By Katie Beckmann, Program Officer, Children, Families and Communities Program, David and Lucile Packard Foundation | Jocelyn Guyer, Managing Director, Manatt Health | Donna Cohen Ross, Senior Advisor, Center for the Study of Social Policy
Editor’s Note: Nearly half of children under age three in the United States get their health insurance through Medicaid and the Children’s Health Insurance Program (CHIP).1 With such broad reach, these programs can play a powerful role in influencing the way pediatric care is delivered. Supporting pediatric approaches that strengthen children’s social and emotional development is a critical place to begin, given that early social and emotional health have lifelong consequences for physical and behavioral health, school success, and productivity.
How can states leverage Medicaid and CHIP to foster children’s healthy social and emotional development? How can Medicaid and CHIP fuel transformation in pediatric care? What strategies and tactics can state Medicaid agencies, managed care plans, pediatric providers and others put into action to optimize the healthy social and emotional development of children? The Pediatrics Supporting Parents Initiative turned to the Center for the Study of Social Policy (CSSP) and Manatt Health to chart a path forward in a new blueprint for fostering children’s social and emotional health. In a recent webinar, we revealed our findings and recommendations—and shared the blueprint for driving the transformation of pediatric care through Medicaid and CHIP. Part 1 of our article summarizing the webinar, published in our July “Health Update,” reviews core practices, how Medicaid and CHIP can influence pediatric care, links to family well-being, and the five core strategies shared in the blueprint. Part 2 of our summary, below, provides a detailed look at each of the five core strategies, including action steps for implementation and real-world examples.
Click here to view the webinar free on demand—and here to download a free copy of the presentation, as well as the full blueprint.
Strategy #1: Cover and Support a Full Range of Screening, Assessment and Treatment Services for Children and Their Parents
It is critical to incorporate screening for social and emotional concerns within routine developmental and behavioral surveillance conducted during well-child visits. Social and emotional screening, assessment, and interventions should be built into care management requirements. Closing the referral loop is critical to ensure that services are received following a child’s screening. We need to talk about screening in the context of not just identifying issues but also connecting families with the right treatment resources to address those issues.
Key to effective implementation is promoting investments in the social and emotional development of children as value-added services that managed care organizations (MCOs) provide. Louisiana provides an excellent example of how the approach has been used successfully for adults. Through Louisiana’s Medicaid managed care procurement process, MCOs receive additional points if they agree to offer adult dental coverage, medical respite care and other value-added services. States could apply this same strategy to incentivize plans to provide other types of enhanced services, such as parenting programs for families with children at high risk for social and emotional issues.
In addition, family well-being and parental health are central to children’s social and emotional development. Therefore, it is crucial to maximize coverage of screening, assessment and treatment services for parents, as well as for children. One best practice is allowing maternal depression screening to be billed under the child’s Medicaid, which 32 states (including Washington, D.C.) already permit.
Strategy #2: Leverage Quality and Performance Improvement Projects to Spur Changes in Pediatric Practice
Quality and performance improvement projects (PIPs) are already driving states and communities to do a better job of providing healthcare to children and families. This approach can be adapted to drive change in pediatric practice and promote the healthy social and emotional development of children.
New York State provides an excellent example of this strategy in action through the state’s First 1,000 Days on Medicaid Initiative. The state is implementing a Kid’s Quality Agenda, which requires Medicaid MCOs to participate in a two-year PIP addressing screening and follow-up on lead testing, newborn hearing and child development.
Other important steps states can take to improve quality and performance include:
- Supporting the use of Child Core Set measures (a set of children’s healthcare quality measures, including several focused on behavioral health, for voluntary use by Medicaid and CHIP programs) and exploring the development of additional measures related to social and emotional development
- In Medicaid managed care states, rewarding plans that perform well on children’s social and emotional development measures by auto-assigning them more beneficiaries
Strategy #3: Establish Payment Models That Incentivize Social and Emotional Development
Leveraging quality incentives to reward plans with strong performance on promoting children’s social and emotional development can be a powerful tool for driving improvement. States that put a priority on improving children’s social and emotional health can set specific performance metrics—and incentives for meeting those metrics—to support achieving their goals. For example, managed care states can challenge plans to earn up to 5% above their capitation payments by meeting set performance objectives or withhold a portion of a plan’s capitation payment pending the achievement of goals.
