Systems of Accountability

Implementing Children's Health Insurance Programs

Margaret Edmunds and Molly Joel Coye, Editors

Committee on Children, Health Insurance, and Access to Care

Division of Health Care Services, Institute of Medicine, and

Board on Children, Youth, and Families,

National Research Council and Institute of Medicine

NATIONAL ACADEMY PRESS
Washington, DC
1998



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Systems of Accountability: Implementing Children's Health Insurance Programs Systems of Accountability Implementing Children's Health Insurance Programs Margaret Edmunds and Molly Joel Coye, Editors Committee on Children, Health Insurance, and Access to Care Division of Health Care Services, Institute of Medicine, and Board on Children, Youth, and Families, National Research Council and Institute of Medicine NATIONAL ACADEMY PRESS Washington, DC 1998

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Systems of Accountability: Implementing Children's Health Insurance Programs NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This study was supported by the Robert Wood Johnson Foundation. The views presented in this report are those of the Institute of Medicine’s Committee on Children, Health Insurance, and Access to Care and are not necessarily those of the funding organization. Additional copies of this report are available for sale from the National Academy Press, Box 285, 2101 Constitution Avenue, N.W., Washington, D.C. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP’s on-line bookstore at http://www.nap.edu. International Standard Book No. 0-309-06149-0 Copyright 1998 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Systems of Accountability: Implementing Children's Health Insurance Programs COMMITTEE ON CHILDREN, HEALTH INSURANCE, AND ACCESS TO CARE MOLLY JOEL COYE (Chair),* Director, West Coast Office, The Lewin Group, San Francisco IRENE AGUILAR, Primary Care Physician, Westside Family Health Center, Denver BRIAN K. ATCHINSON, Second Vice President, Government Relations, UNUM, Portland, Maine STEPHEN BOROWITZ, Associate Professor of Pediatrics, University of Virginia Health Sciences Center RICHARD BUCCIARELLI, Professor, Institute for Child Health Policy, and Associate Chair, Department of Pediatrics, University of Florida College of Medicine PETER BUDETTI, Professor of Health Services Management, Preventive Medicine, and Law, and Director, Institute for Health Services Research and Policy Studies, Northwestern University THOMAS W. CHAPMAN, Senior Vice President for Network Development and Professor of Health Services Management and Policy, The George Washington University Medical Center MARGARET C. HEAGARTY,* Director of Pediatrics, Harlem Hospital Center, and Professor of Pediatrics, College of Physicians and Surgeons, Columbia University ROBERT B. HELMS, Resident Scholar and Director of Health Policy Studies, American Enterprise Institute, Washington, D.C. VELVET MILLER, Deputy Commissioner, New Jersey Department of Human Services, Trenton ARNOLD MILSTEIN, Managing Director, William M. Mercer, Inc., and Medical Director, Pacific Business Group on Health, San Francisco PAUL NEWACHECK,** Professor of Health Policy and Pediatrics, Institute for Health Policy Studies and Department of Pediatrics, University of California at San Francisco DAVID S. WEINER, President and Chief Executive Officer, Children's Hospital, Boston STEVEN WOOLF, Fairfax Family Practice Center and Clinical Professor, Department of Family Practice, Medical College of Virginia, Fairfax Institute of Medicine Staff MARGARET EDMUNDS, Study Director KATHLEEN NOLAN, Research Assistant TRACY McKAY, Project Assistant *   Member, Institute of Medicine. **   Member, Board on Children, Youth, and Families.

