School of Public Health

The Controversial Aspect of the Block Grant Transformation

March 2016

“The national performance measures - this is probably going to be the most controversial part of the transformation,” said Michael Lu, director of the Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau (MCHB).1 The Bureau, which provides federal funds to 59 states and jurisdictions for maternal, child, and family health activities, transformed the Title V Block Grant this year.2 Although MCHB restructured the entire framework, including reducing a burdensome reporting process, it anticipated that the revision of the national performance measures (NPMs) would draw the most attention.3

This is the first time in nearly two decades that the MCHB changed the NPMs. After a two-year process, it retained some of the original 18 measures, dropped others, and added a few new items to the final list of fifteen.4

Previous Performance Measures New Performance Measures
  1. Screen positive newborns with timely follow up
  2. Families of children with special health care needs who are satisfied with services
  3. Medical homes for children with special health care needs
  4. Insurance for children with special health care needs
  5. Easily usable community services for children with special health care needs
  6. Transition to adult care for youth with special health care needs
  7. Immunizations for 19-35 month olds
  8. Teen births
  9. Oral health for third grade children
  10. Childhood deaths by motor vehicle crashes
  11. Infants breastfed through 6 months
  12. Newborn hearing screen pre-hospital discharge
  13. Children without health insurance
  14. Children with BMI at or above 85th percentile
  15. Women who smoke in last trimester
  16. Youth suicide deaths
  17. Perinatal regionalization
  18. Infants born to pregnant women receiving prenatal care beginning in in first trimester
  1. Well-woman visits
  2. Low-risk cesarean delivery
  3. Perinatal regionalization
  4. Breastfeeding
    • infants breastfed
    • breastfed through 6 months
  5. Safe sleep
  6. Developmental screening for children
  7. Non-fatal injury hospitalization for children and adolescents
  8. Physical activity for children and adolescents
  9. Adolescents who are bullied or bully others
  10. Adolescents well visits
  11. Medical home for children with and without special health care needs
  12. Transition to adult care for children with and without special health care needs
  13. Oral Health
    • dental visit during pregnancy and
    • infants and children with a past year dental visit
  14. Smoking
    • women who smoke during pregnancy and
    • children who live in smoking households
  15. Insurance for children 0-17

Table 1: Previous NPMs vs New NPMs

IDENTIFYING POTENTIAL MEASURES

It was not a matter of simply consolidating the existing list. According to Michael Kogan, MCHB’s Director of Epidemiology and Research, there were hundreds of potential national performance measures. Kogan and Christopher Dykton, the Bureau’s West Branch Chief for State and Community Partnership, co-chaired an eight member work group that revised the performance measures. The group considered national health care quality indicators, Healthy People 2010 and Healthy People 2020, and input from external groups and agencies.

“We looked at data that didn’t exist years ago when the old national performance measures were there. We decided to take a really fresh approach and focus on the areas that Title V prioritizes,” explained Dykton. The group used six domains to evaluate potential measures and ensure key MCH populations were represented: maternal and women's health, perinatal and infant health, child health, adolescent health, life course, and children with special health care needs. This is reflected in the first NPM on the new list: preventive medical visits for women, a population underrepresented in the original set of NPMs.

The work group defined potential indicators to measure as those that can be modified by quantifiable state actions and for which there are timely, reliable data sources at both the national and state levels. Government programs require much more rigorous measurement to account for use of funds than they did 20 years ago.3 “We are all facing different pressures than we did when the original performance measures were developed,” said Kogan. “We can get requests from Congress - or Title V state offices may get requests - to talk explicitly about what activities are being done on Title V and how is that affecting outcomes? With the old framework, one could not do that.”

Stakeholder Input and Final Selection

“I think one of the most powerful things about the process were all these external stakeholders providing input all along the way,” said Dykton. The work group presented their initial draft in January 2014 at the Association of Maternal and Child Health Programs (AMCHP) annual conference and invited agencies and individuals to respond. They received more than 200 emails.

Some topics required more consideration than others. Oral health was a complicated measure to frame, explained Kogan. “There was the question of what age and who should the focus be on? Should it be pregnant women? Should it be children? Children at 6 months or 6 years? Consumers and professional organizations weighed in with differing opinions.” In the end, the group determined that oral health should be measured across all MCH age groups, from children ages 1 through 17 and pregnant women.

“There was a really deep conversation around breastfeeding,” said Dykton. “A lot of discussion around measurement at initiation versus at six months and should it be six months? We eventually came to the conclusion to use both data points.” In the new set of NPMs, number 4 monitors “A) Percent of infants who are ever breastfed and B) Percent of infants breastfed exclusively through 6 months."3

Medical homes and transitions to adult care were two other issues that drew a lot of comments. In the previous set of NPMs these measures pertained only to children with special health care needs, but work group discussions and comments from outside groups identified these as important measures for all children. “So we structured the national performance measures [for medical homes and transitions] specifically to say ‘percent of children with and without special health care needs,’” explained Kogan.

In accordance with the Office of Budget and Management, the work group held two public comment periods in June and November of 2014. These were publicized in OMB’s Federal Register. By the following January, OMB approved the current list as part of the new performance measurement system.3

CHANGES IN HOW STATES CHOOSE AND USE NPMs

The transformed Block Grant guidance allows states to adapt the list of NPMs to the particular needs of their MCH populations. Rather than addressing all 15 measures, states choose 8, with at least one from each population domain: maternal and women's health, perinatal and infant health, child health, adolescent health, life course, and children with special health care needs. The MCHB will provide state-specific data to help monitor their progress, a benefit not available under the previous system.3


Table 1: NPMs Selected by Region X States

In Region 10, as shown in Table 2, Well-Woman Visits (NPM 1) and Medical Homes (NPM 11) are priorities for all 4 states. Alaska is the only state to focus on Perinatal Regionalization (NPM 3) and Bullying (NPM 9) and Washington is alone in its selection of Adequate Insurance Coverage (NPM 15). None of the Region X states chose Low-Risk Cesarean Delivery (NPM 2).

Currently, states are identifying evidence-based or evidence-informed strategies that will help them to improve performance for their state-selected measures and implement their action plans. It is these state strategies that Kogan and Dykton are most enthusiastic about. “We are drawing on decades of scientific research about what works in MCH and now we are putting it into practice on a national scale,” said Kogan, who explained that these strategies are the key to the transformation.

“I’m really excited to see how these will be executed and operationalized,” said Dykton. “It will be really exciting to work with states as they develop strategies to address the performance measures and see that Title V can make a difference.”


REFERENCES

  1. Lu M. Transformation of the MCH Block Grant Part I [video]. HRSAtube channel, YouTube Web site. https://youtu.be/LirkzEDD2pE. January 22, 2014
  2. Lu MC, Lauver CB, Dykton C, et al. Transformation of the Title V Maternal and Child Health Services Block Grant. Maternal and Child Health Journal. 2015;19(5):927-931. doi:10.1007/s10995-015-1736-8.
  3. Title V Maternal and Child Health Services Block Grant Program. Health Resources and Services Administration Maternal and Child Health Web site. http://mchb.hrsa.gov/programs/titlevgrants/index.html. Accessed October 16, 2015.
  4. Kogan MD, Dykton C, Hirai AH, et al. A New Performance Measurement System for Maternal and Child Health in the United States. Maternal and Child Health Journal. 2015;19:945-957. doi: 10.1007/s10995-015-1739-5