Performance improvement in state-funded healthcare for children

I noticed a job listing the other day, as "Director, Performance Improvement". It would likely be an intellectually satisfying and fulfilling employment opportunity. The job is a full-time, direct hire position with Health Services Advisory Group Inc. (which goes by the unfortunate acronym, HSAG and pronounced as H SAG), in Phoenix, Arizona.

My previous work in public health was with the Office for Children with Special Health Care Needs (OCSHCN), where I was an employee of the Department of Health Services of the State of Arizona (AZDHS).  My title was Statistical Research Chief, and I had a staff of two programmer analysts. 

OCSHCN and and its associated managed care program, the Childrens Rehabilitative Service (CRS), were in charge of most aspects of program management, including retroactive clinical assessments by nurses, as well as provider contracting decision-making. Arizona's Medicaid agency, the Arizona Health Care Cost Containment System (AHCCCS) provided billing support and auditor oversight.

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 with the independence required to do performance and quality assessor for OCSHCN, while an employee of the program itself.

Programs funded by the U.S. HRSA Title V Block Grant for Women & Children

OCSHCN and CRS's 19,000 Arizona members were a very vulnerable sub-strata of the population (see above): eligibility requirements were defined by Arizona Revised Statutes based on enrollee diagnosis and age. The intent was 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 circumscribed by the severity of their mostly congenital and often intractable medical conditions.

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, Phenylketonuria (PKU) 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 as 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 Durable Medical Equipment (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. 

When resources are scarce, decisions are difficult. 

Fortunately in the cochlear implants issue, a compromise was reached, which allowed for a single cochlear implant while the child was under CRS care, along with audio therapy and support, with the second cochlear implant covered by AHCCCS, the state provider of Medicaid services once the child was 18 years of age.

Arizona: Exemplar

Contrary to misinformation due to the furor regarding State Bill 1070 regarding immigration (mentioned in my prior post here), the State of Arizona was remarkably progressive in certain areas. My former employer, AZDHS and thus CRS, is an instance of such. From its founding in 1929 until 2011, Arizona was one of only three states in the Union with an OCSHCN and CRS, i.e. a dedicated managed care program for children with special health care needs. 

There were a significant number of CRS enrollees who were not Medicaid-eligible. Approximately 2,000 children were covered by private insurance as payor for services. These children could be enrolled with any privately administered managed-care program covered by their insurance, yet their parents choose CRS due to high level of specialist care and coverage. CRS was an accredited provider for several insurance carriers. Fees for service for those CRS members with private insurance were adjusted, i.e. increased to market rates.

AHCCCS

On 1 January 2011, the AZ Secretary of Health announced a reorganization so that all oversight and statutory responsibility for managing CRS would be taken over by AHCCCS, with only temporary support from OCSHCN at the AZDHS. I worked for the AZDHS. I was furloughed indefinitely from my job.

By October 2013, OCSHCN had been phased out entirely.  As of end-of-year in 2019, the CRS program, 

originally created in 1929 to serve children with complex health care needs who required specialized provider-contracted services coordinated by a multidisciplinary team was fully integrated into AHCCCS. 

Children diagnosed with what were formerly designated as CRS conditions now receive physical, acute, and mental health care from the same medical service providers who mostly do Healthy Child check-ups, and in some instances, from the Arizona Department of Child Safety.   

I miss my work, and would welcome the opportunity to analyze and monitor performance, quality, and utilization of services from the outside. Alternatively, it would be great to do similar work for enrollee pools with a more diverse disease prevalence profile than chronically ill children.