andoccupational therapy services for eligible children under age 21.• Administered as a partnership between the state and county healthdepartments but shaped by the counties.• Funded through a combination of county, state, and federal dollars• Children access CCS in three ways:• CCS only (“Straight CCS”)• CCS/Medi-Cal• CCS/Healthy Families• Care for CCS conditions is “carved out” of managed care plans inmost CA counties until 2015*Source: DHCS CCS website
    39. 39. CCS EligibilityFamily IncomeRequirementsAge and CitizenshipstatusReimbursement ModelCCS Only Under $40,000or out of pocket costsfor eligible condition >20% of family’s grossannual incomeOR Medical TherapyProgram onlyUnder 21 years of age- Undocumented- Uninsured- Other insurance withqualifying out of pocketcostFee for ServiceCounty and state dollarsonlyCCS/Medi-CalHas full scope Medi-Caland a CCS eligiblecondition.Under 21 yrs of ageUS Citizen or PermanentResidentMedi-Cal managed carecovers preventative andnon-CCS related diagnosesFFS rates for eligibleconditionsCCS/Healthy FamiliesHealthy Families Eligibleand a CCS eligibleUnder 21 yrs of ageCalifornia ResidentTransitioning to Medi-CalManaged care but retainingHF funding ratio for non-CCS related diagnoses.FFS rates for eligibleconditions*Source: DHCS CCS website
    40. 40. CCS Eligible Conditions**Problems that are physically disabling, or need to betreated with medicine, surgery, rehabilitation.• Congenital heart disease• Cancers• Hemophilia and sickle cell• Serious chronic kidney problems• Spina Bifeda• AIDS• Cystic Fibrosis• Severe head, brain, or spinal cord injuries• Most children in CCS have more than one eligible condition• Some children are eligible for a short amount of time, some willbe CCS kids until they turn 21.
    41. 41. What makes CCS so special?• High quality, specialized providers and care centersthat tailor care to the child’s unique health care needs.• Providers that meet rigorous standards across the rangeof healthcare settings.• Case management, referral and connection toproviders, treatment centers, other state/county agencies.• Provides care that families would otherwise not be able toafford.
    42. 42. Insuring CSHCN - looking ahead• Even with CCS available, almost one quarter (24.2%)of California CSHCN have conditions that causefinancial hardship for their families.*• 28% of California CSHCN have families that pay $1,000 or more inout-of-pocket medical expenses annually.*• Persistent shortages in pediatric subspecialists, lowreimbursement, and lack of access to care in rural areas remainproblematic.• Need to protect and improve medically fragile children’s access tospecialty healthcare services in the new ACA environment.• Hospitals transitioning to risk based payment models – implications for high-riskpatients• Considering the needs of the medically fragile when designing integrated caremodels.• The California HBX and children with special healthcare needs• Section 1115 Waiver CCS Pilots and the future of the CCS program*LPFCH, “Children with Special Health Care Needs in California: A profile of key issues”
    43. 43. Bernardette ArellanoDirector of Government RelationsCalifornia Children’s Hospital AssociationBarellano@ccha.orgPhone: 916-552-7116Cell: 408-607-7726
    44. 44. Children with Special Health Care Needsin CaliforniaLegislative BriefingCalifornia State AssemblyApril 18, 2013www.lpfch-cshcn.org
    45. 45. Children with Special Health CareNeeds in Medi-Cal and the CaliforniaHealth Benefits ExchangeMeg Comeau, MHADirector, The Catalyst CenterBoston University School of PublicHealthApril 18, 2013
