Other factors contributing to the lack of focus on child health services in health care reform efforts include the challenge of capturing the long-term return on investments made during the childhood period, despite the documentation of such long-term benefits demonstrated by the research of Nobel laureate economist James Heckman. Capturing such returns is also a challenge because of the complexities of aligning investments with savings. For example, investments in child health services, early care and education, and family support services, such as home visiting, lead to savings in special education, behavioral health, and the juvenile justice and corrections system. Reconciling investments and returns across these sectors is challenging at best, and not possible in most states.
Other factors contributing to the lack of emphasis on children’s services in health care reform include the challenge of identifying effective and meaningful outcome measures, as the outcomes for promotion and prevention activities are less explicit than those for chronic disease management, such as hospital admissions, ED visits, and treatment costs. Metrics for activities designed to promote children’s optimal health, development, and well-being must include non-traditional, proximate measures that are known to contribute to elusive, long-term outcomes. Examples include such protective factors as family resiliency and such important health-related attributes as hope and happiness. Child health services transformation must encompass a multi-generational approach, since families are the most critical promoters of their children’s optimal health. Also, the relative paucity of successful examples of value-based payment models in child health is a disincentive. To date, there are few tested models, and we must pay close attention to model development and implementation in such pioneering states as New York and Oregon.
Despite the many challenges, there are compelling reasons for us to focus on children in the context of health care transformation and Medicaid reform. Children have near universal access to health services and a portfolio of evidence-based interventions is available for scaling. Such interventions are of relatively lost cost. Furthermore, we have the opportunity to maximally leverage the recommendations, resources, and guidelines of the federal Early and Periodic Screening, Diagnostic and Treatment program. As noted, child health services transformation does provide a long-term return on investment. There is the moral imperative of “children are our future,” and the opportunity to strategically reframe child health services transformation to appeal to important priorities. In some jurisdictions, a focus on child health services is viewed as a workforce development strategy while, in other settings, investing in children is viewed as a national security issue, given the needs for a fit military and cybersecurity skills. In some states, a focus on children is seen as a key strategy to addressing disparities and achieving health equity.
Many states have adopted a variety of strategies for successfully leveraging Medicaid and alternative payment strategies. In general, such strategies fall within three general categories of reform efforts. States may provide optional benefits by securing a federal waiver or securing approval for a Delivery System Reform Incentive Payment (DSRIP) Program. Through such a mechanism, Medicaid programs may expand their coverage of certain populations and/or certain activities such as case management, care coordination, and the linking of beneficiaries to desired services. Another approach is to implement a version of value-based purchasing. Models vary in the extent to which providers share risk, ranging from such low-risk approaches as pay-for-performance and clinical episode/bundled payments to the greater risk sharing inherent in shared savings/risk and capitation/global payments.
The greatest opportunity for more significant impact lies in delivery system reforms, including considerations of how care is delivered to improve population health and how medical services are paid. Such reform typically focuses on such core components of the delivery system as care coordination, value-based payment incentives, provider and community collaboration, quality measurement and accountability, and data sharing and integration. While certainly important, these “conventional” components are likely too limited to achieve greater than incremental advances in population health.
Rather, the key to advancing population health lies in embracing critical principles emerging from our experiences in system building and deriving implications for leveraging Medicaid (and payment reform). Such principles may be used as a “litmus test” to judge the likelihood of certain reforms to truly transform child health services and promote population health.
Our work at the Help Me Grow National Center, a program of Connecticut Children’s Office for Community Child Health, in advancing early childhood system building provides numerous examples of how leveraging Medicaid for a greater purpose can lead to enhanced outcomes for children and what is believed to be a greater long-term payoff in terms of child health and development outcomes.
Promote a universal approach to identifying children with developmental and behavioral concerns and linking them to services, including a particular focus on vulnerable children who are at risk for adverse outcomes. Such an approach maximizes value and impact by ensuring even mild to moderate concerns are identified and addressed as early as possible.
Support community-based efforts that promote the health and safety of children and their families in a variety of settings, such as home visiting, early care and education, neighborhoods and communities.
Support community-based efforts to identify and address children’s and families’ needs as early as possible.
Integrate services and supports for children and families by linking child health, early care and education, family support services, and all other essential sectors, such as housing, neighborhood health and safety, and food and nutrition.
