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  • Measure Summary
  • NQMC:009766
  • Sep 2014

Availability of services: does the state collect and report specific CAHPS results regarding whether parents of Medicaid-enrolled children get treatment or counseling services for their children when their children experience emotional, developmental, or behavioral problems?

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: reporting of supplemental CAHPS data regarding availability of treatment or counseling services for children on Medicaid. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2014 Sep. 34 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2016.

Primary Measure Domain

Population Health Quality Measures: Population Structure

Secondary Measure Domain

Population Health Quality Measure: Population Access

Description

This measure is used to assess whether the state collects and reports specific Consumer Assessment of Healthcare Providers and Systems (CAHPS) results regarding whether parents of Medicaid-enrolled children get treatment or counseling services for their children when their children experience emotional, developmental, or behavioral problems.

This measure uses data on parent perceptions of the availability of treatment or counseling for Medicaid‐enrolled children experiencing emotional, developmental, or behavioral problems. The data are collected via CAHPS, specifically a question from the optional Item Set for Children with Chronic Conditions (CCC) supplement to the CAHPS Health Plan Survey—Child Medicaid. The treatment or counseling availability question is written as follows in the CAHPS CCC Item Set currently offered:

Version 4.0: In the last 6 months, how often was it easy to get this treatment or counseling for your child?

Note:

  • This question is asked of parents who answered affirmatively that they obtained or tried to obtain treatment or counseling for their child for an emotional, developmental, or behavioral problem in the previous 6 months.
  • The term "state" implies other geographical entities, such as United States territories.

Rationale

Availability and Early and Periodic Screening, Diagnosis and Treatment (EPSDT) (the CAHPS Measure)
Medicaid's EPSDT benefit provides the foundation for comprehensive and preventive health care services for all Medicaid-enrolled children under age 21. Health screenings are mandated by the EPSDT guidelines, under which states are required to arrange (directly or through referral) for corrective treatment as indicated by the screenings, which include screening for developmental and behavioral concerns. Further, states must report to the Centers for Medicare & Medicaid Services (CMS) the number of children referred for corrective treatment (Medicaid.gov, 2014). The Consumer Assessment of Healthcare Providers and Systems (CAHPS) measure assesses if parents are able to secure this care, regardless of whether the need derives from EPSDT screening or any other impetus.

The Value of Reporting Results on Availability of Care (the Q-METRIC Measure)
This Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC) measure requires states to report CAHPS data regarding whether parents of Medicaid-enrolled children get treatment or counseling for their children when needed. The value of a parent‐reported measure is that it offers a comprehensive view of both the need for care and the receipt of services across settings. Contrary to specialty care, treatment and counseling can occur in a multitude of settings; therefore, medical record reviews are unlikely to capture services provided through schools or community agencies. Utilization measures will be incomplete if they do not capture behavioral/mental health services provided under both medical benefits and behavioral/mental health carve‐outs, and would not include services provided but not billed. Furthermore, neither of these methods will capture unmet need. Thus, parents' views may be the most accurate indicator on the availability of treatment and counseling services.

Reporting about parental views on the availability of care is presumed to foster improvement through two mechanisms (Werner & Asch, 2005). First, by ensuring a consistent mechanism to generate data on treatment or counseling availability, Medicaid programs can track their progress toward improving parental perceptions of availability of behavioral/mental health services for their beneficiaries. Second, if such information is reported in a forum accessible to the public, patients (parents) have additional information on which to compare health plans (when available), and all stakeholders have a mechanism to compare availability across states and to track progress over time (Werner & Asch, 2005).

Public reporting in the health care setting is defined as data, publicly available or available to a broad audience free of charge or at a nominal cost, about a health care structure, process, or outcome at any provider level (individual clinician, group, or organizations [e.g., hospitals, nursing facilities]) or at the health plan level ("Public reporting," 2012). Public reporting is seen as a possible way to bridge the gap between current and improved levels of quality in the practice of health care (Agency for Healthcare Research and Quality [AHRQ], 2011). Both consumer‐driven and provider‐driven changes can improve the quality of care after the initiation of public reporting (Werner, Stuart, & Polsky, 2010). Likewise, a study of the effect that voluntary information disclosure had on quality of care in health maintenance markets showed a significant and positive effect on quality (Jung, 2010). Disclosing data collected as part of the Health Plan Employer Data and Information Set (HEDIS) led to a ~7% improvement in quality scores, though improvement was not universal across all quality measures (Jung, 2010).