    46. 46. Medicaid Matters to ALL Children...But it’s especially important tochildren with disabilities and specialhealth care needs.Why? Because it offers comprehensive andaffordable health care coverage to low incomechildren who:• do not have access to private insurance;• cannot afford the premiums or the out-of-pocketcosts associated with private insurance;• need services not covered by private insurance
    47. 47. Children with special health care needs(CSHCN) by insurance categorySOURCE: National Survey of Children with Special Health Care Needs, 2009/10. Child andAdolescent Health Measurement Initiative, Data Resource Center on Child and AdolescentHealth website. Retrieved 4/13/13 fromhttp://www.childhealthdata.org/browse/survey/results?q=1810&r=6&r2=1Type of insurance % of CaliforniaCSHCN% of CSHCNin the USPrivate insurance only 60.0% 52.4%Public insurance only(Medicaid/CHIP)28.1% 35.9%Both public andprivate coverage8.3% 8.2%Uninsured 3.6% 3.6%
    48. 48. Medi-Cal: An Overview• State/Federal Partnership– Jointly funded (50/50 split in CA)– State administered program with flexibility underfederal guidelines• Eligibility for Children– Financial Need (family income <250% of FPL)– Medical Need (SSI enrollment)– Institutional Need (ex. Home and Community-basedService waivers)– Out-of-Home Placement (ex. children in foster care)
    49. 49. Covered ServicesMandatory Services• Inpatient and outpatient hospital• Physician services• Family planning services• Nursing facilities• Nurse practitioners• Laboratory and Dx imaging• Transportation• Home health services• Early Periodic Screening,Diagnosis and Treatment(EPSDT) for children under 21Optional Services• Prescription drugs• Occupational, speech andphysical therapies• Targeted case management• Rehabilitative services• Personal care services• Dental services• Hospice services18
    50. 50. Early Periodic Screening, Diagnosisand Treatment (EPSDT)• Applies to all Medicaid-enrolled children underage 21• Screening, diagnosis and subsequenttreatment of identified needs must beprovided even if the service is not included inthe state’s Medicaid plan• Thus, any medically necessary service forchildren is actually mandatory19
    51. 51. State Health Exchangesaka “the Marketplace”• Opening January 1, 2014 in each state• Choice of different individual and smallgroup (<100 employees) “Qualified HealthPlans” (QHPs)• Includes Essential Health Benefits (EHBs)• Help for consumers in choosing a plan• Help with affordability:– Subsidies between 100% and 250% FPL– Tax credits between 100% and 400% FPL
    52. 52. California Health Benefit Exchange:Covered California• State-based Exchange (one of 18)• Independent public entity within stategovernment with a five-member boardappointed by the Governor and theLegislature• CA was the first state to authorize anExchange after the ACA was signed
    53. 53. Medi-Cal,Covered California and CSHCN• Approximately 500,000 children are expected tobe eligible for coverage under CoveredCalifornia• ACA calls for integration of Medicaid, CHIP andthe Exchanges – even though there aredifferences in eligibility– Single application– Plan for seamless movement between them wheneligibility changes is necessary• Essential that they work together to ensure kidsstay covered!
    54. 54. For more information,please contact us at:The Catalyst CenterHealth and Disability Working GroupBoston University School of Public Health617-638-1936www.catalystctr.orgmcomeau@bu.edu
    55. 55. Children with Special Health Care Needsin CaliforniaLegislative BriefingCalifornia State AssemblyApril 18, 2013www.lpfch-cshcn.org
    56. 56. PRIVATE COVERAGE UNDER CALIFORNIA’S ACA:BENEFITS AND COST-SHARING REQUIREMENTS AFFECTINGCHILDREN AND ADOLESCENTS WITH SPECIAL NEEDSPeggy McManusThe National Alliance to Advance Adolescent HealthWashington, DCApril 18, 2013
