My previous work in Public Health was with the Medicare-funded Office for Children with Special Health Care Needs (OCSHCN), where I was actually an employee of the State of Arizona. In addition to performance evaluation and utilization management, I enjoyed a diverse range of duties that included epidemiological studies, PHI (Protected Health Information) security, pharma utilization and provider payment (and beneficiary claim) fraud detection. However, the downside was that it was very difficult to work as a performance and quality assessor for OCSHCN' Childrens' Rehabilitative Services (CRS) while an employee of the program itself.
Well, CRS's 17,000 members are a very vulnerable sub-strata of the population: eligibility requirements are defined by Arizona Revised Statutes for enrollee diagnosis and age. The intent is to provide a healthcare system oriented specifically to the needs of youth and children under the age of 18 whose lives are significantly or entirely circumbscribed by the severity of their mostly congenital and often intractable medical conditions. It was awkward, even emotionally upsetting to present findings that resulted in changes about delivery of care to this member population.
Pharma and formulary
Due to the actuarial principle of adverse selection, it was particularly difficult to make decisions on level of care when resources were limited. Should treatment of a debilitating genetic disorder, PKU (Phenylketonuria), with a wonderful new drug be authorized, given the price: approximately $40,000 per year, depending on the child's weight (grams/cm by age), then doubling, once an adult? The drug does not cure PKU. The treatment regimen is lifelong.
Durable Medical Equipment
In addition to drug therapy, there were also cost and utilization issues pertaining to DME including prosthetics. Regarding DME, relevant questions were:
- whether to allow electric motorized wheelchairs?
- how often should wheelchairs be replaced? Different standards must be applied to children than adults, as handicapped children grow just like other children, even if not at the same rate.
- discontinue coverage of cochlear implants in order that many other services may continue? A pair of cochlear implants costs approximately $50,000 all-inclusive. Those same funds could be used instead for a dozen or more cleft lip or cleft palate surgeries, with funds remaining for a few club foot corrective surgeries too.
Arizona - Progressive Exemplar
Contrary to popular belief due to the furor regarding Arizona State Bill 1070, also known as the "AZ State Immigration Law" and mentioned in a prior post, the State of Arizona is remarkably progressive in certain areas. My former employer, CRS, is an instance of such. Arizona is one of only three states in the Union with a program dedicated to providing services to children with special health care needs. By assembling health care providers attuned specifically to this segment of the population, these children receive much better care than they would through many private managed care programs.
In fact, there are a significant number of additional CRS enrollees who are not Medicare-eligible. Approximately 2,000 children, in addition to the 17,000 count cited above, are covered by private insurance as payor for services. These children could be enrolled with any provider or managed-care program covered by their insurance, yet CRS is considered the best choice. Of course, CRS is an accredited provider for many major commercial insurance carriers, and cost for services is adjusted accordingly.
I miss my work, and would welcome the opportunity to analyze and monitor performance and quality of services from outside the program provider. Alternatively, it would be great to do similar work for enrollee pools with a more diverse disease prevalence profile than chronically ill children.