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Systems of Accountability: Implementing Children's Health Insurance Programs BOARD ON HEALTH CARE SERVICES INSTITUTE OF MEDICINE DON E. DETMER (Chair),* Senior Vice President, The University of Virginia STUART H. ALTMAN,* Sol C. Chaikin Professor of National Health Policy, The Florence Heller Graduate School for Social Policy, Brandeis University NANCY W. DICKEY, Private Practice, College Station, Texas B. KEN GRAY, Corporate Medical Director, Metroplex Emergency Physician Associates, P.A., Dallas PAUL F. GRINER,* Vice President and Director, Center for the Assessment and Management of Change in Academic Medicine, Association of American Medical Colleges, Washington, D.C. BRENT C. JAMES, Executive Director, Institute for Health Care Delivery Research, and Vice President, Medical Research and Continuing Medical Education, Intermountain Health Care, Salt Lake City JACQUELINE KOSECOFF, President and Co-Chief Executive Officer, Value Health Sciences, Inc., Santa Monica, California SHEILA T. LEATHERMAN, Executive Vice President, Center for Health Care Policy and Evaluation, United Health Care Corporation, Minneapolis JOHN LUDDEN, Senior Vice President for Medical Affairs, Harvard Pilgrim Health Care, Brookline, Massachusetts BARBARA J. McNEIL,* Ridley Watts Professor and Head, Department of Health Care Policy, Harvard Medical School RUSSELL L. MILLER, State University of New York Health Science Center, Brooklyn MILDRED MITCHELL-BATEMAN,* Clinical Director, Huntington Hospital, Huntington, West Virginia MARY MUNDINGER,* Dean and Centennial Professor of Health Policy, Columbia University UWE E. REINHARDT,* James Madison Professor of Political Economy and Professor of Economics and Public Affairs, Princeton University MARY LEE SEIBERT, Acting Provost, Ithaca College GAIL L. WARDEN,* President and Chief Executive Officer, Henry Ford Health System, Detroit Institute of Medicine Staff CLYDE J. BEHNEY, Deputy Executive Officer and Director, Board on Health Care Services, Institute of Medicine *   Member, Institute of Medicine

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Systems of Accountability: Implementing Children's Health Insurance Programs BOARD ON CHILDREN, YOUTH, AND FAMILIES NATIONAL RESEARCH COUNCIL AND INSTITUTE OF MEDICINE JACK P. SHONKOFF (Chair), Professor and Dean, Heller Graduate School, Brandeis University DAVID V.B. BRITT, President and Chief Executive Officer, Children's Television Workshop, New York City LARRY BUMPASS, Professor of Sociology, Center for Demography and Ecology, University of Wisconsin at Madison FERNANDO A. GUERRA, Director of Health, San Antonio Metropolitan Health District, San Antonio, Texas BERNARD GUYER,* Professor and Chairman, Department of Maternal and Child Health, Johns Hopkins School of Hygiene and Public Health ALETHA C. HUSTON, Professor, Department of Human Ecology, University of Texas at Austin RENEE R. JENKINS, Professor and Chairman, Department of Pediatrics and Child Health, Howard University SARA McLANAHAN, Office of Population Research, Princeton University ROBERT MICHAEL, Professor, Harris Graduate School of Public Policy Studies, University of Chicago PAUL NEWACHECK, Professor of Health Policy, Institute for Health Policy Studies, and Department of Pediatrics, University of California at San Francisco MARTHA PHILLIPS, Executive Director, The Concord Coalition, Washington, D.C. JULIUS B. RICHMOND,* Professor of Health Policy, Emeritus, Department of Social Medicine, Harvard Medical School TIMOTHY M. SANDOS, Vice President, Education Division, ETC, Inc., Littleton, Colorado DEBORAH STIPEK, Professor of Education, Graduate School of Education, University of California at Los Angeles DIANA TAYLOR, Director, Women's Health Program, Department of Family Health Nursing, University of California at San Francisco GAIL WILENSKY,* Senior Fellow, Project Hope, Bethesda, Maryland National Research Council and Institute of Medicine Staff DEBORAH PHILLIPS, Executive Director, Board on Children, Youth, and Families, National Research Council and Institute of Medicine *   Member, Institute of Medicine.

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Systems of Accountability: Implementing Children's Health Insurance Programs Preface and Acknowledgments In the summer of 1996, the Robert Wood Johnson Foundation asked the National Academy of Sciences to conduct a study of the relationship between health insurance coverage and access to care for children. In response to this request, the Institute of Medicine's (IOM's) Division of Health Care Services and the Board on Children, Youth, and Families of the National Research Council and the IOM—in a joint activity—formed an expert committee to: examine the extent of health insurance coverage for children; analyze evidence on the relationship between health insurance coverage and children's access to health care; identify trends in the availability and size of safety net programs (e.g., community health centers, children's hospitals, and public health departments), and how these programs affect children's access to health care services; and consider the potential effects of significant changes in public and private insurance coverage on children's access to health care. Between March and June 1997, the committee met three times and convened a public workshop. Members of a liaison panel (see Appendix B) made presentations at the workshop and submitted a variety of materials and statements for the committee's review. Based on its deliberations and an extensive review of national databases, published health services research findings, policy and news analyses, and other publicly available information, the committee prepared a report entitled America's Children: Health Insurance and Access to Care. America's Children presents the committee's review of evidence and draws conclusions about the relationship of children's health insurance and access to care. The committee met again in January 1998 specifically to consider the new State Children's Health Insurance Program (SCHIP) enacted as part of the Balanced Budget Act of 1997. This meeting led to the development of the current report, Systems of Accountability: Implementing Children's Health Insurance Programs as a companion to America's Children. Systems of Accountability addresses practical concerns about the implementation and evaluation of SCHIP and presents the committee's recommendations about accountability for measuring the program's impact. The committee hopes that this report will help a variety of policy makers make more informed decisions about how to achieve their multiple—and often competing—objectives as SCHIP is implemented across the country.

