AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
TOM MILLER: MCH is in my blood. It's a pleasure to be here and to follow these two outstanding presentations.
And I've got to make a couple of comments. I think this is really at the heart and soul of what AMCHP is all about when you look at the opportunities for networking and learning about our states and how they grapple with issues and address challenges, and to have folks of this caliber who look from a national perspective through these surveys and contacts and pull all of that together is a vital part of what we're all about in terms of, I guess, lifelong learners and leaders in MCH.
I do want to follow what they have presented in terms of giving what's more a Title V director's viewpoint. And I'm going to recap.
Basically, Donna talked about the reversing trends in eligibility and enrollment in children's health insurance programs, and Chris talked about programatic initiatives, particularly in Medicaid, that look at improving the birth outcomes.
What I looked at doing was stepping back and saying, well, why is this important to us as MCH directors, as MCH leaders? And, again, it's the very foundation of what we're all about in terms of improving the health of our state's women and children.
And so I thought about our block grant process, and I went through and I kind of pulled some of the national performance measures and then the state performance measures for us here in Alabama, as well as our (inaudible) needs, and really did kind of a cross check, looking at the information Donna shared, and I'm capturing that broadly as health insurance, and then Christopher, improving birth outcomes.
So if you'll walk with me, I know a lot of people are on different levels in terms of how close they're associated with MCH block grant, but basically the feds promulgate national performance measures, so this will be familiar to some of you and to others it might not be as familiar. But this is in your state's block grant.
So that's the first piece. The second piece, I'm going to talk a little bit about Alabama 's SCHIP experience, relating it to some of the challenges that you heard from Donna, and then one particular initiative that we're doing to expand the coverage for the unborn maternity, unborn ‑‑ anyway, to expand SCHIP to cover maternity through the unborn coverage.
The first performance measure ‑‑ and I am really going to go through these fairly quickly ‑‑ this talks about newborn screening. That obviously is area where we're looking at improving birth outcomes. Again, think about the connection with programatic pieces that play out in Medicaid and other health insurance programs that Chris touched upon.
The second is CSHCN that has comprehensive ongoing care in a medical home. Again, medical home connotes having access and eligibility vis‑a‑vis health insurance.
The third one ‑‑ and the numbers don't flow that way. Really, if you look to the national performance measures, you can make some kind of a connection across the whole bunch of them individually, but I really pulled those that I thought were a lot easier to make a more up‑front connection than having to think as much about that.
National performance measure No. 4 again hits home at public insurance or private insurance as far as having that available to pay for needed services.
No. 8 looks at the rate of birth for teenagers age 15 to 17, and certainly that's an area in the domain of improving birth outcomes.
No. 11 talks about birth feeding ‑‑ breast‑feeding. I am sorry. Birth feeding? Let me tell you just a short diversion. You made an excellent comment that we get in our own worlds and we don't always ‑‑ bedside manner, you sit and explain to a patient about preeclampsia. Well, preeclampsia is like speaking Latin. You need to talk in terms of what your audience needs in terms of hearing and understanding. And there was some rich discussion yesterday, and the fellow, I hope he's not in this room, but he was talking about uninsured maternal patients show up at the hospital a lot of times crowning. And I'm obstetrician. I know what crowning is. How many people don't know what crowning is? Y'all are disapproving my point. It just hit me when he said that that how many people realize the baby's head is halfway out and it's just too late to do any planfull kind of things, certainly care coordination or whatever, in advance. Okay. Forget that point.
Breast feeding, improving birth outcomes. Percent of children without health insurance. Again this hits right at the heart and soul of what we're talking about here.
And then No. 14 is the percent of potentially eligible Medicaid children who receive a service paid for by Medicaid. That means they've gotten through certain of these checkpoints, if you will, along the pathway of eligibility and enrollment.
And then No. 15, the percent of very low birth weight infants among all live births, improving birth outcomes. That one as well.
