Next-Generation Strategies for Pediatric Primary Care: Key Questions Answered

Health Highlights

Editor’s Note: For years, leading pediatricians, families and advocates have called for transforming pediatric care to focus more on addressing the family, social, emotional and economic issues that affect child health outcomes. With the unprecedented events of 2020 accelerating this trend, the Massachusetts Child and Adolescent Health Initiative (CAHI) has issued a new report identifying concrete actions that can be taken in Medicaid to spur such a transformation in the Commonwealth of Massachusetts.

A recent Manatt webinar, sponsored in collaboration with the Center for the Study of Social Policy as part of the Pediatrics Supporting Parents initiative, shared key recommendations, tactics and lessons learned from the report, providing a playbook for leaders in the vanguard of children’s healthcare. The program included valuable insights from a panel of guest experts, including:

  • Dr. James Perrin, Professor of Pediatrics, Harvard Medical School; former Director, Division of General Pediatrics, Mass General Hospital; former President, American Academy of Pediatrics
  • Dr. Charles Homer, Chief Improvement Officer, EmPATH; Co-Founder and former President and CEO, National Initiative for Children’s Healthcare Quality
  • Dr. Greg Hagan, Chief of Pediatrics, Cambridge Health Alliance
  • Yaminette Diaz-Linhart, Public Health Social Worker & Scholar, Brandeis University

We received so many excellent questions during the session that we did not have the time to address them all. Below we provide the answers to eight key questions from the program. To view the full webinar for free on demand and access a free copy of the presentation, click here.

1.  How can states and advocates ensure that equitable investment in pediatric care will not be lost in larger state efforts to increase the proportion of spending in primary care, given adults are often the key cost drivers?

The CAHI white paper recommends that MassHealth require managed care organizations (MCOs) to increase their investment in pediatric primary care, including physical and behavioral health services. Specifically, it suggests requiring MassHealth MCOs to spend a share of their premium dollars on pediatric primary care that is set at a percent equal to 60 percent of the share of beneficiaries under age 21 in the MCO. For example, if 35 percent of an MCO’s enrollees are under age 21, then the MCO should document expenditures of no less than 21 percent (60 percent of 35 percent = 21 percent) on pediatric care.

2.  How do you define “rising risk” for children and families?

CAHI continues to review the options for defining “rising risk” with respect to children and families, drawing on some other states that already have begun to do so. North Carolina offers an example of a way to identify children for extra support on social drivers of health, including children with three or more adverse childhood experiences (ACEs), such as psychological/physical/sexual abuse, household dysfunction related to substance use, mental illness, parental violence, and criminal behavior in the household. (See Attachment G of the state’s approved Section 1115 waiver for more specific details.) By specifying “rising risk,” the CAHI White Paper aims to expand health promotion and prevention by providing preventive care to children who are not yet high cost, but could become so if their families do not receive some support.

3.  What can the federal government do to encourage more states to dedicate time and attention to children and youth and the care that they receive?

As discussed in the webinar, the Centers for Medicare and Medicaid Services (CMS) has a number of tools available to it to support a greater focus on children and youth. For example, it could issue a State Medicaid Director (SMD) letter or Center for Medicaid and Children’s Health Insurance Program (CHIP) Services (CMCS) Informational Bulletin (CIB) that lifts up state examples, options, and opportunities for state Medicaid agencies to improve the pediatric delivery system. Similarly, CMS could issue sub-regulatory guidance (accompanied by a preprinted State Plan Amendment (SPA) template for states to use) to add community health workers to the care teams serving children (and other populations). Although not addressed in the CAHI paper, note that children’s health advocates and a number of leading pediatric organizations are calling for a White House Office of Children and Youth, which can serve as another vehicle for increasing attention to children and youth.

4.  The CAHI White Paper presents recommendations aimed at all children and youth up to age 21, but can these recommendations be tailored to young children’s development, such as from birth to age five?

A number of the CAHI White Paper recommendations are particularly important to young children, birth to age five. These include recommendations to identify children with “rising risk” for developmental delays and social-emotional concerns, as well as to improve the coordination and interface with early identification and intervention services. Other recommendations that specifically aim to improve young children’s care include utilizing the ZERO TO THREE DC:0-5 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood for age-appropriate diagnoses for young children.

5.  Is there any work underway in Massachusetts or other states to calculate the additional operating costs of the advanced pediatric primary care model? For example, how much of a per-member, per-month (PMPM) bump would be needed for the average pediatric primary care practice to sustain it?

