A Statewide Approach To Improving Child Health And Health Care

Photographs by Glenn Russell

Judy Shaw remembers that when she walked into Children’s of Alabama, in Birmingham, in 2014, she was greeted by some executives “with their arms crossed.” Shaw, the director of the Vermont Child Health Improvement Program (VCHIP), run through the University of Vermont in Burlington, had been invited to Alabama by the children’s hospital to provide guidance on implementing an improvement program for the state.

VCHIP has proved to be a success in improving the care delivered to children across Vermont. It has achieved this progress not by instituting new regulations or inventing new payment models but, rather, by serving as a central and honest broker to help pediatric providers, payers, and policy makers navigate the complex and constantly evolving push toward quality improvement in health care. VCHIP’s work has yielded positive results for children in Vermont, achieving high marks on nearly all metrics it has tracked: improved communication among family and pediatric providers, more well-child visits, better immunization rates, and better compliance with national guidelines for chronic conditions such as asthma.^1–3

But even if VCHIP’s approach has worked in Vermont, a small, homogeneous northeastern state represented by Bernie Sanders in the US Senate, one question kept coming up during Shaw’s visits to other states: Could it work elsewhere, in different regions with different populations and different health care markets? Alabama’s officials weren’t convinced, and Shaw had her own reservations. Still, she was used to traveling around the country—having visited nearly thirty states to speak on the topic—and was willing to share her experiences.

Her approach in Birmingham was convincing: Two hours later, representatives of the hospital, a local insurer, and the state Medicaid program had pledged $3 million in funding over the course of three years to institute a program similar to VCHIP in Alabama. With the help of VCHIP and the National Improvement Partnership Network (NIPN), the Alabama Children’s Health Improvement Alliance was created in 2015. Since then, the funding has been renewed.⁴

Since its launch two decades ago, VCHIP has never paid for, provided, or reimbursed directly for health care. Rather, it solves problems and identifies gaps in current health care delivery models and helps pediatricians meet the quality improvement metrics created by payers. In doing so, VCHIP has become the go-to problem solver for hospitals, insurance networks, providers, and advocacy groups in the state. And when its leaders go to places similar to Children’s of Alabama and share their successes, VCHIP finds willing allies who want to learn and gain from its expertise.

“Those that deliver, regulate, mandate, and pay for health care would love … someone to turn to,” says Shaw, who believes that a statewide improvement program like VCHIP can provide states with the strong foundation necessary for more targeted improvement efforts. A 2018 study published in Academic Pediatrics looking at human papillomavirus vaccination rates found that practices in six states that had worked with quality improvement programs similar to VCHIP had a 6-percentage-point greater reduction in missed opportunities for vaccination compared with practices that had not.⁵

NIPN, the national network with a mission to help states set up improvement partnerships, was created by VCHIP’s leaders, who were eager to share lessons learned from their success.⁶ Beginning in 2003 with New Mexico and Utah, NIPN has provided consultation to more than twenty states, including Alabama, looking to start their own improvement partnerships.⁷

Creating an effective improvement program in Vermont has taken more than twenty years and remains a work in progress.

But creating an effective improvement program in Vermont has taken more than twenty years and remains a work in progress. Shaw, who has been with VCHIP since its inception, acknowledges that there have been hurdles along the way. Chief among them is the fact that when it comes to quality improvement, children’s health care doesn’t get much attention from insurers because it is a small line item compared with spending on other populations.

Also, children tend to be healthy, so much of their care is preventive, and savings, therefore, are not fully realized until years later. Even today, with an increasingly broad focus on prevention and the social determinants of health, the economics of health care continue to favor investments that show short-term results and significant cost savings such as interventions and care for costly, long-term, chronic illnesses in adults.

Starting Small

Shaw and many of her colleagues will tell you that Vermont is unique, and not just for its picturesque mountains and covered bridges. On metrics for children’s health care, the state ranks as one of the top in the country, largely as a result of how accessible care is in Vermont. Some 97–98 percent of children are covered by insurance, and nearly all pediatricians accept Medicaid reimbursement in their practices, which is bolstered by Vermont’s expanded Medicaid eligibility level (up to 300 percent of the federal poverty level for families with children).⁸ For children’s health in particular, access to affordable care makes a significant difference in metrics that determine long-term outcomes, including vaccination, nutrition, and preventive services for chronic ailments such as asthma.

