In February 2009, 2 weeks after his inauguration, President Barack Obama signed the Children’s Health Insurance Program Reauthorization Act
Children’s Health Insurance Program Reauthorization Act of 2009, 42 USC, Public Law 111-3.
(CHIPRA), followed by the American Recovery and Reinvestment Act
American Recovery and Reinvestment Act of 2009, 42 USC, Public Law 111-5.
(ARRA) 2 weeks later. These events created a pivotal opportunity to enhance each state’s ability to measure the quality of care delivered through Medicaid and the Children’s Health Insurance Program (CHIP). Together, Medicaid and CHIP served nearly 40 million children during 2009, and Medicaid pays for nearly half of all births in the United States, making these programs a critical source of health care for children.
Since the CHIP program was created in 1997, states and the federal government have made significant strides in expanding and improving health coverage for low-income children through Medicaid and CHIP. Much of the progress has focused on increasing eligibility levels and making it easier for eligible children and families to enroll in public programs and stay enrolled for as long as they are eligible. States and the federal government struggled to bring a similar focus to quality management, with some states moving forward with comprehensive quality improvement programs and others lagging behind.
CHIPRA renews the federal commitment to measuring and managing children’s health care quality with a substantial new investment and a much needed infrastructure. CHIPRA establishes an evolutionary process in which states can participate to monitor their performance in assuring optimal health care quality, including the identification of a core set of health care quality measures for children. In addition, CHIPRA provides targeted funding for purposes of developing a pediatric electronic health record program and a model format that could be adopted over time to more effectively promote continuity of care and effective communication across health systems.
States enrolled an additional 2.6 million children in Medicaid and CHIP during fiscal year 2009, and the federal government did its part by temporarily boosting federal Medicaid matching rates under ARRA, providing $40 million in outreach and enrollment grants to 68 grantees across 42 states, awarding $73 million in performance bonuses to 9 states that demonstrated significant enrollment increases in Medicaid in concert with a series of streamlined enrollment and retention strategies, and offering new policy approaches designed to provide states new tools to enroll and retain eligible children. CHIPRA and ARRA also provided the Centers for Medicare & Medicaid Services (CMS) new authorities to work with state Medicaid and CHIP programs to improve the quality of health care through establishment of consistent, national quality improvement and data collection opportunities. This includes providing financial incentives to eligible health care providers under the Health Information Technology for Economic and Clinical Health Act
Health Information Technology for Economic and Clinical Health Act, 42 USC, Title XIII (2009).
(HITECH) to demonstrate meaningful use of electronic health records through the use of more efficient health care delivery processes, such as e-prescribing and clinical decision support tools, that ultimately improve patient safety and the collection of health information to assess health outcomes.
CHIPRA establishes the foundation for building a comprehensive, high-quality system of health care for children by addressing key components essential to quality improvement strategies. CMS is collaborating with federal and national expert partners to establish a voluntary quality measurement program, annual quality reporting procedures for Medicaid and CHIP, mechanisms for ongoing evaluation of the status of health care for children, and incentives to use a newly developed pediatric electronic health record format. On December 29, 2009, the secretary of the US Department of Health and Human Services released an initial core set of child health quality measures. Public comments on those measures are being used for developing technical assistance to states on voluntary reporting of those measures and for addressing opportunities for quality measures being developed under a new National Pediatric Quality Measures Program of grants and contracts being rolled out in 2010 and 2011.
Additionally, CHIPRA authorizes $100 million for states and state collaborative groups to test and evaluate approaches to assess and improve quality of care for Medicaid and CHIP. These grant awards were announced on February 22, 2010, and the following states/collaboratives received demonstration grant funding: Maine (with Vermont), Oregon (with Alaska and West Virginia), Pennsylvania, North Carolina, Florida (with Illinois), Massachusetts, Colorado (with New Mexico), Utah (with Idaho), South Carolina, and Maryland (with Georgia and Wyoming). The 5-year grant awards range in size from $7.8 million to $11.3 million.
Through these efforts we expect to learn:
promising practices for quality measurement and reporting that may be applied nationally, across populations and delivery systems
how health information technology might improve validity and reliability of information regarding quality of care—particularly for children with special health care needs—and increase transparency and accessibility for stakeholders
which provider models are the most effective and patient-focused when coordinating and transitioning care
how using a new electronic health record format might lead to a more comprehensive evaluation of health care delivery needs that are unique to children; this initiative will complement activities funded through the American Recovery and Reinvestment Act HITECH incentive provisions for electronic health records
broaden our understanding of methods for evaluating quality of care for other targeted priority areas (eg, medical homes and Early and Periodic Screening, Diagnostic, and Treatment)
Beyond providing the increased matching rates for Medicaid during the economic downturn, ARRA provides important incentives to encourage and enable new and evolving technology in electronic health records for exchanging health information across the health care system, regardless of the site of care. CMS released a final regulation in July 2010 that included criteria for meaningful use of electronic health records, in part to establish enhanced provider and state accountability and reporting on the quality of care delivered to Medicaid beneficiaries. CMS is working closely with the US Department of Health and Human Services Office of the National Coordinator in its efforts to issue certification requirements and standards for that technology to apply consistent and reliable mechanisms for documenting care.
The adoption and integration of all of these sophisticated systems will require a more comprehensive and collaborative relationship between state and federal agencies as well as the provider and beneficiary community. CMS is committed to supporting state efforts and will be establishing a specific plan for technical assistance to include webinars, learning networks, national workgroups and technical expert panels, state meetings, sharing of promising practices and lessons learned, and an annual CMS quality conference.
With the enactment of the Affordable Care Act of 2010,
The Patient Protection and Affordable Care Act, 42 USC, Public Law 111–148(2010).
CMS is adopting a similar process with respect to developing quality measures for adults. We are working productively with states, the provider, and beneficiary communities, and other stakeholders to ensure high quality of care through effective measurement of health care quality for children and ultimately all Medicaid and CHIP beneficiaries.
Children’s Health Insurance Program Reauthorization Act of 2009, 42 USC, Public Law 111-3. () ()
American Recovery and Reinvestment Act of 2009, 42 USC, Public Law 111-5. () ()
Health Information Technology for Economic and Clinical Health Act, 42 USC, Title XIII (2009). () ()
The Patient Protection and Affordable Care Act, 42 USC, Public Law 111–148(2010). () ()
The opinions expressed herein are those of the author and may not reflect the views of the US Department of Health and Human Services, the Agency for Healthcare Research and Quality, or the Centers for Medicare & Medicaid Services.
The authors have no conflicts of interest to disclose.
Publication of this article was supported by the US Department of Health and Human Services or the Agency for Healthcare Research and Quality .
Published by Elsevier Inc.