Improving Children's Health Through Health Services Research

Opportunities and Challenges for Children's Health Services Research

Patricia MacTaggart, Linda Bilheimer, Ph.D,
Alan Weil, J.D., M.P.P., Lois Salisbury, J.D.

Improving Children's Health Through Health Services Research was a special 1-day meeting held June 26, 1999, in Chicago. The state of the science in children's health services research was explored, including public and private funding opportunities, networks for conducting research, and uses of research in policy and practice. The meeting was co-sponsored by the National Association of Children's Hospitals and Related Institutions (NACHRI), with the Agency for Health Care Policy and Research (AHCPR), the American Academy of Pediatrics (AAP), the David and Lucille Packard Foundation, the Association for Health Services Research (AHSR), the Robert Wood Johnson Foundation, and Data Harbor, Inc.

Emerging Issues

Ms. MacTaggart provided an overview of emerging legislative and regulatory issues of importance to child health services researchers. Title XXI, Sections 2107 and 2108, emphasize accountability by addressing performance measurement, evaluation, and reporting of information to be used in holding providers and States accountable. Performance measurement focuses on:

• Insurance coverage.
• Access to care.
• Use of services.

Health Care Financing Administration (HCFA) reporting mechanisms include:

• Quarterly financial and statistical reports.
• An annual State report.
• State evaluation in March of 2000.
• An evaluation by the Secretary of Health and Human Services by the end of the year 2001.

Quarterly reporting has a number of components:

• Expenditures.
• Enrollment numbers for State Child Health Insurance Program (SCHIP) Medicaid expansion.
• SCHIP and Medicaid by age groups (0-1, 2-5, 6-12, and 13-18).
• Enrollment by service delivery system (managed care organizations, primary care case management models, and fee for service.)
• Enrollment by countable household income at cost sharing breaks, or if no cost sharing breaks, at less than or equal to 150 percent of the Federal poverty level or more than 150 percent of the Federal poverty level.

Annual reports for the previous fiscal year will address the progress of States toward reducing the number of uncovered, low-income children and their ability to meet their strategic objectives and performance goals.

States will be evaluated on the effectiveness of their plans in increasing the number of children with "creditable" health coverage and the effectiveness of other public and private programs in the State. The State evaluation will describe:

• The characteristics of children and families.
• Access to coverage by other health insurance prior to and after eligibility.
• Service area and time limits for coverage.
• Quality and sources of non-Federal funding.
• Activities to coordinate the State's SCHIP plan with other programs.
• Trends that affect access, affordability, and quality of health care for children.
• Description of plans for improving availability.
• Recommendations for improving the program.

These reports will include a number of sections:

• Environment: stakeholder involvement.
• Purchasing strategy: fee for service/capitation; mandatory/voluntary; who to contract with/where/when.
• Access and Quality: adequate network, cultural competency and compliance with the American with Disabilites Act.
• Evaluation and Reporting.
• Benefits and Delivery System: selective contracting and long-term care/acute care integration.
• Financing: reimbursement/risk adjustment methodologies.

These new developments suggest significant opportunities for child health services researchers to assist their States in responding to the Federal Government's requirements. With the increasing emphasis on children's health issues, insurance coverage for children, the desirability of a medical home, etc., research is needed.

Also, the knowledge and skills of child health services researchers are needed to address data issues such as:

• Lack of encounter data in managed care.
• Need for national, standard quality measures.
• Addressing income variations across States.
• Need for timely and immediate data and information.

As researchers work with their States to address the needs for information to evaluate these programs, they will need to keep in mind:

• The "small numbers problem."
• Issues related to Medicaid expansion and the evolution of the SCHIP program.
• State variation.
• The challenges of simplification, expediency, and research and policy needs.
• Race and ethnicity.
• Children with special health care needs.

New Federalism

Dr. Weil suggested that the trend toward New Federalism provides significant opportunities and challenges for children's health services researchers. He described new data being made publicly available from the New Federalism project. Case studies provide data about such areas of interest as the uninsured, knowledge about new programs, and reasons why families fail to apply for health care coverage. Survey and case study data are available on 13 focal States, with other data available for all 50 States.

The New Federalism project is defined by a number of characteristics:

• The breadth of health care issues of interest to the public and policymakers.
• Focus on national data, but with States as the unit of analysis.
• Focus on low income families.
• The extensive amount of data being collected and needed.
• Private funding.
• Demand for dissemination of knowledge gained through health services research (HSR).

Another component of New Federalism and its impact on health policy issues is the need for the examination of "cross-program" interactions. Examples include:

• The effects of welfare reform on Medicaid enrollment.
• The reliance of child welfare agencies on Medicaid funding.
• Health programs for immigrants.
• The relationship between health status and employment.

All suggest the need for complex methodologies to assess the impact of New Federalism on the health care system.

Research efforts related to the State Child Health Insurance Program (SCHIP) illustrate the types of health services research required to understand the impact and effectiveness of policy interventions. Much of the current SCHIP analysis is descriptive. Studies focus on the effects of this policy in a non-experimental environment, and require comparing similar populations in the same States, and comparing populations in states where there was no change. In addition, analysis is needed to understand the relationships among SCHIP, Medicaid, private insurance, and the uninsured.

Although there is considerable research related to New Federalism policies and their impact, much remains to be done. Children's health services researchers have opportunities to address a number of important areas:

• Traditional measures of quality, within State variations.
• Methods for using and matching administrative data sets to answer critical policy and research questions.
• The impact of broader market changes on the health and health care of children and adolescents, and their families.
• Research about often neglected populations and services, such as mental health, substance abuse, and children and adolescents with disabilities.

Other topics for research include:

• Trends and variations in insurance products and coverage.
• Public policy responses to access and insurance-related problems.
• The relationship between insurance (public, private, and none) and access to utilization of health care services.
• The changing environment for safety net providers.

Internet Citation:

Opportunities and Challenges for Children's Health Services Research. Presentation Summary, Improving Children's Health Through Health Services Research, Chicago, June 26, 1999. http://www.ahrq.gov/research/chsropps.htm

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