Public reporting has also been noted to have the potential for unintended and negative consequences (Werner & Asch, 2005). These largely derive from the scenario in which physicians or providers screen their patients to avoid negative outcomes in their reported performance scores. As this measure relies on aggregate and anonymous reporting, it is not expected that these unintended negative consequences will occur.

Evidence for Rationale

Agency for Healthcare Research and Quality (AHRQ). Public reporting as a quality improvement strategy: a systematic review of the multiple pathways public reporting may influence quality of health care. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2011 Aug 17. 18 p.

Jung K. The impact of information disclosure on quality of care in HMO markets. Int J Qual Health Care. 2010 Dec;22(6):461-8. PubMed External Web Site Policy

Medicaid.gov. Early and periodic screening, diagnosis and treatment. [internet]. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2014 Jun 17 [accessed 2014 Jul 09].

Public reporting as a quality improvement strategy. Closing the quality gap: Revisiting the state of the science. Evidence Report No. 208. (Prepared by the Oregon Evidence-Based Practice Center under Contract No. 290-2007-10057-I.) AHRQ Publication No. 12-E011-EF. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2012 Jul.

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: reporting of supplemental CAHPS data regarding availability of treatment or counseling services for children on Medicaid. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2014 Sep. 34 p.

Werner R, Stuart E, Polsky D. Public reporting drove quality gains at nursing homes. Health Aff (Millwood). 2010 Sep;29(9):1706-13. PubMed External Web Site Policy

Werner RM, Asch DA. The unintended consequences of publicly reporting quality information. JAMA. 2005 Mar 9;293(10):1239-44. [62 references] PubMed External Web Site Policy

Primary Health Components

Emotional, developmental, and behavioral problems; treatment or counseling services; children

Denominator Description

The denominator is the individual state required to report the CAHPS Health Plan Survey – Child Medicaid version, and therefore will always be one (1).

Numerator Description

A numerator of one (1) demonstrates that a particular state collects the treatment or counseling availability question from the CAHPS Item Set for Children with Chronic Conditions and publicly reports the results of the individual question among its Medicaid population. A numerator of zero (0) demonstrates that the state does not publicly report those results. See the related "Numerator Inclusions/Exclusions" field.

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Performance Gaps
Research shows a variety of issues related to the availability of behavioral/mental health treatment and counseling for Medicaid-enrolled children:

  • Physicians report varying degrees of success in their ability to refer Medicaid- and Children's Health Insurance Program (CHIP)-enrolled patients versus privately insured patients to specialists. Mental health care (such as psychology and psychiatry) is one of "the most frequently cited specialties for children" by physicians when asked with which specialties they experienced the most difficulty when referring children (United States Government Accountability Office, 2011).
  • Parents may have different expectations regarding their roles in setting up specialist appointments for a child (Stille et al., 2007; Clark et al., 2014). It is possible this type of relationship extends to treatment and counseling appointments when parents are referred or directed by other authority figures.
  • Many states and regions have variable geographic distribution and shortages of specialists. In particular, developmental behavioral pediatrics typically requires larger populations of children to attract a physician (Mayer, 2006).

Research shows that consumers are beginning to seek out health care quality data. A report by the Kaiser Family Foundation (2004) noted that the number of consumers seeking such information increased from 27% in 2000 to 35% in 2004; moreover, 14% of consumers reported using quality information to choose health plans. However, the extent of public reporting varies by state.

Availability and Medicaid/CHIP
According to the Centers for Medicare & Medicaid Services (CMS), approximately 43 million children are currently covered by Medicaid/CHIP programs (Medicaid.gov, n.d.). Recent research estimates one in six U.S. children experience developmental disorders of one kind or another (Boyle et al., 2011). Other research estimates that nearly half of all children will experience an emotional or behavioral disorder (separate from developmental disorders) at some point in their life (Merikangas et al., 2010). Combined, this evidence suggests that a significant proportion of children at some point will be in a situation to require treatment or counseling services and that the overall number of Medicaid‐enrolled children needing these services could be substantial. Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data are focused on capturing the parent's success in obtaining this care. The Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC) measure is focused on ensuring that states collect and report this data in a systematic manner, demonstrating whether states and programs make this information publicly available to allow tracking over time.