The percent of very low birth weight infants delivered at high risk sorts of facilities, improving birth outcomes.
And what I'm going to do now is shift from the national performance measures to state specific. Each your states has to, based on the needs assessment process in developing their block grant application, has to develop their own state performance measures that are more the group that I call the customized or state specific that kind of meet your needs more on a local aspect. And for us, the first one is the degree to which my bureau, the Bureau of Family Health Services, addresses folic acid intake; certainly improving birth outcomes.
The second is, more broadly, the key MCH databases. We all know how important the epidemiological and data and statistical sorts of activities are, and I think those undergird both of these areas that we're talking about today.
The third one for the Alabama looks at assuring case management ‑‑ I think that came up several times in Christopher's presentation. In Alabama ‑‑ in our Patient First plan. That is our Medicaid plan's title for health insurance through Medicaid for the
children.
And then the fourth one for Alabama is, again, focusing on the percent of children in this age range in that Patient First program who get case management services.
Our fifth one again speaks to data. We have one at the state level that talks about the ‑‑ I'm sorry, this is on dental, utilization of dental services, health insurance, and then one on preventing adolescent pregnancy, improving birth outcomes.
And then our priority needs. This is flashing forward just a bit because what you just saw were the national performance measures coming from the feds, and then our states performance measures, those are what are currently on the books that we report on each year. We're in the process of developing new priority needs in the midst of our current needs assessment. So these are in draft, if you will. But our first one is to assure access to appropriate primary care, very much a health insurance issue, reducing infant mortality, especially addressing the disparity, the racial disparity, which is significant in our state, and then further reducing adolescent pregnancy rate. That goes with improving birth outcomes. And then maintaining and further developing the Title V program and our state's ability to do the data thing that I mentioned earlier, again, thinking that that undergirds both of these areas.
And then looking at the health education sort of thing with evidence‑based education and outreach along high‑priority topics. Again, I think that undergirds both of them.
What I shared with you is kind of an overview of why this really is part of our lives, what you heard the two previous presenters present, and I really tried to build a foundation for that and make the case for that through those elements of the block grant.
I'm going to shift now to talk just a few minutes about a couple of issues that are also relevant but, again, on a state kind of perspective. And I'm going to walk you through real briefly the All Kids program. This is our SCHIP expansion in Alabama . And our timeline ‑‑ as you know, the original Balanced Budget Act was in 1997. Alabama , in January of 1998, had the distinction, and I've considered it an honor, to have the first in the nation, the first plan approved in the nation. That early component was expansion of Medicaid, and then the phase II in October was the non‑Medicaid portion that covered children.
And you look across the different eligibility groups, you've got your Medicaid for low‑income families, SOBRA Medicaid, All Kids, and then Child Caring Foundation. Child Caring Foundation is a non‑profit Blue Cross/Blue Shield product for the higher‑income children.
These are the breakdowns on the percentages of the federal poverty level, and you can see the MLIF across the bottom is the lowest‑income individuals, and then you have the SOBRA Medicaid eligible. An important thing to note is Alabama historically forever has done the least possible in terms of federal requirements, and that's what you see depicted on this graph. We did take All Kids, though, to the 200 percent level, and you see the Child Caring Blue Cross product above that, up to 235 percent of poverty.
These are basically the income eligibility guidelines, just to refresh your memory, for those of you. See what happens when you lift slides from another presentation and you don't know how to get this automatic piece out?
But you see from March of 2004 the federal poverty level ranges for eligibility for those four different products.
And this was our All Kids enrollment kind of profile leading up to the third quarter of fiscal year '04, I guess about two quarters ago, and you can see that Alabama 's program reached about 60,000. I've seen some numbers in some of the more populous states or the states with more generous benefits in the 330, 400 and on up range, but this is where we are in terms of enrollments sorts of statistics.