Vermont also accepted the Medicaid expansion as part of the Affordable Care Act and reduced its overall uninsurance rate by nearly 40 percent between 2013 and 2017. According to data from 2018,⁹ it now has one of the highest insurance rates in the country—second only to Massachusetts.

At just under 10,000 square miles, Vermont is one of the smallest states in the US. Its lone medical school—located in Burlington, its most populous city—often serves as a de facto leader in health care delivery statewide. With its small size, centralized leadership, and wide access to care, Vermont has all the right ingredients to foster a “naturally collaborative” health care system, as Shaw describes it.

Other more populous, sprawling states have multiple health systems that are often focused on different population centers or demographics, sometimes competing against one another within the same region. Establishing a single entity for coordination can be a more difficult and complicated task in those states compared with Vermont, especially in the face of overlapping jurisdictions and priorities. And in some states that have opted to not expand their Children’s Health Insurance Program (CHIP) and Medicaid programs, fewer children have coverage, which can correlate to fewer pediatric practices accepting those patients.

“Generally speaking, small states with a lack of diversity aren’t seen as leaders to any other state,” says Tricia Brooks, a research professor at the Georgetown University Center for Children and Families, in Washington, D.C. “That said, VCHIP is a good model that other states would want to imitate.”

‘Set Up The Groundwork’

“In the late ’90s, measurement in pediatrics was becoming a thing,” says Breena Holmes, a pediatrician who currently serves as the director of the Maternal and Child Health Division at the Vermont Department of Health.

In 1999 the American Academy of Pediatrics put out a periodicity schedule called Bright Futures, detailing recommended screenings and assessments at each well-child visit from infancy through adolescence, such as blood lead levels in infants and depression screening in adolescents. These guidelines required a shift in thinking and practice for pediatricians, who began to see standards of care shaped to a greater degree by specific metrics.

At the same time, commercial insurers were beginning to pay attention. That same year the Vermont chapter of the American Academy of Pediatrics partnered with the state health department and the Department of Pediatrics at the Robert Larner, M.D. College of Medicine at the University of Vermont to form VCHIP. Together they were seeking new ways to improve child health outcomes throughout the state while helping pediatricians adapt to using the new metrics in their day-to-day work.

“At the time, people weren’t doing the developmental screening in line with those guidelines,” says Wendy Davis, a pediatrician at University of Vermont Children’s Hospital and the associate director of NIPN. Davis saw this moment of transition as an opportunity to bring more pediatricians together into a network, which could be tapped for other quality improvement projects.

“All of that was starting to bubble, and the busy pediatrician was thinking, ‘Uh oh! How will I manage all of this?’” says Holmes, who was in private practice in Middlebury, Vermont, at the time, trying to adapt to using quantitative metrics within her own office.

“None of us had any idea what quality improvement was. We didn’t know what to do, but people came in to help us,” Holmes says, referring to the network spearheaded by Davis that would become an important part of VCHIP. It “met a primary care need before people even knew they had a need,” Holmes says.

Holmes remembers the VCHIP team’s first visit to her office: They came during her lunch break with flashcards, a sandwich, and bottle of water for her, ready to explain the quality improvement metrics and how the individual pediatric offices around the state could incorporate these metrics into their practices.

Barbara Frankowski, a professor of pediatrics at the University of Vermont who has worked with VCHIP since the early 2000s, remembers taking those initial steps to get in the door of a pediatrician’s office to talk about structural changes to adolescent care.¹⁰ In the early 2000s she began visiting pediatric offices on behalf of VCHIP to discuss improvements in adolescent care. They’d arrange a day to come and bring lunch for the entire office. “You had to involve the whole practice,” Frankowski explains. “If you just relied on the pediatrician to change the behavior, it didn’t stick.”

Frankowski’s goal, as she describes it, was to encourage pediatric practices to focus on a specific adolescent area such as sexuality (sexual health, sexual orientation, contraception, and sexually transmitted infections), mental health and depression, substance use, nutrition, and healthy weight. Each of these areas was connected to a metric: screening for chlamydia, screening for depression, screening for substance abuse, and measuring and discussing the body mass index.

“Initially, these personal visits to the practices to meet with the entire office staff were intended to have them understand the art of talking with adolescents and help them overcome office barriers to important things, like having private time with the adolescent,” Frankowski notes. “This set up the groundwork for a more rigorous project where practice teams came together for learning sessions and collected data.”

