More than 10 years ago, the Children’s Health Insurance Program (CHIP) sparked investments in child and adolescent healthcare quality measurement and improvement. On March 11, a panel of experts discussed progress and barriers to performance measurement and reporting in pediatric care.
The webinar was co-sponsored by the Agency for Healthcare Research and Quality, L&M Policy Research, and AcademyHealth.
Kamila Mistry, Ph.D., M.P.H., associate director of the Office of Extramural Research, Education & Priority Populations at the AHRQ, gave some background on the Pediatric Quality Measures Program (PQMP), an AHRQ and CMS partnership that's focused on developing and implementing pediatric quality measures in conjunction with state and private sector partners. Previously, there had been a dearth of pediatric quality measures, Mistry explained. “The overall goal is to improve quality of care for children, particularly those on Medicaid,” she said. Among the objectives are developing a portfolio of publicly available and new quality measures, strengthening partnerships with states and other public and private stakeholders, and building a knowledge base regarding the connection between measurement and improvement to facilitate use and uptake of measures.
The first phase of PQMP was launched in 2011 and focused on developing new measures. The second phase, launched it in 2016, focused on assessing the feasibility and usability of the new PQMP measures and also other core set measures at the state health plan, hospital and provider level to support performance monitoring. “We really aimed at looking at implementation of a subset of measures and kind of diving deep and looking at and using quality demonstration projects to increase our learning about feasibility and usability to improve quality of care in real-world settings,” she said.
All of the panelists agreed that there has been considerable progress in pediatric quality measure development over the last several years. However, Nathan Chomilo, M.D., medical director for Medicaid & MinnesotaCare at the Minnesota Department of Human Services, raised health equity issues and asked whether the quality measures are capturing what we need to improve health outcomes. “When we look at quality metrics, we have better outcomes for those who have private insurance or employer-sponsored insurance than we do for those in public programs,” he said, adding that there are racial disparities. Black and Native American communities, in particular, have poor quality metrics. “We have to figure out what this is telling us,” he stressed. “It makes sense that we would gravitate toward things that are easier to measure and capture at scale. But are the measurements getting us to make the changes that are needed?”
Kelly Kelleher, M.D., vice president of health services research at Nationwide Children’s Hospital in Columbus, Ohio, echoed Chomilo’s concern about equity. “It’s important that we come back to the fact that we are actually developing separate health systems in the United States for people who have very low incomes. The Federally Qualified Health Centers now see about 21 to 24 percent of all children in the United States. So we are saying there's a separate and potentially unequal, unmeasured health system for children who are extremely poor, and largely children of color and from minority or immigrant backgrounds. How we use quality measurement in those contexts is really unclear. That’s one area that's completely untouched with all this measurement we are talking about today.”
Mistry said that in terms of the roll-out of measures, there are issues around alignment and burden and data capacity. “There might be more meaningful measures, but can we do them? Do we have the capacity to do it? I think different states are at different levels in terms of this capacity. We really need to continue to evolve, we need to continue to innovate,” she said. “We're thinking about the idea of mentorship, where some states that are further ahead can help other states move forward. As Nathan said, I think this is about meaningfulness of measures. And that's the only way that we're going to have real impact on children at the population level.”
Kelleher said that when health systems are incentivized in the right way, fairly rapid change is possible. He pointed to the Meaningful Use incentives to make EHRs widespread as a success in this way. “I think, in quality measurement, we're still stuck in asking whether it is possible, and I don't think that that's the question. I think it is possible; we just have to choose how we're going to do it. What are the capacities of hospitals and states and others? Well, there are large healthcare institutions that are acquiring hospitals, consolidating, with lots of money in the bank, and they should be measuring and be held accountable for population-level measures of children. Because they have that accountability, in my opinion. It's equity, equity, equity, as Nathan pointed out, because if you don't measure the population level, all the people who aren't showing up don't get counted.”
The panelists were asked about the potential for pediatric value-based care models from the Center for Medicare & Medicaid Innovation.
Chomilo said he hasn’t seen models for value-based care and pediatrics at the level that we've seen them for adult care. One issue, he noted, is that a lot of the needs that are being addressed to help promote pediatric outcomes are actually the parents’ or caregivers’ needs. The question then is who's the patient and is Medicaid paying for this child enrollee or is the parent the enrollee, and then how does that get captured and tracked? “But I think that's where there's a lot of opportunity, particularly in early childhood, where we know that there are so many gaps,” he said. “We see long-term healthcare and education and other outcomes start early, and if there's good evidence that the more we can support not only the child but the parent or the caregiver, the better the child will do, then that could decrease costs down the road for everyone involved,” he added. ‘So I am really hoping that some minds more attuned to the different levers than mine currently is can crack that nut as far as figuring out how do we really use these potential models to support parents.”
Kelleher said such models are possible. “We are 15 years in on an accountable care organization that is soon about to go to 410,000 children,” he said. “I will tell you that it's been a very successful model for us. We use quality measurement to both get some incentive money from the state to expand our work, and also to think about what prevention we want to do in the community. Because preventive services are not reimbursed. But the organization recognizes these are long-term costs.”
He said the greatest insights on value are actually coming from experiments that managed care companies are being forced to do in places like Oregon and Seattle where truly innovative measurements like kindergarten readiness, high school graduation and infant mortality, are being deployed. “These things suggested by the National Academy of Medicine Vital Signs are being rolled out, and managed care companies are being held accountable for populations. Those are the things that, in my mind, will take us to the next level. And those are things that are available already. We don't have to go develop new measures; we don't have to go create something. The data are available, not we have to go get it. Our hospital is committed to goals in those areas as well. Large-scale measures like those recommended in the Vital Signs measures from the National Academy that are functional, like infant mortality, high school graduation and kindergarten readiness, have very direct implications for equity measurement.”