Transforming Pediatric Primary Care: Moving From Theory To Practice In Massachusetts And Beyond

For years, pediatric providers, children’s advocates, parents, and others have advocated that the child health delivery system focus more on family-based primary and preventive care, including social and economic drivers of health. Unfortunately, reforming the pediatric delivery system often has taken a back seat to other health policy priorities.

However, 2020 has moved the issue to center stage. The COVID-19 pandemic has laid bare the indelible connections between a child’s well-being and the status of their families, schools, and communities, as well as the lifelong health impact of systemic racism and discrimination that begins in childhood. It is more important than ever to identify the specific policy options that can support transformation of the child health delivery system, particularly for the over four in ten of the nation’s children covered by Medicaid or the Children’s Health Insurance Program (CHIP).

In Massachusetts, the Child and Adolescent Health Initiative (CAHI), a group sponsored by the state’s chapter of the American Academy of Pediatrics, has worked to identify concrete policy options to change the way that the state’s Medicaid program (known as “MassHealth”) funds and organizes the delivery of care to children and their families. In the new roadmap, Moving to the Vanguard on Pediatric Care: CAHI Recommendations for the MassHealth Section 1115 Waiver Renewal, CAHI converted established principles for child health delivery transformation—integration of behavioral health in family-based care, attention to social and economic drivers of health, increased investment in children and their families—into specific, actionable reforms that Massachusetts can adopt in the upcoming renewal of the its Medicaid 1115 waiver or through other, existing Medicaid authorities.

The roadmap was designed for MassHealth officials but offers policy options that other states and the Biden-Harris Administration can pursue. In this post, we outline CAHI’s recommendations and examine the tools the new administration could use to help states beyond Massachusetts implement these ideas. The CAHI proposals include:

Support And Maintain Advanced Pediatric Primary Care

 Child health providers are a trusted source of information and support for many families and often the only point of regular contact until pre-school or school begins for the nation’s youngest children. CAHI recommends taking advantage of this important relationship by providing fiscal incentives to pediatric primary care practices that deliver an advanced model of team-based care consistent with the standards below.

Provide Integrated Physical And Behavioral Health Care

Upstream prevention and promotion for families with children should be emphasized. Although there may need to be exceptions for small or rural practices, advanced practices should have a behavioral health specialist available on-site. Along with supporting such practices, Massachusetts (and other states) can modify its Medicaid benefit policy to provide mental health services to families where a child is at risk but does not have a behavioral diagnosis, as California recently did with the clarification of family therapy as a Medi-Cal benefit.

Adopt A Clear Family Focus

States should employ two-generation strategies that reflect the connection between the health and well-being of children and their caregivers. These strategies include, as a routine matter of practice, screening parents and other caregivers for depression, anxiety, substance use disorder, and other behavioral health conditions during pediatric visits, and offering linkages to follow up care.

Identify And Address –Directly Or With Community Partners—Social, Economic, Educational, And Equity Issues

Examples include the need for food, transportation, housing, and interpersonal violence prevention and treatment. Providers can be expected to work with regional networks of community-based organizations when issues are identified, ensure follow-up, and monitor the outcome of referrals. Screening alone is not enough.

Provide Care Coordination For Children With Chronic And Complex Medical Conditions

Many children with chronic medical conditions receive a substantial amount of their care through community-based pediatric primary care practices, even as others are served primarily by children’s hospitals or other specialty medical centers.

Include Community Health Workers In The Care Team

Community health workers are “experience-based experts” who can help promote family confidence and well-being, address social drivers of health, prevent and/or identify behavioral health concerns, facilitate access to and coordinate care, and refer families for further treatment. These workers (including navigators, family coordinators, and other peer specialists) possess critical knowledge of community resources and organizations. They also often reflect the communities they serve and have shared lived experiences. Community health workers can be particularly effective at working with families and bridging trusting relationships with pediatric primary care providers.

Address Social Drivers Of Health, Including Through Linkages With Early Intervention And Schools

A key goal of pediatric care in general—and certainly of the Medicaid program, in particular—is to provide preventive care to children who currently are healthy but at risk for poor outcomes and high health care and other societal costs in the future. Pediatric care should include a strong focus on identifying these children at “rising risk,” often due to social drivers of health, and connecting them to services.

In Massachusetts, an existing Medicaid 1115 waiver allows the Commonwealth to use Medicaid funds to provide health-related services through a network of community-based providers. To date, however, the services have been largely restricted to high-cost, and therefore adult populations. CAHI recommends that, in its renewal application, the Commonwealth seek to expand funding for health-related services, broaden the scope of services to include those needed by families with children (e.g., interpersonal violence services as well as employment and transportation), and extend eligibility for these services to children and families at rising risk of poor outcomes.

CAHI also recommends promoting greater coordination among the state’s Medicaid agency, early intervention programs and the educational system. When children face developmental, growth and/or learning issues, they often require supports across their physical health, mental health, family, and educational needs, leaving families to navigate a complex system of multiple agencies. To break down these silos, CAHI recommends more formal interagency work between MassHealth and other governmental agencies; improving access to and consultations for mental health supports for pre-school children; helping families with young children access early childhood education resources; expanding school-based health clinics to address behavioral and developmental concerns; and supporting families when their children age out of early intervention services. While Medicaid alone cannot solve all of the issues at the intersection of health and education, it clearly has a role to play, as evidenced by states such as Oregon that increasingly are expecting their Medicaid managed care plans to contribute to kindergarten readiness.

