HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

CAHPS Title V Assessment

CARLA ZEMA: So Chuck gave everyone an overview of CAHPS and the program and the different surveys that are available, but really, what does this mean for Title V? We’re not here to tell you that every Title V program means to run out and conduct a CAHPS survey but there is significant overlap between Medicaid and SCHIP and Title V and you have seen us refer to a lot of the Medicaid version and initially back in the mid 1990’s, Medicaid were the drivers of the development of the survey and so when you say Medicaid version, it is really a State specific survey. It’s geared towards beneficiaries who cycle a little bit more frequently through the program, with Medicaid you on and you’re off and the same way in a lot of cases with Title V, is that your enrollment date is changing a lot and so some of the questions from the commercial version were based upon your last year of health care experiences and that just wasn’t practical in a State population. So the Medicaid version really refers to, again the similar type items, so that you have that standardization, but it’s really asking you the last six months rather than the last year, so when we say Medicaid version, it really does mean a State entitlement population that that survey is looking at.

So there has been some work done that shows the CAHPS Survey results can be used for your Federal Maternal Child Health Bureau reporting requirements. A lot of the CAHPS items will map to the domains and the key indicators and some of the outcomes that you are required to report on for your programs.

We want to focus on the potential for collaboration, there are many State Medicaid agencies that already administer the CAHPS survey and so we’ve begun to work with some Title V Programs, some Medicaid agencies and really say, how can we maximize our minimum resources that we have to get this type of information that’s beneficial to both programs, so that’s really what we want to focus on today.

Medicaid and SCHIP programs have come to the user network so we really are interested in coordinating a little more with Title V because we know that we have the same needs for information so we really want to understand what the collaboration would look like.

You may or may not already be aware of the National Survey for Child’s Health. There are actually CAHPS items that were used in that survey, as well as the National Survey for Children’s Special Healthcare Needs. Also, CAHPS items can be used to examine medical home, if you look at the AAP definition, 34 of the CAHPS items from the health plan survey with the children with chronic conditions module, map to six of the seven components of medical home.

So, I know you guys have been in presentations all day yesterday and for most of the day today so we really want to spend a little bit of time talking with you about, how do you measure, I know similarly when we talked with other States and other MCH programs, you really do struggle with getting data and just looking at some of the data sources you have available to you, certainly the two that we mentioned, give you information about children or beneficiaries within your State at the State level, but none of them really give you direct information about your program population and the population that you serve. So we really want to have a discussion of how are you measuring some of these domains, and these are the ones that are coming from your State key indicators, some of the Federal reporting requirements, and these are all areas where CAHPS will address.

Focusing on again, the importance of why do we care about the beneficiary’s perspective. Certainly you can measure access, for example, with administrative data or with other data sources but to really have a comprehensive view of access, you really need the beneficiary’s perspective to be able to say, you know, you can do a geographic mapping, you can do looking at office hours, looking at the infrastructure within your health care system but you really need the beneficiary to tell you, yes I could or could not get access to health care when I needed it.

So I would just like to take a moment if we can just kind of go around and you are more than welcome to move forward, we’re in such a large room and tell us what State you are from and what side of Title V you represent and if you just want to touch base on how do you currently measure these domains. So I am going to start right here in the front, you have to talk nice and loud.

JULIE: Hi I’m Julie Ganser from Indiana and I am sort of on both sides, I guess MCH and Children with Special Healthcare Needs and the reason I came was to see if this might be useful for Children with Special Healthcare Needs really, because I don’t think we can really (inaudible) much of this, I mean in this way at all. We have some home grown patient satisfaction surveys in the past. Preventative healthcare is a real issue in well both if you look at the information we’re supposed to be getting from Medicaid, which, did they have one (inaudible) or something, (inaudible) and then in our own sponsored projects we tried to look at, were they getting preventative healthcare but we never came up with a very good tool. So, we are not getting a while lot of this right now at all.

CARLA ZEMA: Your Medicaid program probably is and some of it is coming through the CAHPS surveys, again which is where we kind of see that natural infinity to say you both have very similar information needs and again, the flexibility with the modularity of the CAHPS survey, it makes it very easy for the survey to meet both program needs.

NANCY: I’m Nancy (inaudible) with Arkansas with the Children with Special Healthcare Needs Program and we’ve done some of those homegrown surveys ourselves and I did a poor job on this last year and that’s one of the promises I made to myself that we’ve got to get something better that actually measures what we need to do and I guess in the interpersonal aspects, I guess I need to understand the family perception of the quality. It may be something that I--it may be something on the target.

CARLA ZEMA: Well, we see a lot of that and I know with the SCHIP Programs actually mandated to do a survey and there are many States that again, kind of do the homegrown surveys because in some aspects it seems very easy to put together a survey of what you want to know, but from a survey development perspective, if you look at all of the cognitive interviews and the focus groups and all of that input goes into testing and developing items, there really is a benefit to using a standardized instrument and being able to compare so we can come up with Medicaid benchmarks, we can come up with SCHIP benchmarks.

NANCY : Does every state’s Medicaid program utilize this survey?