We do have a low‑fee no‑fee premium cost‑sharing component that is in addition to the no‑fee aspect. It covers the general things that you would think about. And I want to point out on this slide in particular the dental services ‑‑ y'all just bear with me ‑‑ the dental services, because I'm going to mention that in just a minute. There's no preexisting clause exclusion, which is a good thing. Just the profile of what we do in terms of how the money is split across dental, prescriptions, physician services and hospital.
I want to tell you that what faced us is that we actually had to end up, because of cost issues and state dollars to drawn down the federal dollars, we had to look at how we wanted to address fewer dollars available. And you've seen a lot of different approaches states have taken from Donna's presentation. We decided, when we ultimately had to go ahead and put something into place, and that was depicted on one of our slides, but it was approximately October of 2003, that we had to do something to rein in the cost. And we decided philosophically that the better approach would be to freeze enrollment. The alternative is this menu of different approaches that I've listed a couple here. Change in eligibility requirements in terms of ratcheting down the federal poverty limit in terms of income eligibility. Barriers to enrollment. That would be income verification or having every six months or once a year eligibility determination or whatever.
The last one on this list, reducing benefits. You know, all these things come on the table when you're struggling with policy making to address the limited dollars. And we did have some discussion about dental benefits. Kind of been up for possibly eliminating them.
And at the end of the day, what folks felt like was that it was a better choice for us, all things considered, in Alabama to freeze enrollment, create a waiting list, if you will, instead of, I think, selecting some of these different things for cost savings that, I think you made the point very well, are very hard to undo, so to speak, in an easy way.
So we opted to freeze enrollment. And, fortunately, we were able to open up the waiting list and identify some additional dollars. And I think that was just probably within the six months or so, ballpark, from when we had the freeze. Again, the points I just made.
I want to spend just a couple of minutes on the currently underway plan to look at expanding SCHIP for maternity coverage. We're one of those states where the Hispanic influx has just been absolutely phenomenal, and we had several counties where this is a bigger issue than others based on local industry, on their location within the state, but also the local industry being those businesses that utilize them in terms of employment.
And right now the SOBRA eligibility is not covering, as a Medicaid program, not covering non‑citizens. And we do have the opportunity, as a lot of states have already done this, to provide care based on the unborn for those non‑citizens who are under 133 percent of poverty. This would cover prenatal and delivery services.
What we're looking at is a Medicaid look‑alike program, that's what we're currently considering. And our figuring right now is, best guess, is that we've got about 2000 individuals that would be eligible for this. We've used the $5,000 global maternity rate, and that gives us a total cost of about $10 million, 2 million of this at a 20/80 match rate would be the state's share. We're one of those states that has a very favorable match rate for the SCHIP program.
And when we look at Medicaid and what they're currently paying in terms of state dollars for the emergency coverage for Hispanic women, it's about 1.24 million, and so potentially we would need to cover the rest of the requirements for the state match with $760,000.
Now, nothing is written in stone. Actually, where we are with this is Medicaid right now is undergoing the process to put out the request for proposals and accept the bids from geographic district‑based providers who do the maternity business for Medicaid. And we have gotten Medicaid to agree to put a place‑holder, if you will, in that RFP that is kind of a contingency, if everything else works out, that those bidders would give a price for that enhanced component of what they say they would do with the knowledge that the money isn't nailed down and that all the other pieces, political and otherwise, have still got to be negotiated out.
But because of their time frame for rolling that out, which was already on the tracks, leaving train station, we did work with them to get that what I call, for lack of a better word, a place‑holder in that RFP. Whether or not it will come to pass, I don't know. I've got my fingers crossed.
And, in summary, what I want to do is step back, and what I hope I've shared with you is that the information from the national perspective on the trends around children's health insurance enrollment ‑‑ it's getting in and staying in, I like to call it ‑‑ is really a key piece of good outcomes for the MCH community and the people that we are concerned about, and that policy decisions that we all struggle with really are informed when we have knowledge of what other states are doing. So that was it.