Identifying an appropriate PMPM to support advanced pediatric primary care is critical but also challenging. Some physicians and leaders in Massachusetts’ accountable care organizations (ACOs) are already working to identify an appropriate and equitable PMPM for advanced pediatric primary care practices, taking into account that it may be necessary to adopt an approach that allows for variation based on geography, practice size or other factors. For other examples of work aimed at identifying an appropriate PMPM, see analysis done by the United Hospital Fund on value-based payments in New York State for pediatric care.

6.  How did CAHI think about the “wrong pocket” challenge with some of these recommendations, in which the potential benefits of the interventions are realized in other sectors?

CAHI considered while drafting the recommendations that other sectors—education, child welfare, juvenile justice and others—may realize some of the long-term benefits if the CAHI recommendations are adopted. In response, CAHI recommends that MassHealth consider a pediatric-specific approach to financing care for children that reflects that most pediatric care investments generate longer-term, cross-sector savings, thus not lending themselves to traditional payment arrangements focused on short-term shared savings. Note, however, that the analysis also flags that it still is important to invest in young children even if it does not generate a traditional “return on investment” (ROI). The United States routinely makes investments in the health and well-being of other populations—without requiring that the investments pay for themselves—simply because doing so can improve quality of life and well-being.

7.  Many states are considering how to expand early childhood development programs leveraging the pediatric primary care practice, such as Reach Out and Read, a program promoting early childhood literacy and development, to bridge the gaps between families, children’s development and pediatric primary care practices. How can Medicaid support these initiatives?

Although not called out specifically in the CAHI analysis, Reach Out and Read is a well-known, highly regarded and researched initiative that helps integrate reading into pediatric practices, advises families about the importance of reading with their children, and shares books that serve as a catalyst for healthy childhood development. By focusing on the importance of providing whole-child care and building stronger connections between pediatric providers and the early intervention and educational sectors, the analysis flags the importance of many of the issues addressed via Reach Out and Read. Outside of Massachusetts, a growing number of states are looking for ways to use Medicaid or CHIP dollars to support the integration of Reach Out and Read into pediatric practices. Oklahoma and North Carolina, for example, have expanded Reach Out and Read statewide via a CHIP Health Services Initiative (HSI), allowing these states to receive federal matching dollars for their Reach Out and Read initiatives set at 77.59 percent and 77.18 percent, respectively, in fiscal year 2021.

8.  What were the advocacy strategies and targets CAHI utilized to make this CAHI white paper and presentation happen? What practical advice do you have for other pediatricians and child health colleagues?

CAHI was supported by the Massachusetts Chapter of the American Academy of Pediatrics (MCAAP) and organized by three leading physicians in Massachusetts—Dr. Jim Perrin, Dr. Greg Hagan and Dr. Charlie Homer. With the support of MCAAP, they coordinated six sub-working groups—unique needs of children and youth; integrated mental and behavioral health in primary care; social determinants of health (SDOH)  and health-related services; children and youth with complex medical conditions; interface between healthcare and education; and performance measurements—with experts and participants including pediatric providers within ACOs and at community clinics, community-based organizations that provide social and developmental supports, a major children’s hospital, family members with lived experience, parent engagement experts, and healthcare advocacy organizations, including Health Care for All, a leading Massachusetts advocacy organization on healthcare issues. The broad array of stakeholders that participated in the process, as well as the active and constructive engagement of MassHealth leadership, helped to shape the work and move it forward.


Papers & Resources

  • Child and Adolescent Health Initiative (CAHI). Moving to the Vanguard on Pediatric Care: CAHI Recommendations for the MassHealth Section 1115 Waiver Renewal. September 2020. Available here.
  • National Institute for Children’s Health Quality (NICHQ) and Pediatrics Supporting Parents (PSP). Core Practices, Strategies, and Resources for Supporting Social Emotional Development in Pediatric Care. 2019–2020. Available here.
  • S. Doyle, D. Willis, and K. Johnson. Webinar: Guide to Leveraging Opportunities Between Title V and Medicaid for Social-Emotional Development. The Center for the Study of Social Policy. September 2020. Available here.
  • National Academies of Sciences, Engineering, Medicine (NASEM). Collaborative on Healthy Parenting in Primary Care. Available here.
  • Substance Abuse and Mental Health Services Administration (SAMHSA). Evidence-Based Practices Resource Center. Available here.

Calls for Action & Advocacy

  • First Focus on Children, Nemours Children’s Health System, Mental Health America, the Education Redesign Lab at Harvard Graduate School of Education, and the Forum for Youth Investment. National Coalition Calls for Creating New White House-led Focus on Children and Youth. November 2020. Available here.
  • InCK Marks National Advisory Team. Statement to the Next Administration on Child Health Care Transformation. November 2020. Available here.
  • National Association for the Education of Young Children and the Early Care and Education Consortium. National Industry Organizations Call on Congress for $50 Billion in Urgent Stimulus. 2020. Available here.


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