    57. 57. Key Questions for Presentation1. How well does Kaiser’s benchmark plan meet the needs of children andadolescents with special health care needs?2. Are there particular services important to children and adolescents that arelimited or excluded from the benchmark plan?3. What differences in out-of-pocket payments(deductibles, copays, coinsurance) will families face inplatinum, gold, silver, bronze, and catastrophic plans?4. To what extent will families who qualify for cost-sharing subsidies beprotected from high out-of-pocket costs?5. What pediatric-specific requirements were part of CA’s qualified health plansolicitation?6. What critical issues should policymakers, families, and health careproviders focus on with the new private coverage options that California’sACA will be implementing?58
    58. 58. Funding and Approach• Funding: Packard Foundation for Children’s Health• Information Sources– Benefits: Kaiser’s benchmark plan and KP interview, CA’s ACA legislation, CAmandated benefits, and CCS interview– Cost-sharing: Covered California final standard benefit plan designs– Qualified health plan requirements: CA’s solicitation/RFP• Child/Adolescent Services– 48 services important to children and adolescents with special needs under 10essential health benefit categories• Final Policy Brief– Preliminary findings today (minus dental and vision services) and policy briefsubmitted to Foundation in next 2 weeks59
    59. 59. Important Background• Kaiser’s small group HMO plan was selected as CA’sbenchmark plan• CA prohibits insurers from making benefitsubstitutions, except for prescription drugs• CA also prohibits insurers from imposing treatmentlimits that exceed Kaiser’s benchmark plan• The Kaiser plan is the “reference” plan for most privateindividual and small group products sold inside andoutside of CA’s exchange starting next October60
    60. 60. More Important Background• Kaiser’s benchmark plan did not cover habilitative services orpediatric dental and vision services – two of 10 required essentialhealth benefits. CA supplemented Kaiser’s coverage to include:– Habilitative covered under the same terms as rehabilitative– Pediatric dental care covered as Healthy Families– Pediatric vision care covered as FEDVIP Blue Vision• State-mandated benefits important to children will becovered, including:– Asthma and diabetes treatment and equipment/supplies, FDA-approved contraceptives, PKU testing and treatment, mentalhealth parity, and behavioral treatment for PDD and autism61
    61. 61. How well does Kaiser’s benchmark planmeet the needs of children and adolescentswith special needs?• Very well! Kaiser offers a broad set of covered benefits for childrenand adolescents, mostly without visit limits• Certain services are especially expansive: preventive care (beyondACA requirements), mental health and substance abuse services(continuum of care), rehabilitative services, home health care, andskilled nursing facility care (more than most small groups cover)• Small group plans typically set very restrictive visit limits on servicessuch as ancillary therapies and home health, and fail to coverintensive outpatient care or residential treatment for mental healthand substance use disorders62
    62. 62. Are there particular services important tochildren with special needs that are limited orexcluded from the benchmark plan?• Benefit exclusions: family therapy, hearing aids, and cochlearimplants, and inpatient treatment beyond detoxification for chemicaldependency• Benefit limitations:– Intensive outpatient/partial hospitalization and residentialtreatment for mental health and substance use disorderscovered on short-term basis– Home care is covered up to 2 hours per visit and up to 3 visitsper day for 100 visits/year– Skilled nursing facility care is covered up to 100 days per benefitperiod63