Encourage the design and dissemination of, and support for, new roles for such staff as community health workers, parent mentors, home visitors, and care coordinators to support families’ promotion of children’s healthy development.
Elevate and expand the role of care coordination in accessing services within and across sectors.
Identify ways to achieve cost efficiencies through the blending of administrative and financial resources of departments and agencies.
Develop methodology to document short- and longer-term cost savings of an integrated approach to developmental promotion, early detection, referral and linkage.
Encourage the formal financial scoring of interventions over years to decades, so called “dynamic scoring,” to capture ROI.
Employ effective strategies to demonstrate real-time cost-effectiveness. Such strategies include addressing developmental and behavioral concerns through de-medicalization before medical care is needed, and identifying children with mild to moderate concerns through mid-level developmental assessment, as opposed to utilizing higher level evaluations, and linking such children to community-based programs and services.
We believe that health care reform should not only include a focus on child health services transformation, but that the latter should be the key priority for Medicaid. We suggest that the following six strategies deserve our support and advocacy.
Shift the primary focus of reform efforts from health services for adults to children’s health services. The rationale for such an approach includes the lower costs associated with a focus on children (and their families); the opportunity to have the greatest impact upon health from a life course perspective; the efficacy of available, evidence-based innovations; and the large ROI for investments in early childhood.
Expand the target population for health care reform efforts from an overarching focus on chronic, high cost conditions to a universal approach that pays special attention to the needs of vulnerable children who are at risk for adverse health, developmental, and behavioral conditions. The U.S. Centers for Disease Control and Prevention estimates that, depending on the specific jurisdiction, this population comprises 30 to 40 percent of all children. It is important to note that a universal approach does not exclude a focus on children with complex medical conditions, but rather expands the target population.
View the delivery of child health services within the context of comprehensive system building through an “all sectors in” approach, which includes child health services; early care and education; family support; housing; transportation; food and nutrition; safe neighborhoods, and other areas. Such an approach responds to social as well as bio-medical determinants of health and provides fiscal support for care coordination across sectors.
Encourage and support innovation and the diffusion of innovation, with the resources to design, test, and disseminate evidence-based strategies to achieve scale, impact, and cost savings.
Supporting the development and application of broad measures of child health and well-being, including measures of social determinants that are integrally tied to health and well-being, and rewarding the aligning of data, such as kindergarten readiness and reading proficiency, to strengthen systems, support families, and promote health equity.
Develop sound and convincing methodologies to project long-term return on investment, cost savings, and cost benefits for transforming Medicaid and child health services that measure progress in strengthening families and improving child health and developmental trajectories.
I am cautiously optimistic that Medicaid will soon embrace a child-first focus on healthcare transformation. We are already seeing movement in the right direction.
In March 2017, the Center for Medicare & Medicaid Innovation (CMMI) drafted a request for proposals on developing alternative payment models for pediatrics. In December 2017, CMMI drafted for internal review the Communities for Healthy Children and Youth Model Innovation Center Investment Plan, which reportedly includes a new Medicaid-focused payment service and delivery model that supports state- and locally-driven innovation to improve the health of children and youth.
In Connecticut, the Office of Health Strategy’s State Innovation Model (SIM), launched a pediatric primary care payment reform study group to focus on developing new pediatric payment models. Recommendations are now under consideration by the SIM Primary Care Modernization initiative.
In addition, examples from Oregon, in which the state has implemented a K-12 Literacy Framework to ensure all students read at or above grade level, and New York State, which adopted the First 1000 Days on Medicaid initiative recognizing a child’s first three years are the most crucial for development, also provide promise in leveraging Medicaid to build stronger systems to reform child health service delivery.
The key to success in leveraging Medicaid for greater impact centers on comprehensive system building to strengthen families to promote children’s optimal health, development and well-being. Such systems must embrace an “all sectors in” approach that builds cross-sector collaboration. Our experience with our Help Me Grow model in 30 states suggests that such an approach can and will pay off in both the short- and long-term making our goal of enhancing outcomes for all children a reality.
Paul H. Dworkin, MD is executive vice president for community child health at Connecticut Children’s, director of Connecticut Children’s Office for Community Child Health and founding director of the Help Me Grow National Center. Dr. Dworkin is also a professor of pediatrics at UConn School of Medicine.
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