Evidence for Additional Information Supporting Need for the Measure

Boyle CA, Boulet S, Schieve LA, Cohen RA, Blumberg SJ, Yeargin-Allsopp M, Visser S, Kogan MD. Trends in the prevalence of developmental disabilities in US children, 1997-2008. Pediatrics. 2011 Jun;127(6):1034-42. PubMed External Web Site Policy

Clark SJ, Kauffman AD, Singer DC, Gebremariam A, Davis MM. Seeing specialists: Roles of parents and providers unclear. Ann Arbor (MI): University of Michigan; 2014 Jan.  (C.S. Mott Children’s Hospital National Poll on Children’s Health; no. 2). 

Kaiser Family Foundation (KFF). Five years after IOM report on medical errors, nearly half of all consumers worry about the safety of their health care. [internet]. 2004 Nov 15 [accessed 2014 Jul 09].

Mayer ML. Are we there yet? Distance to care and relative supply among pediatric medical subspecialties. Pediatrics. 2006 Dec;118(6):2313-21. PubMed External Web Site Policy

Medicaid.gov. Children. [internet]. Baltimore (MD) : Centers for Medicare & Medicaid Services (CMS); [accessed 2014 Jul 08].

Merikangas KR, He JP, Brody D, Fisher PW, Bourdon K, Koretz DS. Prevalence and treatment of mental disorders among US children in the 2001-2004 NHANES. Pediatrics. 2010 Jan;125(1):75-81. PubMed External Web Site Policy

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: reporting of supplemental CAHPS data regarding availability of treatment or counseling services for children on Medicaid. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2014 Sep. 34 p.

Stille CJ, Primack WA, McLaughlin TJ, Wasserman RC. Parents as information intermediaries between primary care and specialty physicians. Pediatrics. 2007 Dec;120(6):1238-46. PubMed External Web Site Policy

United States Government Accountability Office (U.S. GAO). MEDICAID and CHIP: most physicians serve covered children but have difficulty referring them for specialty care. [internet]. United States Government Accountability Office (U.S. GAO); 2011 Jun [accessed 2014 Jul 09].

Extent of Measure Testing

Reliability
Data and Methods. This measure has two aspects of reliability to consider: reliability of reporting the specific availability measure and reliability of the data collected.

The first aspect, reliability of reporting the specific availability measure, has not been assessed. Reliability of reporting is expected to be high, as common threats to reliability identified by the National Quality Forum (2011) (specifically "ambiguous measure specifications" and "small case volume or sample size") are not expected to be concerns.

The second aspect is the reliability of the underlying Consumer Assessment of Healthcare Providers and Systems (CAHPS) data. This measure is based on parents' responses to the CAHPS survey. CAHPS surveys have been extensively tested for reliability and have been consistently found to have high reliability (>0.70) (Dyer et al., 2012; Scholle et al., 2012). There may be some concern over using a single‐item question to assess the concept of availability. However, West et al. (2012) found that reliability of single‐item measures is relatively unaffected compared with multiple‐item measures of the same concept. Hays, Reise, & Calderón (2012) hypothesized that this may be due to the narrowness of the concept being measured, which would be consistent with the current measure's conceptual focus. As a consequence, a high degree of reliability is anticipated for this measure.

Validity
Validity of CAHPS Questions. CAHPS is a well-established tool for obtaining patient reports of their health care experience and is accepted by a variety of stakeholder groups. The measurement question was only asked of parents who responded Yes when asked if they got or tried to get treatment or counseling for their child for an emotional, developmental, or behavioral problem in the previous 6 months. CAHPS tests their surveys for reliability and validity, and notes that the survey results "will be reliable and valid if (the survey) specifications are followed" (Agency for Healthcare Research and Quality, 2012). Medicaid programs are likely to contract with approved CAHPS vendors who agree to adhere to CAHPS specifications, and thus their CAHPS results would be expected to maintain their validity.

