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  • Measure Summary
  • NQMC:010451
  • Sep 2015

Availability of services: the number of hematologists/oncologists who have provided any outpatient care to at least one enrolled child, per 1,000 eligible children.

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: access to outpatient specialty care for children. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2015 Sep. 52 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 2017.

Primary Measure Domain

Related Health Care Delivery Measures: Use of Services

Secondary Measure Domain

Related Health Care Delivery Measure: User-enrollee Health State

Description

This measure is used to assess the number of hematologists/oncologists who have provided any outpatient care to at least one enrolled child, per 1,000 eligible children.

This measure summary represents one of ten respective rates of participating cardiologists, dermatologists, endocrinologists, gastroenterologists, hematologists/oncologists, nephrologists, neurologists, otolaryngologists, pulmonologists, and rheumatologists who have seen at least one enrolled child in the measurement year for at least one outpatient visit. See related NQMC measure summaries.

This rate will be expressed in terms of 1,000 eligible children (number of providers/1,000 eligible children), where the eligible population includes children younger than 18 years of age who have been enrolled in a Medicaid program or health plan that includes outpatient specialty care for at least one 90-day period (or 3 consecutive months) within the measurement year. Specialists are identified by specific taxonomy codes.

Rationale

Many children have conditions that would benefit from confirmatory testing, definitive diagnosis, initial treatment, and/or ongoing management provided by specialists. Given the variety of specialties and the associated conditions those specialists treat, providing prevalence estimates for all relevant conditions is beyond the scope of this measure description. In its place, assessing the overall prevalence of children's need for specialty care can serve as a direct proxy. 

Evidence for Rationale

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: access to outpatient specialty care for children. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2015 Sep. 52 p.

Primary Health Components

Access to specialty care; hematologists; oncologists; children; adolescents

Denominator Description

The eligible population for the denominator is the number of children born on September 30 or earlier in the measurement year but younger than 18 years on December 31 of the measurement year, who are enrolled in a Medicaid program or health plan that includes outpatient specialty care for at least one 90-day period (or 3 consecutive months) within the measurement year. This denominator is divided by 1,000 to calculate the rate per 1,000 eligible children.

Numerator Description

The number of hematologists/oncologists who have provided any outpatient care to at least one enrolled child (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Prevalence among Children
According to the 2011-2012 National Survey on Children's Health (NSCH), nearly one quarter of U.S. children (22.6%) saw a specialist in the previous year (Child and Adolescent Health Measurement Initiative [CAHMI], "Indicator 4.12a," n.d.). The 2003 NSCH included questions on need to see a specialist, in which the results were comparable: 18.3% of children 0 to 5 years were reported to have needed specialty care; the figures for older children were 18.9% of those 6 to 11 years, and 22.4% of those 12 to 17 years (CAHMI, "Specialists," n.d.).

Performance Gaps
A primary shortcoming regarding children's access to specialty care is the type of insurance they have, specifically whether they have private insurance or either of the two main forms of public insurance – Medicaid or Children's Health Insurance Program (CHIP). The 2011-2012 NSCH reported that 19% of children with Medicaid/CHIP coverage received specialty care in the prior year, compared with 26% of privately insured children; 8% of Medicaid/CHIP-covered children had problems accessing specialty care, compared with 5% of privately insured children (CAHMI, "Indicator 4.12a," n.d.). A 2010 study in Illinois found that callers posing as parents of children enrolled in Medicaid/CHIP were denied specialty appointments six times more often than parents of privately insured children (Bisgaier & Rhodes, 2011). A 2010 national survey conducted by the United States Government Accountability Office (GAO) found that specialists participated in Medicaid/CHIP less frequently than primary care providers (71% vs 83%). Moreover, among specialists who participated in Medicaid/CHIP, 84% accepted all privately insured children while only 51% accepted all Medicaid/CHIP-enrolled children. These findings were mirrored in responses by primary care providers: 34% reported having "great difficulty" referring Medicaid/CHIP-enrolled children for specialty care compared with only 1% for privately insured children (GAO, 2011).

A related challenge is that even specialists who accept Medicaid patients may not be open to new patients, or may not participate in a child's specific Medicaid health plan or program. A 2014 report from the Office of the Inspector General (2014) explored this issue among a sample of specialists who were listed as participating in a Medicaid health plan, and found that only 43% would offer an appointment to a new Medicaid patient. Not participating in the health plan, despite being listed, was the major contributor to not offering an appointment.

Severity and Burden of Condition
Lack of specialist availability can affect children in at least three ways. The most severe outcome would be that children would not see a specialist at all and would go without needed care. In the event they do obtain an appointment with a specialist, it may require a longer wait period than is appropriate for their condition, delaying their care. The specialist may also be located much further away than is optimal, forcing longer travel times.

These obstacles are a greater burden for families with fewer financial resources, as they may not have reliable transportation or be able to take time off work when appointments are available. Challenges are likely to be exacerbated for families who face language or cultural barriers with their health care providers (Jewett, Anderson, & Gilchrist, 2005).

