• Issue Brief
  • October 1, 2013

Renewing CHIPRA Title IV: Closing Gaps in Pediatric Quality Measurement


Before the Children’s Health Insurance Program Reauthorization Act (CHIPRA) was enacted in 2009, most federal performance measurement and quality improvement efforts centered on Medicare and were not meeting the needs of children and pregnant women. In order to close the gap in quality measurement for children, Congress enacted Title IV of CHIPRA, which was the first significant national investment in children’s health care quality. The statutory authority for Title IV expires Sept. 30, 2013. While much has been accomplished, there is still much that remains to be done in order to close the gap in quality measurement and improvement for children.

Key Provisions of the Current Law

Title IV created important initiatives to advance the quality of care for children and pregnant women, including an innovative, transparent, and accountable system for the development, validation, and dissemination of pediatric quality measures. Since the passage of this provision, the federal government, states, and Centers of Excellence (COEs) have had great successes in addressing the lack of pediatric quality measures. Overall, the investments have accelerated our ability to improve the quality of care for children.

  • Establishment of the Initial Core Set of Measures. Title IV directed the Department of Health and Human Services (HHS) to publish an initial core set of pediatric quality measures for states to use to measure the quality of care provided to Medicaid and CHIP beneficiaries. The initial core set was published in Dec. 2009.
  • Development of Additional Measures. Title IV also established the Pediatric Quality Measures Program (PQMP). This program is designed to improve and strengthen the initial core set and increase the portfolio of evidence-based measures available. The initial legislation stated that the PQMP should expand on pediatric quality measures in use by both public and private health care purchasers. Seven COEs have been formed to improve the initial set and develop new measures to address current gaps in quality measurement. In addition, Title IV required the National Academy of Sciences to fund a study on the extent of efforts to measure child health status and quality of care across a spectrum of needs. The Institute of Medicine issued a report, Child and Adolescent Health and Health Care Quality: Measuring what Matters, in April 2011.
  • Demonstration Projects. Title IV included funding for demonstration projects focused on improving children’s health care and the use of health information technology. Eighteen states are engaged in 10 demonstrations across a range of cutting-edge projects, including experimenting with and evaluating the use of new quality measures, promoting the use of health information technology, evaluating models of care delivery and demonstrating the use of the model electronic health record format for children.
  • Reporting by States. Title IV included provisions to incentivize and encourage voluntary reporting by states through standardized formats for reporting and other procedures as well as technical assistance. As a result, after just two years, 48 states are reporting on at least one pediatric core set quality measure, and 27 states are reporting on at least half of them. In addition, CHIPRA required the Secretary to submit a regular report on quality of care for children and Medicaid and CHIP. Annual Reports on Quality of Care for Children in Medicaid and CHIP for 2011 and 2012 have been produced.

Thanks to these provisions, virtually every state Medicaid program is now engaged in pediatric and maternity quality improvement efforts and a number are engaged in projects involving the private sector as well. Currently, the COEs and state demonstrations are testing and refining the core set of measures to make them more broadly applicable to Medicaid, CHIP, and other programs. In addition, the COEs are developing additional quality measures that address dimensions of care where standardized measures do not currently exist. Six of the COEs are housed in children’s hospitals.

The Need to Advance Pediatric Quality Measures Continues

Moving forward, it is important to refine and improve upon the pediatric quality advancements that have already been made.

  • Improving the Initial Core Set. The initial core set and first update of the set are dominated by measures related to prevention and health promotion. Fewer measures are related to management of acute or chronic conditions. Only one measure is specifically related to pediatric inpatient care. It is important to extend funding to ensure that the core set addresses the wide variety of domains as envisioned in the initial legislation. In addition, the program should be modified by requiring the core set to measure not just duration of health care coverage, but type of coverage as well.
  • Advancing PQMP COEs. In order to leverage the significant progress currently underway, it is important to continue to fund the PQMPs. In addition, a competitive process for strengthening the current COEs should be established. This may include developing new centers that have a particular emphasis on populations that are too small to be most effectively addressed at the state level, such as children with medical complexity and children with rare conditions.
  • Reporting Full Complement of Measures. States should be required to report on the full complement of pediatric core measures within five years of the provisions’ extension. State reporting requirements would include a standardized format and plan for states to collect and report on the full complement of pediatric measures.
  • Strengthen Demonstration Projects. The current demonstration projects should also continue. In addition, perinatal learning collaboratives that would have substantial impact either by affecting a large percentage of the pediatric population or by substantially improving outcomes in smaller populations requiring intensive resources should be implemented and expanded.
  • Measure Implementation, Dissemination and Maintenance. A mechanisms to facilitate the adoption, dissemination, stewardship and reporting of the core measures as well as new measures developed through the PQMP at the state, hospital and plan levels as well as across different health care delivery and coverage systems, including health insurance Exchanges should be established.

Association Contact: Jenny Rudisill, (202) 753-5340