Face Validity. The validity of this measure was determined from face validity, the degree to which the measure construct characterizes the concept being assessed. The face validity of the relevant CAHPS question was reviewed by a panel convened by Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC). The Q-METRIC expert panel included nationally recognized experts representing pediatrics, family medicine, psychiatry, dentistry, and two parent representatives. In addition, validity was considered by experts in state Medicaid program operations, health plan quality measurement, health informatics, and health care quality measurement. In total, the Q-METRIC Availability of Specialty Services panel included 13 experts, providing a comprehensive perspective on the availability of specialty services and the measurement of quality metrics for states and health plans.

The Q-METRIC expert panel concluded that this measure has a high degree of face validity through a detailed review of concepts and metrics considered to be essential to the ability of parents to obtain appointments for children referred to treatment and counseling. Concepts and draft measures were rated by this group for their relative importance. The measure was rated as follows: parent-reported-availability of specialty appointments received a score of 6.7 on a scale of 1 to 9, with 9 representing the highest possible ranking.

The Q-METRIC expert panel had additional discussion about the data that would be reported out for this measure. Prior to deciding to use the CAHPS measure, this discussion included such topics as whether appointments should refer to urgent or non‐urgent appointments, and whether the measure should be stratified by age due to the typical practice that mental health practitioners often do not see patients under age 3 or 4.

Evidence for Extent of Measure Testing

Agency for Healthcare Research and Quality (AHRQ). Established child health care quality measures: child health care quality toolbox. [internet]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2012 Sep [accessed 2014 Jul 24].

Dyer N, Sorra JS, Smith SA, Cleary PD, Hays RD. Psychometric properties of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Clinician and Group Adult Visit Survey. Med Care. 2012 Nov;50 Suppl:S28-34. PubMed External Web Site Policy

Hays RD, Reise S, Calderón JL. How much is lost in using single items?. J Gen Intern Med. 2012 Nov;27(11):1402-3. PubMed External Web Site Policy

National Quality Forum (NQF). Guidance for measure testing and evaluating scientific acceptability of measure properties. 2011 Jan. 52 p.

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: reporting of supplemental CAHPS data regarding availability of treatment or counseling services for children on Medicaid. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2014 Sep. 34 p.

Scholle SH, Vuong O, Ding L, Fry S, Gallagher P, Brown JA, Hays RD, Cleary PD. Development of and field test results for the CAHPS PCMH Survey. Med Care. 2012 Nov;50 Suppl:S2-10. PubMed External Web Site Policy

West CP, Dyrbye LN, Satele DV, Sloan JA, Shanafelt TD. Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment. J Gen Intern Med. 2012 Nov;27(11):1445-52. PubMed External Web Site Policy

State of Use

Current routine use

Current Use

Decision-making by consumers about health plan/provider choice

Monitoring and planning

Population health improvement

Public reporting

Measurement Setting

Managed Care Plans

State/Provincial Public Health Programs

Professionals Involved in Delivery of Health Services

Does not apply to this measure (e.g., measure is not provider specific)

Least Aggregated Level of Services Delivery Addressed

State/Provincial

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Does not apply to this measure

Target Population Gender

Does not apply to this measure

Public Health Aims for Quality

Population-centered

Transparency

Vigilant

National Quality Strategy Aim

Healthy People/Healthy Communities

IOM Care Need

Not within an IOM Care Need

IOM Domain

Not within an IOM Domain

Case Finding Period

Unspecified

Denominator Sampling Frame

Geographically defined

Denominator (Index) Event or Characteristic

Geographic Location

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
The denominator is the individual state required to report the CAHPS Health Plan Survey – Child Medicaid version, and therefore will always be one (1).

Exclusions
None

Exclusions/Exceptions

Does not apply to this measure

Numerator Inclusions/Exclusions

Inclusions
A numerator of one (1) demonstrates that a particular state collects the treatment or counseling availability question from the CAHPS Item Set for Children with Chronic Conditions (CCC) and publicly reports the results of the individual question among its Medicaid population. A numerator of zero (0) demonstrates that the state does not publicly report those results.

Note:

  • The treatment or counseling availability question is written as follows in the CAHPS CCC Item Set currently offered:

    Version 4.0: In the last 6 months, how often was it easy to get this treatment or counseling for your child?