    63. 63. What differences in out-of-pocket paymentswill families inplatinum, gold, silver, bronze, and catastrophicplans face?• Huge differences for families who do not qualify for cost-sharingsubsidies!• Actuarial values– Platinum: 88% (on average, family will pay 12% out of pocket)– Gold: 78%– Silver: 68.3%– Bronze: 60.4%– Catastrophic: 60.4%64
    64. 64. More cost-sharing differences• Deductible differences (per family)- Platinum and gold: NONE- Silver: $4,000 for certain medical services and $500 for brand-name drugs- Bronze: $10,000- Catastrophic: $12,800• Out-of-pocket limit on expenses (per family)- Platinum: $8,000- Gold, silver, bronze, & catastrophic: $12,80065
    65. 65. More differences• Copay or Coinsurance Amounts in Platinum versusBronze Plans– Ambulatory care (deductible in bronze applies after 1st 3 visits) PCP visit: $20 vs $60 Specialist visit: $40 vs $70– Emergency care (deductible applies in bronze) ER services: $150 vs $300– Hospitalization (deductible applies in bronze) Inpatient hospital room: $250/day up to 5 days vs. 30% Outpatient hospital fees: $250 vs 30%66
    66. 66. More differences– Lab services (deductible applies in bronze) Lab tests: $20 vs 30% CT/PET scan/MRI: $150 vs 30%– Rehabilitative/Habilitative Services and Devices (deductibleapplies in bronze) Therapy services: $20 vs. 30%– Prescription Drugs (deductible applies in bronze) Generic: $5 vs $25 Preferred brand name drugs: $15 vs $5067
    67. 67. To what extent will families who qualify forcost-sharing subsidies be protected from highout-of-pocket costs?• Quite a bit of protection for families at income levels from 100% FPL up to400% FPL, as required by ACA• Premium tax credit varies by income, ranging from the premium limit being2% of family income for families between 100-133%% FPL to 9.5% ofincome for those with incomes at 350-400% FPL.• Premium subsidies are only for the silver plan in the exchange.• Cost-sharing assistance subsidies available for those at 100-250% FPL• Out-of-pocket spending protections also vary by income, based onmaximum limits for Health Savings Accounts68
    68. 68. More on subsidized cost-sharing inCA’s Silver PlanDeductibles (family)100% - 150% FPL: None150% - 200% FPL: $1,000 for medical, $100 for drugs200% - 250% FPL: $3,000 for medical, $500 for drugsOut-of-Pocket Limit (family) for Covered Expenses100% - 200% FPL: $4,500200% - 250% FPL: $10,400Copays/Coinsurance for Selected ServicesPCP: $3 (100-150% FPL), $15 (150-200% FPL), $40 (200-250% FPL)Specialist: $5 vs $20 vs $50ER: $25 vs $75 (deductible applies) vs $250 (deductible applies)Hospitalization: 10% vs 15% (deductible applies) vs 20% (deductible applies)Generic drugs: $3 vs $5 vs $20Brand name drugs: $5 vs $15 (deductible applies) vs $30 (deductible applies69
    69. 69. What pediatric-specific requirements were partof CA’s qualified health plan solicitation?• Introduction recognized CA’s history of multi-specialty and organized medical groups• RFP emphasized contracting with providers and networks that have historically served low incomeand insured populations– Essential community health providers (eg, FQHCs, county hospitals and consider SBHCs)• RFP emphasized provider network adequacy– Yet, no requirement for identifying the PCP and specialists with pediatric certification– QHPs allowed to have 2-tiered in-network benefit levels with higher cost-share for moreexpensive in-network choice• RFP emphasized quality improvement– QHPs must report on pediatric and adult performance measurement (HEDIS)• RPF emphasized innovation– QHPs encouraged to describe medical home, QI, patient engagement, and communityprevention efforts70