Assure Investment In Children And Youth As A Base For Better Outcomes And Investment In The Future

There is a strong case to be made that we should be investing more in children and youth, as opposed to seeking to reduce pediatric expenditures. CAHI recommends using Medicaid as a vehicle to promote greater investment in primary and preventive care for children, as well as new pediatric-specifics approaches to value-based payment. Specifically, CAHI calls for:

Establishing A Floor For Expenditures On Children By Managed Care Organizations (MCOs) And Accountable Care Organization (ACOs)

This would ensure that sufficient resources are spent on health-promoting activities, taking into consideration that children overall are healthier than adults and, thus, it would be unrealistic to expect that they receive the same level of expenditures as adults. Specifically, CAHI recommends that the proportion of an organization’s total health care expenditures allocated to children be required to reach at least 60 percent of the proportion of the plan’s population that represents children and youth (through age 21).

Requiring ACOs And MCOs To Increase Their Investment In All Pediatric Care

The increase should be 30 percent over three years at a minimum, aligning with a recent proposal from Massachusetts Governor Baker’s (HB 4134).

Adjusting The Shared Savings Calculation Used In The Commonwealth’s Medicaid ACO Program

Investments in a child’s health can pay off with better health, and lower health care costs, over a long period of time, even a lifetime. As ACOs are rewarded and penalized in part based on how much they spend in relation to benchmarks, discounting the reported costs of serving pediatric enrollees, in recognition of the longer time horizon associated with investments in child health, would effectively create more incentive for such investments.

Broader Application Of The CAHI Strategies

Other states could adopt each of the strategies outlined above through Medicaid and CHIP, most often without requiring a Section 1115 waiver. States can move forward on their own, and the Biden-Harris Administration could also take steps to encourage states to do so.

Existing tools at the new administration’s disposal include:

Issuing State Medicaid Director Letters And Other Guidance On Existing Options

The US Department of Health & Human Services (HHS) can issue State Medicaid Director letters or Center for Medicaid and CHIP Services (CMCS) Informational Bulletins that describe the tools available to states to strengthen the child health delivery system. Such issuances could outline how a state can use Medicaid authorities to establish pediatric-specific advanced medical homes; promote use of community health workers; incentivize or require screening and follow up for maternal depression, anxiety, and other issues that affect the entire family; and address social and economic issues that affect families with children. Such guidance is a common tool used by administrations to signal their priorities, provide reassurance to states that various innovations are consistent with federal rules and regulations, and offer examples of states that already are engaged in such work.

Expanding The Innovation Accelerator Program

Pediatric delivery system reform should be included in the Innovation Accelerator Program (IAP). Launched in 2014, the IAP is a joint initiative of the Center for Medicare and Medicaid Innovation (CMMI) and the CMCS, providing technical assistance and support to states on delivery system reforms for Medicaid. To date, the initiatives have largely focused on issues of primary concern to adults, but the Biden-Harris Administration could open a new track for states that want to pursue reform of their child health delivery system.

Establishing A New Federal Initiative To Improve Child Health In Light Of COVID-19

As HHS has done in the past in response to urgent and pressing issues, the Biden-Harris Administration could elect to establish an agency-wide initiative to identify the options available for strengthening the child health delivery system and long-term child well-being. The initiative could be coordinated with a newly-created White House Office of Children and Youth, which a number of provider and advocacy organizations are recommending that the Biden-Harris Administration establish. Similar action has been taken in the past with respect to the opioid epidemic, and other “hot button” issues.

Expanding The Medicaid And CHIP Learning Collaborative To Include A Segment On Child Health Delivery System Reform

CMCS routinely brings states together to discuss key issues related to eligibility and enrollment. In the new administration, CMCS could consider adding a delivery system component to the learning collaborative that addresses pediatric delivery system reform.

Launching A New Value-Based Payment Initiative Out Of CMMI Aimed At Primary And Preventive Care

CMMI has broad discretion to test various models for delivery system reform and is specifically charged with considering initiatives related to Medicaid, not just Medicare. In Spring 2019, CMMI initiated two pediatric-specific delivery system models – Integrated Care for Kids and Maternal Opioid Misuse– both of which aim to address relatively high-need children and their families. The incoming administration could explore an additional model aimed at testing new value-based payment strategies supporting pediatric primary care transformation; this would address the shortcomings of traditional value-based payment models when it comes to child health.

Welcoming Section 1115 Waivers To Improve Care For Children

Through waivers, states could provide continuous eligibility for a period of three years for children and youth under 21 (as recommend by CAHI for Massachusetts), offer Medicaid matching funds for health-related services for children, and promote pediatric-specific approaches to value-based payment.

With children expected to feel the impact of the events of 2020 for years to come, it is important to continue to assess how to improve health care for children and youth. The CAHI recommendations offer a useful roadmap for MassHealth but also for other interested states and the Biden-Harris Administration. Any such effort—whether in Massachusetts, other states, or at the federal level—should include families in the policy development process, rely on data, and address emerging issues in the stability of coverage for children and their families.

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