Oregon has used this approach with great success. In Oregon, Coordinated Care Organizations (CCOs) can earn up to 4.25% above their capitation payments for performance on specific measures. As a result of this program, Oregon’s child development screening rates tripled from 2011 to 2017. As an example of how paying out incentives can move the needle, HealthShare of Oregon—a CCO that earned $69 million from the program—reinvested that money in parent coaching strategies and reducing disparities in developmental screenings among the communities it serves.
Other effective strategies for incentivizing a focus on children’s social and emotional development include:
- Providing enhanced payments to providers for pursuing high-performing pediatric medical homes that integrate the promotion of social and emotional development
- Developing value-based payment initiatives that prioritize children’s social and emotional development
Strategy #4: Facilitate Investment in Team-Based Care and Training on Children’s Social and Emotional Development
Pediatricians have been leading the way on advancing children’s social and emotional development for decades, and are willing partners in moving initiatives forward. However, no one person can do it all—and to succeed, we need to start thinking beyond the four walls of the pediatrician’s office and transition to a team-based model. Fortunately, Medicaid and CHIP have a lot of levers for incentivizing team-based care, including administrative funds that can be used to provide practical support in pediatricians’ offices.
South Carolina provides a real-life example of this approach. South Carolina and the state’s American Academy of Pediatrics (AAP) chapter jointly operate the Quality Through Technology and Innovation in Pediatric Practice (QTIP) initiative, providing peer-learning opportunities to support pediatric practices with practice transformation, quality improvement and the integration of mental health services.
Strategies for promoting team-based care and training include:
- Encouraging or requiring the use of community health workers and allowing for the provision of services in home and early childhood settings
- Requiring Medicaid managed care plans to contract with pediatric providers that deploy a team-based approach
- Promoting training for providers on the social and emotional development of young children and the use of screening tools to identify and address potential concerns
Strategy #5: Leverage a CHIP Health Services Initiative (HSI)
Implementing a CHIP HSI can be a very effective way to support programs that foster social and emotional health. CHIP gives states the opportunity to use up to 10% of what they spend on CHIP benefits for administrative costs. Most states do not spend the entire 10% administrative cap. Remaining funds can be used for outreach activities and an approved HSI. HSIs may cover a broad array of activities that a state decides are supportive of health coverage for children, particularly low-income children. Unlike the standard CHIP benefits package, HSIs offer significant flexibility in how dollars can be spent.
Oklahoma provides an excellent example of an HSI in action. Oklahoma implemented an HSI that provides funding to pediatric primary care providers to promote early literacy during well-child visits through its “Reach Out and Read” program. As a result of its HSI, Oklahoma is increasing the percentage of young children attending well-child visits and receiving standardized developmental screening.
There are four action steps states need to take to implement a CHIP HSI:
1. Assess the state’s administrative funds and current spending relative to the 10% limit.
2. Identify appropriate interventions and estimate spending.
3. Identify additional sources of funding (public or private) for the nonfederal share.
4. Prepare a CHIP State Plan Amendment (SPA) including:
- A description of the HSI
- The number of low-income children to be served
- A statement of the cost and the source of the nonfederal share the state expects to dedicate to the initiative
- Available research findings and evidence of the efficacy of the initiative for improving the health of low-income children
A broad array of tools is now available to support programs for fostering children’s social and emotional development. There is enormous energy focused on children’s social and emotional health—and significant room for creativity in finding new and effective solutions. By systematically leveraging Medicaid and CHIP as part of the toolbox, states can make concrete changes in pediatric practice to improve children’s social and emotional health.
NOTE: To download the full blueprint detailing how Medicaid and CHIP can support social and emotional development through pediatric care, click here.
1 Haley, J., Wang, R., Buettgens, M., Kenney, G. (2017). Health Insurance Coverage among Children Ages 3 and Younger and Their Parents: National and State Estimates. The Urban Institute. Retrieved from https://www.urban.org/research/publication/health-insurance-coverage-among-children-ages-3-and-younger-and-their-parents-national-and-state-estimates/view/full_report.