Refer to the original measure documentation for additional evidence supporting the measure.

Evidence for Additional Information Supporting Need for the Measure

Bisgaier J, Rhodes KV. Auditing access to specialty care for children with public insurance. N Engl J Med. 2011 Jun 16;364(24):2324-33. PubMed External Web Site Policy

Child and Adolescent Health Measurement Initiative (CAHMI). Indicator 4.12a: during the past 12 months, did [child name] see a specialist other than a mental health professional?. [internet]. Baltimore (MD): Child and Adolescent Health Measurement Initiative; [accessed 2015 Sep 01].

Child and Adolescent Health Measurement Initiative (CAHMI). Specialists are doctors like surgeons, heart doctors, skin doctors, psychiatrists etc. During the past 12 months did you or (child's name)'s personal doctor or nurse think that he/she needed to see any specialist doctor or doctors? (S5Q09). [internet]. Baltimore (MD): Child and Adolescent Health Measurement Initiative; [accessed 2015 Sep 01].

Jewett EA, Anderson MR, Gilchrist GS. The pediatric subspecialty workforce: public policy and forces for change. Pediatrics. 2005 Nov;116(5):1192-202. PubMed External Web Site Policy

Office of Inspector General. Access to care: provider availability in Medicaid managed care. Washington (DC): U.S. Department of Health and Human Services; 2014 Dec.

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: access to outpatient specialty care for children. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2015 Sep. 52 p.

U.S. Government Accountability Office (GAO). Medicaid and CHIP: most physicians serve covered children but have difficulty referring them for specialty care. Washington (DC): U.S. Government Accountability Office (GAO); 2011 Jun. 62 p.

Extent of Measure Testing

The Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) used two methods to test the reliability of the measure: 1) Replication of the measure calculation process demonstrated excellent reliability, with some minor variance observed due to the dynamic nature of health administrative data. 2) Comparison of the taxonomy-based provider identification data sources showed very good reliability. Validity testing was performed to assess three aspects of the measure: 1) Testing to determine whether the identified specialists' content of care provided to Medicaid-enrolled children reflected the respective specialty areas showed excellent validity for all 10 specialty areas. 2) Testing to determine whether the identified specialists had specific certification and/or training in the respective areas showed excellent validity in all 10 specialty areas. 3) Testing to determine whether the inclusion of alternate provider specialty data sources would enhance specialist identification did not demonstrate good validity, suggesting that verification should be performed before using non-taxonomy, program-specific data sources in the measure calculation.

Refer to the original measure documentation for additional testing information.

Evidence for Extent of Measure Testing

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: access to outpatient specialty care for children. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2015 Sep. 52 p.

State of Use

Current routine use

Current Use

External oversight/Medicaid

Measurement Setting

Ambulatory/Office-based Care

Hospital Outpatient

Managed Care Plans

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Age less than 18 years

Target Population Gender

Either male or female

IOM Care Need

Not within an IOM Care Need

IOM Domain

Not within an IOM Domain

Case Finding Period

The measurement year

Denominator Sampling Frame

Enrollees or beneficiaries

Denominator (Index) Event or Characteristic

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
The eligible population for the denominator is the number of children born on September 30 or earlier in the measurement year but younger than 18 years on December 31 of the measurement year, who are enrolled in a Medicaid program or health plan that includes outpatient specialty care for at least one 90-day period (or 3 consecutive months) within the measurement year. This denominator is divided by 1,000 to calculate the rate per 1,000 eligible children.

Exclusions
None

Exclusions/Exceptions

Does not apply to this measure

Numerator Inclusions/Exclusions

Inclusions
The number of hematologists/oncologists who have provided any outpatient care to at least one enrolled child

Note:

  • These specialist physicians are identified using taxonomy codes (refer to Table 1 in the original measure documentation for taxonomy codes by specialty) linked to a National Provider Identifier (NPI) with the National Plan & Provider Enumeration System (NPPES) registry. Only individual physicians are included as eligible providers.
  • For this measure, outpatient care is defined as any visit within the measurement year to a facility with a Place of Service code listed in Table 2 of the original measure documentation. The outpatient visit must be with a child enrolled in a Medicaid program or health plan, without regard to duration of enrollment.

Exclusions

  • NPIs representing organizations and clinics.
  • NPIs representing professionals who are not physicians (e.g., nurse practitioners and physician assistants).

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Type of Health State

Proxy for Health State

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Does not apply to this measure (i.e., there is no pre-defined preference for the measure score)

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

Access to outpatient specialty care for children: hematologists/oncologists.

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 Panel

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

2015 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 2017.

Source(s)

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: access to outpatient specialty care for children. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2015 Sep. 52 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 January 11, 2016. The information was verified by the measure developer on March 2, 2016.

The information was reaffirmed by the measure developer on January 16, 2017.

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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