  • Reporting of this CAHPS measure by a state program may take any form that clearly conveys the results of this question; it may be reported alone, or as one component of a broader array of parent-reported availability and access measures that include this specific treatment or counseling availability question.

Exclusions
None

Numerator Search Strategy

Fixed time period or point in time

Data Source

Patient/Individual survey

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

CAHPS Health Plan Survey (Child Medicaid Questionnaire) - Item Set for Children with Chronic Conditions, Version 4.0

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Dichotomous

Interpretation of Score

Desired value is presence of a characteristic

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Original Title

Reporting of supplemental CAHPS data regarding availability of treatment or counseling services for children on Medicaid.

Measure Collection Name

Availability of Specialty Services Measures

Submitter

Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) - Academic Affiliated Research Institute

Developer

Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) - Academic Affiliated Research Institute

Funding Source(s)

This work was funded by the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) under the Children's Health Insurance Program Reauthorization Act (CHIPRA) Pediatric Quality Measures Program Centers of Excellence grant number U18 HS020516.

Composition of the Group that Developed the Measure

Availability of Specialty Services Expert Panels

Representative/Feasibility Panel

  • George Baker, MD, Retired, Co-Director, Office of Medical Affairs for Michigan Medicaid, Medical Director of Michigan's Title V program for Children and Youth with Special Health Care Needs, Michigan Department of Community Health, Lansing, MI
  • Laura-Mae Baldwin, MD, MPH, Director of Research and Professor, Department of Family Medicine, University of Washington, Seattle, WA
  • Patricia Barrett, MHSA, Vice President for Product Development, National Committee for Quality Assurance, Washington, DC
  • Angie Davis, MA, Parent Representative, DeWitt, MI
  • Lisa Huckleberry, Parent Representative, DeWitt, MI
  • Renee Jenkins, MD, FAAP, Professor, Department of Pediatrics and Child Health, Howard University College of Medicine, Washington, DC
  • David Kelley, MD, MPA, Chief Medical Officer, Office of Medical Assistance Programs, Pennsylvania Department of Public Welfare, Harrisburg, PA
  • Maureen Milligan, PhD, MPA, MA, Director, Texas Institute of Health Care Quality and Efficiency, Texas Health and Human Services Commission, Austin, TX
  • Sue Moran, BSN, MPH, Director of the Bureau of Medicaid Program Operations and Quality Assurance, Michigan Department of Community Health, Lansing, MI
  • R. Gary Rozier, DDS, MPH, Director and Professor, Dental Public Health and Residency Training Program, Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC
  • Aradhana (Bela) Sood, MD, MSHA, FAACAP, Professor and Chair, Division of Child and Adolescent Psychiatry, Medical Director, Virginia Treatment Center for Children, Virginia Commonwealth University, Richmond, VA
  • Mark Wietecha, MS, MBA, President and CEO, Children's Hospital Association, Alexandria, VA

Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) Investigators

  • Sarah J. Clark, MPH, Associate Research Scientist, Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, MI
  • Meredith P. Riebschleger, MD, MS, Clinical Lecturer, Department of Pediatrics and Communicable Diseases, Pediatric Rheumatology, School of Medicine, University of Michigan, Ann Arbor, MI
  • Gary L. Freed, MD, MPH, Professor of Pediatrics, School of Medicine and Professor of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI (principal investigator)
  • Kevin J. Dombkowski, DrPH, MS, Research Associate Professor of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, MI

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2014 Sep

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2016.

Source(s)

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: reporting of supplemental CAHPS data regarding availability of treatment or counseling services for children on Medicaid. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2014 Sep. 34 p.

Measure Availability

Source available from the Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) Web site External Web Site Policy. Support documents External Web Site Policy are also available.

For more information, contact Q-METRIC at 300 North Ingalls Street, Room 6C08, SPC 5456, Ann Arbor, MI 48109-5456; Phone: 734-232-0657; Fax: 734-764-2599.

NQMC Status

This NQMC summary was completed by ECRI Institute on May 5, 2015. The information was verified by the measure developer on June 10, 2015.

The information was reaffirmed by the measure developer on January 7, 2016.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

Inform Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) if users implement the measures in their health care settings.

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