Once in the office, Frankowski and her team could see how the practice was laid out. Simple changes, such as giving adolescent patients a private space to fill out a lifestyle screening form away from a parent’s prying eyes, could give providers a better foundation with their patients from which to build a trusting relationship. The in-person visits allowed Frankowski to take ideas that worked well at one practice and share them with another. “It feels very respectful for the practices that you are visiting. The time you are there, it is not just, ‘I am going to tell you how to do things. Show me your waiting room, your exam room.’ You are showing an interest in the way they have set things up,” she explains.

As VCHIP became more established and gained a good reputation with the pediatric practices, its projects, too, became more sophisticated, and more demanding, in terms of data collection and assessment of individual practices’ metrics.

In 2012 VCHIP formalized its network of pediatric practices in the state, calling it CHAMP (Child Health Advances Measured in Practice). “Champ” also happens to be the common nickname for the mythical sea monster said to live in the depths of Lake Champlain, which extends 100 miles along Vermont’s western border. (VCHIP has yet to measure the extent to which this sea monster inhabits the nightmares of its pediatric patient population.)

The CHAMP network currently comprises more than fifty pediatric practices, which encompass nearly all of the child-serving family medicine practices in the state and many of the family practices that also see pediatric patients. Each participating practice agrees to be a part of annual VCHIP coordinated projects with goals such as reducing asthma hospital visits or improving adolescent mental health screening. The practices also submit their patient records to VCHIP for a formal chart audit. In exchange, they get VCHIP’s support and guidance. VCHIP’s support is free, making it an offer that is, for many practices, hard to refuse.

When these pediatric practices submit a random set of their records and data as part of VCHIP’s formal chart audit, Davis’s team drills down on measures such as immunization rates and vision screenings to see how far the practices need to go to catch up to what the American Academy of Pediatrics expects. After reviewing the data, VCHIP’s consultants identify the ripest areas for improvement in any given practice and recommend specific, actionable changes the practice can implement.

The practices, Davis found, wanted to improve the care they were providing. Having VCHIP coordinate the audit, Davis explains, is different than when an insurance company asks to see the charts. The practices were willing to share their health records and hear out VCHIP’s advisers in exchange for help planning a path forward to achieve better outcomes for their patients.

Years of working in the medical field have shown Davis and her team that it’s hard for a pediatrician to take time out of their day for administrative tasks, so they have prioritized making the administrative burden on practices low, auditing as few charts as statistically possible to get a good read.

“We are so sensitive to how difficult it is to be in primary care pediatric practice in 2020,” Davis says. She remembers her own surprise at starting the auditing and assessment process with her own practice at the University of Vermont, assuming she would be ahead of what the standards suggested. Instead, she realized that the practice’s immunization rates were not what they could or should be. It was a bit of a wake-up call. “That is when you start to say, I need to start looking at the indicators,” she says.

Davis also saw this as an opportunity for pediatricians to earn credits toward their board certifications. The American Board of Pediatrics requires all pediatricians to earn points over different areas every five years to stay board certified as a pediatrician. One area is quality improvement, so VCHIP started registering certain CHAMP network projects with the American Board of Pediatrics. According to Frankowski, this incentive to earn board certification credits made voluntary participation and data collection even easier.

VCHIP was also able to leverage Medicaid funding to compensate providers for attending statewide health meetings in person, such as a colloquium on children’s mental health. Under a fee-for-service model, physicians have limited financial incentive to take time out of their schedules to attend in-person events. By using the Medicaid administrative match, which allows participating states to spend state Medicaid dollars to assist with the administration of the Medicaid program, VCHIP can reimburse physicians for their time at selected collaborative or statewide planning meetings. All states have some flexibility in using the match for Medicaid administrative activities, which are reimbursed at a slightly lower match rate (50 percent) for “proper and efficient” costs associated with the state’s administration of its Medicaid program, which can include in-person events.¹¹

In 2008, nearly a decade after the release of Bright Futures, its first periodicity schedule, the American Academy of Pediatrics provided more specific developmental screening guidelines against which pediatricians could be more definitively and quantitatively measured. “Before that, the guidelines were general and not specific for implementation,” says Paul Lipkin, a pediatrician from Johns Hopkins University who chaired the American Academy of Pediatrics commission on the developmental guidelines. Before the 2008 publication of Bright Futures, the consensus was that children should be given a developmental screening at every visit, but Lipkin and his team found that very few pediatricians were actually doing so. This version of Bright Futures provided a set of concrete guidelines for developmental screening, with ages and instruments deemed acceptable for use. By the time the 2008 recommendations came out, VCHIP didn’t have to start from scratch—it was already well established within the state and, importantly, trusted by the pediatricians who had grown accustomed to the network’s support and collaborative approach.