    70. 70. What critical pediatric issues should policymakersconsider with implementation of new private coverageunder CA’s ACA?• Work with CCS and state AAP and AACP chapters to establish a clear definition of “medically frail”children exempt from private benchmark coverage. (Others exempt: children on SSI, in foster careor receiving adoption assistance, dual eligibles, the medically needy, and pregnant adolescents)• Review qualified health plans’ (QHPs’) adherence to Kaiser’s benchmark benefits• Examine QHPs’ prior authorization and medical necessity standards for children’s care• Review QHPs’ pediatric provider in-network services, including CCS providers and child andadolescent mental health providers, and also formulary• Ensure QHPs have mechanism to coordinate CCS benefits and inform families• Ensure family information and education about cost-sharing differences by plan type• Monitor access to care and experience among families whose children and adolescents havespecial needs at different income levels in different plans• Form a children’s ACA advisory group to assist in reviewing formularies, prior authorizationcriteria, provider adequacy, QI, and access to care.71
    71. 71. Critical Issues for Families and HealthCare Providers• Inform families who may qualify as disabled or medically frail or as a“special group” of their exemption from mandatory enrollment inbenchmark benefits• Encourage families, if able, to purchase the platinum or gold plans• Inform families about the cost-sharing liabilities in silver andespecially in bronze plans• Inform older adolescents and young adults and their families aboutthe cost-sharing liabilities in catastrophic plans• Encourage families to find out about participating providernetworks, noting the differences between the different “tiers” ofparticipating providers and the implications for out-of-pocketpayment liabilities and protections72
    72. 72. Children with Special Health Care Needsin CaliforniaLegislative BriefingCalifornia State AssemblyApril 18, 2013www.lpfch-cshcn.org
    73. 73. Juno DuenasApril 18 , 2013of California
    74. 74. What Works Well
    75. 75. MCHB Core Performance Measures• Families partner in decision making at all levelsand are satisfied with the services they receive• coordinated comprehensive care in a medicalhome• adequate private and/or public insurance to payfor the services they need• Children are screened early and continuously• Community-based services for children and youthare organized so families can use them easily• Youth with special health care needs receive theservices necessary to make transitions
    76. 76. What Works Well?Communitiesthatrecognize theparent as thecustomer andthe centralcarecoordinator
    77. 77. Families Partner In Decision MakingAt All Levels And Are Satisfied• Information AndEducation• At Risk Families• PlanningImplementationEvaluation• Copies of Reports• Peer ParentServices
    78. 78. Coordinated Ongoing ComprehensiveCare Medical Home Define CareCoordination Access To PrimaryAnd Specialists Autonomy To WorkDirectly With TheirProviders Continuity AndTime Training
    79. 79. Families Have Adequate PrivateAnd/Or Public Insurance• Clear Payment Policies• Payer Of First Resort• Clear Information What How andWho• Multiple Methods• Linguistic And CulturalResponsiveness
    80. 80. Children Are Screened Early AndContinuouslyScreenScreenScreen
    81. 81. Community-based services areorganized• Systems Issues Across At StateAnd Local Level• Community Based Information
    82. 82. Youth receive the services to maketransitions Infrastructure to develop andimplement transition plans Build capacity of adult care providers
    83. 83. AccountabilityAssessmentEvaluationTable
    84. 84. THANK YOU!!!
    85. 85. THE TRANSFORMATION OFCHILD HEALTH IN CALIFORNIAWhy The CCS Program Has BecomeCrucial To All Children In CaliforniaPaul H Wise, MD, MPHRichard E Behrman Professor of Child Health and SocietyProfessor of PediatricsStanford Universitypwise@stanford.edu650-725-5645