CARLA ZEMA: Not every State does, I believe at one time we had as many as 34 States and they cycle because some States do it every other year, so in any year you’ve got a slightly different number. We have some that use the majority of the CAHPS items, when you talk about State uses of surveys you become a little bit less standardized because State programs are so very different. But there still is kind of, it’s a caveat when you do any State benchmarking, you know, compare at your own risk.

CHUCK DARBY: At one time or other all there were all but two States that used CAHPS.

CARLA ZEMA: At one time all but two States have used CAHPS for, including all commercial Medicare and Medicaid, or commercial and Medicaid. So, again, we have a wide reach of use of CAHPS, and it really does, we can get you more information from the CAHPS user network if you have specific questions.

NANCY : So you would be able to tell us (inaudible) Arkansas (inaudible).

CARLA ZEMA: Absolutely, and not only that, you would be able to get access through the National CAHPS database for all of the States’ specific information as well.

UNKNOWN SPEAKER: A lot of things that we get are a lot of statistics for health departments. I think (inaudible), so for any assistance we did, surveys (inaudible) some of our University and (inaudible). I’m interested to find out if like Medicaid is using this (inaudible) forth coming and (inaudible), that they use this kind of thing and if it’s something that we can share.

CARLA ZEMA: Sure. We were just sitting in one of the earlier sessions and you know, in the same way that almost the Federal Government kind is more of SILO and that you deal with HRSA and CMS is dealing with Medicaid and they don’t talk to each other in a lot of ways. I mean you see that within many if not most States, the programs just don’t talk to each other and that’s why we are really starting to try to foster our conversation, if you will.

UNKNOWN SPEAKER: Their priority is not always our priority and our priority is not always theirs.

CARLA ZEMA: Absolutely. You’re with her. Okay. You want to come up here to the front?

MARIAN: I’m Marian (inaudible) and this--are Medicaid, (inaudible) programs. If first came to my attention, just recently, because I was looking at different survey models and ran across this and asked it was used, but I’m in the Children with Special Healthcare Needs, and you’re right a lot of questions are the same, but I’m really (inaudible) I’m here today to learn more about this so I can take it back and help withstand that collaboration and children who are in end-stage renal failure can qualify for can quality for Medicaid.

CARLA ZEMA: There you go, but we do not have a child version of the Medicare. Thank you.

TED RYAN: Hi, I’m Ted Ryan from Ohio. We have (inaudible) look at the national surveys and (inaudible) we got a survey with Medicaid (inaudible) a statewide survey that has something to say.

CARLA ZEMA: Absolutely, both Kansas and Ohio have been the initial adopters of CAHPS on the Medicaid side.

TED RYAN: We haven’t had, we’re just like everybody else, probably about five years ago, I had another contact with (inaudible) so I don’t.

UNKNOWN SPEAKER: I actually, and I’m from HRSA too. But I have a question (inaudible) the national survey for Children with Special Healthcare Needs. If the state has used, the tax on the Medicaid side and now we’ve got data from the national survey, how comparable is it?

CARLA ZEMA: Well, again, your populations are not going to be the same because the National surveys are really just a cross cut regardless of insurance type.

UNKNOWN SPEAKER: The National surveys can get state data and then you can break it down to (inaudible). The National survey for Children with Special Healthcare Needs can break it down so I can get Ohio ’s answers to the National survey and you can break it down, now the numbers become a little smaller.

CARLA ZEMA: Right.

UNKNOWN SPEAKER: But you can break it down to (inaudible).

CARLA ZEMA: The other thing that you would need to do with the National data is when you sample for CAHPS, there is a requirement that you have had at least one medical visit, so there is a claims data portion in your sampling so you would need to use your item that asks whether you have had and that subset would be a very similar, it should be a comparable version. Now some States sample differently among different eligibility groups and that’s kind of again the caveat, you really have to know how your State implements the Medicaid version because some sample differently.

Let’s go to the back table, in the middle. Introduce yourself and kind of tell us which side of the program you are on and if you want to give us some information on how you measure some of these topic domains.

UNKNOWN SPEAKER: Are we introducing our selves?

CARLA ZEMA: Yep, introduce yourself; kind of tell us which side of the program you’re on and if you want to give us some information on how you measure some of these topics, domains.

UNKNOWN SPEAKER: (Inaudible).

CARLA ZEMA: That’s fair. Can move here to the front? How about the front?

JENNIFER: I’m Jennifer (inaudible). Medicaid, you usually get higher numbers of enrollment and (inaudible) quality of care. We do ask that our friends (inaudible).

CARLA ZEMA: Okay.

NICK LORENZ: Nick Lorenz, MCH (inaudible) on the MCH side. Primarily, I guess what we do is publish the surveys such as (inaudible) and also some early childhood school based surveys, where we try to get population (inaudible) status, and access to begin, you know, the access for (inaudible) health status from the person (inaudible).

CARLA ZEMA: Right – absolutely.

NICK LORENZ: That’s what we do. And satisfaction also a great limit to the others and (inaudible) share decision making and so forth (inaudible).

CARLA ZEMA: Okay.