Multiple Roles

Without VCHIP in place, fewer physicians would have access to instant pandemic-related information.

This connectedness has been crucial in facilitating up-to-date communication between providers during the coronavirus disease 2019 (COVID-19) pandemic, with the state offering thrice-weekly calls for pediatric providers with the Vermont Department of Health and other key players in the state with updates on state-specific data and protocols. Shaw speculates that without VCHIP in place, fewer physicians would have access to instant pandemic-related information, and the Department of Health would be inundated with requests for details.

But VCHIP’s leaders see the organization as having other roles in addition to providing direct support and consultation to practices. One is to serve as a forecaster of sorts, anticipating problems such as adapting to new metrics before individual pediatricians might be able to see them coming. Another, as Holmes describes it, is to act as the “implementation arm” of the Department of Health’s pediatric public policy work. Her team studies best practices—evidence-based approaches in pediatrics and maternal and fetal medicine. Then it’s up to VCHIP to bring these concepts to the providers in a way that will work with the patients and payers successfully.

Shaw has a senior advisory board whose members include representatives from the American Academy of Pediatrics, the American Academy of Family Physicians, the Vermont Department of Health, and state Medicaid officials, which meets monthly to identify and discuss areas of improvement before assigning them to a faculty member at the University of Vermont’s Robert Larner, M.D. College of Medicine to take up the initiative, as the medical school has dedicated a portion of its faculty workload to VCHIP work.

Looking Ahead

When Shaw goes to other states, as she did during her visit to Alabama, she stresses her belief that there are four specific and active participants necessary for any improvement program to succeed: an academic medical center, a Medicaid program, the state health department, and professional member organizations. In Vermont this multifaceted approach allows any provider, payer, academic, or advocacy organization to approach VCHIP about finding ways to improve child health outcomes within their state or to work with VCHIP to use metrics to demonstrate success in their quality improvement initiatives.

Even with all of the pieces in place, however, it can still be an uphill battle. Pediatrics remains a very small percentage of overall health spending for payers. As a consequence, even as VCHIP has shown savings and improvements, payers and policy makers have been less interested in focusing on children’s health than adult health, and particularly chronic illness and care.

Brooks traces the focus on health care quality improvement to the concerns about increasing costs that employers and insurers were bearing in the 1990s. “The number-one goal of most quality improvement is saving money,” she notes. With a relatively small piece of the pie at stake, it can be harder for health care initiatives focused on children to gain traction.

Having advocates rely on the VCHIP data, even without giving the organization explicit credit, paves the way for future projects.

Still, Shaw and colleagues have found a way to attract and engage partners in a way that feels sustainable. That feeling, Shaw believes, comes from the organization’s willingness to cede control and credit for projects. So, for example, when a state Medicaid director relies on VCHIP data to document for legislators the work it is doing on behalf of kids, Shaw sees it as a sign of their partners’ long-term investment in VCHIP work. The same is true when an insurer cites results of the VCHIP initiative on adolescent health to show future health care cost savings.¹² In both instances, having advocates rely on the VCHIP data, even without giving the organization explicit credit, paves the way for future projects.

“I don’t need the recognition,” Shaw remembers saying. “If I can figure out a solution to their problem,” she says of the insurer and the state’s Medicaid group that rely on VCHIP projects to show their success, “then they are going to keep funding us.” And the funding allows her team to keep tackling child health metrics and improve on them.

Frankowski acknowledges that the introduction of a “Zoom world” of video interaction created by the COVID-19 lockdown could diminish the fundamental importance of in-person visits, both for pediatrics in general and for groups such as VCHIP, which has nurtured its improvement efforts with the persistent, authentic work of relationship building. “I don’t know how this would translate moving forward,” she says. “The more interaction and the more genuine interest you take in other people, the more willing they are going to be to launch into difficult and complicated projects.”

Frankowski and colleagues are optimistic that the same underlying flexibility and collaborative spirit that have allowed VCHIP to thrive during the past two decades will also give them the resilience to pursue their work in a post-COVID-19 universe. Whether those characteristics will surface in similar programs in other states facing the same (and often more acute) challenges remains an outstanding question. NIPN’s leaders believe that the programs they’ve supported are, at the very least, well prepared to confront with patience and creativity any tests that come their way.

NOTES

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