    86. 86. CHILD HEALTH IN THE UNITED STATESHAS BEEN TRANSFORMED• Sharp reduction in serious, acute diseases
    87. 87. CHILD HEALTH IN THE UNITED STATESHAS BEEN TRANSFORMED• Sharp reduction in serious, acute diseases• Concentration of illness, mortality andexpenditures in chronic diseases
    88. 88. CHILD HEALTH IN THE UNITED STATESHAS BEEN TRANSFORMED• Sharp reduction in serious, acute diseases• Concentration of illness, mortality andexpenditures in chronic diseases• However, chronic illness in children remainsrelatively rare compared with chronic illnessin adults
    89. 89. HEALTH STATUS AND LIMITATIONSBY AGE, US 2005 WHILE ALMOST HALF OFTHE ELDERLY ARE LIMITEDBY THEIR CHRONICCONDITIONS, LESS THAN 8PERCENT OF CHILDRENARE LIMITED BY CHRONICILLNESS051015202530354045<12 years 12–17years18–44years45–64years65–74years75+ yearsPercentHealth Status Fair/PoorLimited by Chronic ConditionSERIOUS CHRONICCONDITIONS ARE RARE INCHILDREN
    90. 90. CHILD HEALTH CARE SYSTEM MUST BEDIFFERENT THAN THAT FOR ADULTS• IN GENERAL, HIGH QUALITY SERVICESASSOCIATED WITH EXTENSIVE EXPERIENCE ANDHIGH VOLUME
    91. 91. CHILD HEALTH CARE SYSTEM MUST BEDIFFERENT THAN THAT FOR ADULTS• IN GENERAL, HIGH QUALITY SERVICESASSOCIATED WITH EXTENSIVE EXPERIENCE ANDHIGH VOLUME• BECAUSE SERIOUS CONDITIONS ARE RARE INCHILDREN, REGIONAL REFERRAL CENTERS WITHSPECIAL EXPERTISE WERE CREATED
    92. 92. CHILD HEALTH CARE SYSTEM MUST BEDIFFERENT THAN THAT FOR ADULTS• IN GENERAL, HIGH QUALITY SERVICES ASSOCIATEDWITH EXTENSIVE EXPERIENCE AND HIGH VOLUME• BECAUSE SERIOUS CONDITIONS ARE RARE INCHILDREN, REGIONAL REFERRAL CENTERS WITHSPECIAL EXPERTISE WERE CREATED• REGIONALIZED SPECIALTY CARE SYSTEMS SHOWN TOBE AMONG THE MOST IMPORTANT ADVANCES INMODERN PEDIATRICS
    93. 93. REGIONAL SPECIALTYCARE CENTERCH CH CHPRIMARYCAREPRIMARYCARETO ENSURE HIGH QUALITY SERVICES FOR SERIOUSLY ILL CHILDREN,RARE CONDITIONS MUST BE REFERRED FROM COMMUNITY HOSPITALS (CH)TO REGIONAL SPECIALTY CARE FACILITIES
    94. 94. THE IMPORTANCE OF THE CALIFORNIACHILDREN’S SERVICES PROGRAM• ARCHITECTURE FOR REGIONALIZED SPECIALTYCARE SERVICES IN CALIFORNIA
    95. 95. THE IMPORTANCE OF THE CALIFORNIACHILDREN’S SERVICES PROGRAM• ARCHITECTURE FOR REGIONALIZED SPECIALTYCARE SERVICES IN CALIFORNIA• PROVIDES REGIONALIZED STRUCTURE FORALL CHILDREN IN CALIFORNIA, NOT ONLYPOOR CHILDREN
    96. 96. CCS HAS BECOME MORE THANSAFETY NET PROGRAM• BECAUSE SERIOUS CONDITIONS ARE RARE INCHILDREN, PRIVATELY INSURED CHILDRENDEPEND UPON THE SAME REGIONALIZEDCENTERS AS CCS PATIENTS
    97. 97. CCS HAS BECOME MORE THANSAFETY NET PROGRAM• BECAUSE SERIOUS CONDITIONS ARE RARE INCHILDREN, PRIVATELY INSURED CHILDRENDEPEND UPON THE SAME REGIONALIZEDCENTERS AS CCS PATIENTS• ANY UNRAVELLING OF CCS REGIONALIZATIONWILL AFFECT THE CARE OF ALL SERIOUSLY ILLCHILDREN IN CALIFORNIA
    98. 98. A SMALL GROUP OFCHILDREN ACCOUNTFOR THE MAJORITYOF CCSEXPENDITURESEXPENDITURES IN CCS ONLY 10% OF CHILDRENACCOUNT FORAPPROXIMATELY TWO-THIRDS OF CCSEXPENDITURES PROVIDES REMARKABLEOPPORTUNITY TO REDUCEEXPENDITURES BYIMPROVING EFFICIENCYAND QUALITY FOR ARELATIVELY SMALL GROUPOF CHILDREN50340335174271200102030405060708090100Children AnnualexpendituresPercentChartTitle
    99. 99. CRITICAL CHALLENGES• PROTECT WHAT IS WORKING IN THE CCSPROGRAM – REGIONALIZED SPECIALTY CARE
    100. 100. CRITICAL CHALLENGES• PROTECT WHAT IS WORKING IN THE CCSPROGRAM – REGIONALIZED SPECIALTY CARE• EROSION OF CCS PROGRAM WILL AFFECT THEQUALITY OF CARE FOR ALL SERIOUSLY ILLCHILDREN IN CALIFORNIA
    101. 101. CRITICAL CHALLENGES• PROTECT WHAT IS WORKING IN THE CCSPROGRAM – REGIONALIZED SPECIALTY CARE• EROSION OF CCS PROGRAM WILL AFFECT THEQUALITY OF CARE FOR ALL SERIOUSLY ILLCHILDREN IN CALIFORNIA• WE KNOW WHERE THERE ARE MAJOROPPORTUNITIES TO IMPROVE CARE AND REDUCEEXPENDITURES
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×