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Systems of Accountability: Implementing Children's Health Insurance Programs The committee and its IOM staff express their deep appreciation to all those who contributed to Systems of Accountability. These include speakers at the committee's meeting on January 28, 1998: Ellen Bayer, American Association of Health Plans; James Crall and Burton Edelstein, American Academy of Pediatric Dentistry; Stan Dorn, Children's Defense Fund; Carrie Gavora, The Heritage Foundation; Joan Henneberry, National Governors Association; and Judith Moore, Medicaid and State Operations, Health Care Financing Administration. Gary Claxton, Denise Dougherty, Margaret Hamburg, Patricia MacTaggart, and Marina Weiss also made contributions. This report has been reviewed by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the authors and the IOM in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review process: Melvin Worth, Institute of Medicine; Judith Feder, Institute for Health Care Research and Policy and Georgetown University; Julius Goepp, University of Rochester School of Medicine; David Nathan, Harvard Medical School; Stuart Orkin, Children's Hospital and Harvard Medical School; and Diane Rowland, Kaiser Commission on the Future of Medicaid. While the individuals listed above have provided many constructive comments and suggestions, responsibility for the final content of this report rests solely with the authoring committee and the IOM. The committee expresses its deep gratitude to Study Director Margo Edmunds for her creative and energetic guidance and leadership. Her efforts were well supported by Kathleen Nolan, research assistant, and Tracy McKay, project assistant. The contributions of several other IOM and Academy staff members are gratefully acknowledged. They include Clyde Behney, Claudia Carl, Mike Edington, Karen Hein, Roger Herdman, Jim Jensen, Marion Ein Lewin, Constance Pechura, Dan Quinn, and Kenneth Shine. Sue Barron, Kay Harris, and Evelyn Simeon also contributed to the study's activities. In developing the recommendations for Systems of Accountability, the committee tried to address the interests and needs of different stakeholders, including members of Congress, federal and state agencies, managed care organizations, professional provider groups, policy researchers, and parents. The committee's intention is to offer practical suggestions. Some of the recommendations describe evaluation efforts that are feasible within the limits of existing resources and easy to implement quickly. Other recommendations describe efforts that will take longer because of the need to identify funding sources to support the design and development of an evaluation infrastructure. At this very early stage in the program, it is vitally important to design and develop systems of accountability and to anticipate information and communication needs based on experiences with other national programs. Our recommendations emphasize an open exchange of meaningful information that can be used to improve SCHIP as well as to guide future efforts to reduce the number of uninsured children, to improve their access to health care, and, ultimately, to improve their health. Molly Joel Coye Chair

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Systems of Accountability: Implementing Children's Health Insurance Programs Contents     SUMMARY   1     OVERVIEW OF THE STATE CHILDREN'S HEALTH INSURANCE PROGRAM   5     Purpose of this Report   6     Who Is Accountable for SCHIP?   6     What Is Accountability?   6     Congress   7     U.S. Department of Health and Human Services   9     States   10     Recommendations   11     Congressional Accountability for SCHIP   12     Federal Government Accountability for SCHIP   12     Performance Monitoring for SCHIP   12     Children's Health Indicators   14     State Accountability for SCHIP   15     Designing Accountability Systems   15     Public Information   16     Data Collection and Performance Reporting   16     Performance Incentives and Rewards   17     Conclusion   17     References   17     APPENDIXES     A   Committee and Staff Biographies   19 B   Members of the Liaison Panel   23

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