UNKNOWN SPEAKER: (Inaudible) I’m from North Dakota, I’m the MCH director. We actually, our (inaudible) coordinator has done an excellent job of making (inaudible) with Medicaid, Federal records, we have PRAMS, I want to hear (inaudible) I’m a fairly new director given the position about a year and a half. I guess I’m here to see if, I have several that are North Dakota, (inaudible) programs in my division now that have never been evaluated and I am just here to see if this would, if we could utilize this to evaluate some of the programs. We don’t have MCH, (inaudible) although we are getting one, it’s taking me a year and a half to get that position. But we’ve applied for Fellowship positions to help evaluate some of our other program needs, but unfortunately we’ve been accepted, but people are very often, they’re not like clambering to come to North Dakota. So, anyway I’m just here to see if this was meet the meets to do some evaluations for specific programming.

CARLA ZEMA: Okay, great. Your stories are very common themes that we hear. There is a mutual interest, even on the Medicaid side of coordinating. There are lots of barriers, as you may already know from trying to get information from your Medicaid agency. Most Medicaid and SCHIP programs already conduct some type of beneficiary survey; again, we average about 34 programs. Not all programs use the chronic condition set so if you’re here because your look interested in Children with Special Health Care Needs, when we say that no everyone has adopted that survey yet, so you really need to find out within your own State. And again, we think that this is a huge benefit because it is expensive to do a survey. It’s expensive for the Medicaid programs to do a survey. It’s expensive for the SCHIP programs, they are required to. So to the extent that we can work together across these agencies and maybe add a couple of items that will help the needs of both programs, that’s really the end goal.

There are lots of considerations so those of you who want to run back and find out if your State is doing this or find out how you can get information, you are absolutely correct that Medicaid Programs, they have different program goals, they are not the same as yours and they often make modifications to the survey that would be counter to your needs, so that’s definitely something to keep in mind. It’s very, very difficult to find the right person in the Agency that has the information about the CAHPS survey. I wish that I could tell you that it’s the same person within every State but within States we see a variety of different people that take responsibility for the CAHPS survey. We can connect you through the CAHPS User Network to the person, the Medicaid Agency contact that we work with through the National CAHPS Benchmarking database, and we would be happy to make that connection with you.

Medicaid programs define children with special healthcare needs differently for eligibility reasons. The actual definition that the Children with Chronic Conditions set was developed for it actually operationalizes the Maternal and Child Health Bureau definition. However, when States implement the survey, we found that a lot of times they change the items around because it doesn’t meet their definition.

There are lots of technical considerations that you need to think about in terms of again, survey content, sampling strategies, a lot of the State agencies sample according to their eligibility. So, for example, when they implement the children with chronic conditions set, they may only do it on their SSI population and sub-group and not their whole program, and again a different administration, different types of analyses that they do in different ways of reporting the data.

We recently, in mid-September had a Web cap you can access this from the CAHPS user network. We’ll soon have a transcript and a summary of that where KaraAnn Donovan from the Colorado Public, Department of Public Health and Environment, she is on the Children with Special Healthcare Needs side and she described her experiences with trying to get the data through their Medicaid Agency. She actually became knowledgeable about CAHPS from a web base search. She found out about the National CAHPS Benchmarking database before she even realized that she could have gotten that data within her own State. We actually helped her make the connection within her Medicaid Agency and then there are lots of challenges in terms of HIPAA requirement, different dissemination requirement. The National CAHPS Benchmarking database is linked to the survey sponsor so if it’s your Medicaid Agency if you want the release of your own State’s specific information, you will need the release from the survey sponsor. We can release research files that would have State level identification, but to go beyond that you would need the permission from the survey sponsor.

And so again, as Chuck mentioned, we are always reaching out to the users of CAHPS and all of our stake holders and we consider Title V programs to be very important stake holders within the CAHPS survey, so we really are interested in understanding if you are at all using information from beneficiary surveys. To think about how the consortium and how CAHPS can really support your needs, whether it is through the User’s Network in helping you make connections with your Medicaid Program, whether it’s the development of aspects that we may not look at within the survey but we want to help make our products meet all of our stake holders needs. CAHPS has really, we are in the CAHPS II phase now and the CAHPS II phase and all the work within the CAHPS II phase has really been driven primarily by User feedback.

So we have mentioned a lot about the CAHPS User Network and these are the ways that you can reach the CAHPS User Network. There is a toll free phone line that we offer free technical assistance, we can connect you up with different users, we can help you make the connection within your Medicaid Agency. Again, if you go out on the Website you will find information about the Web cast that we had and we will soon have the transcript of that out. So we really are again trying to focus on how to best serve State users needs as one audience.

So, what will we do with the feedback that you give us; this actually will help inform the development of CAHPS products. We are actually working to develop some specific technical assistance, focusing on States. Because State programs differ, it’s very difficult when, you know, we kind of say health plan service, the States use CAHPS and not necessarily they don’t have health plans but they might sample at the program level and still use the health plan survey. So we really are going to develop some tools that will help States select the appropriate survey item, supplemental items, based upon the differences in program structure.

At this point I am going to turn it over to Chuck again. He is going to tell you a little bit about the refinement process that we are going in now with the current health plan instrument in the development of a clinician group level instrument.