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Are We There Yet? Reflections on the 5 Years of Children’s Medicaid Transformation

It is hard to believe that five years have passed since the New York State Children’s MRT Subcommittee released its blueprint to address the unique and complex needs of children in Medicaid Managed Care. In many ways the time has flown by yet today, New York State’s target date to fully integrate specialty child welfare and behavioral health services into the Medicaid Managed Care Program remains over a year away. In this important edition of Behavioral Health News, dedicated to the transformation of children’s services, it is timely to step back to reflect on our current position in the context of the October 2011 Children’s MRT Recommendations.

The Children’s MRT included the voices of families, youth, providers, advocates, educators and thought leaders. In representing the diversity of the State, the MRT offered the following points of emphasis:

  • An effective children’s system should intervene early in the progression of behavioral health disorders. Early identification and intervention is effective in keeping children on track developmentally, improving educational and vocational futures and in reducing long term health care costs.
  • It is essential that children and families have access to the right service at the right time in the right amount.
  • Accountability across all payers must be established. Children are covered by a variety of insurance (public/private) products with historic cost shifting to Medicaid and State general funds to support behavioral health needs, which increase the demand on state and county funded services.
  • We have to find a way to make our service delivery system easier to navigate and less siloed. Families are often served by a disjointed, overlapping, non-comprehensive and costly series of services. Medicaid redesign must better align systems to yield continuity of care, access and cost efficiency, and promote greater integration of primary care and behavioral health. Special considerations are required to address the complex needs of children in the foster care system.
  • The current behavioral healthcare system for children and their families is underfunded. Per capita investment in behavioral health for adults far outweighs investment in children, which could be remedied through reinvestment of existing resources.
  • The Managed Care benefit package and processes for children will require innovative and targeted focus on children with special needs.
  • The Managed Care initiative must develop outcome measurements and standards to review program performance that are targeted to children with special needs.

The principles articulated in October 2011 remain relevant and collective efforts to advance a strong system of care for children have been steadfast. The New York State Children’s Team, the Children’s MRT and key Advocates have worked seemingly non-stop over the past five years. And yet, the ability to translate State policy for inclusion of specialty children’s services in Medicaid into the day-to-day operations of service providers remains elusive and the future pathway unclear.

Refocusing on the “Why”

Let’s face it, we have been working towards Children’s Health Home, Waiver Reform, transitioning kids to Medicaid Managed Care for what seems like an eternity! Over time our conversations and gestalt have shifted from focus on our future vision to one limited by the next implementation step or hurdle before us. Have you completed your CANS-NY Training? Do you have a Business Agreement with a Health Home? Will you apply to be designated for the new SPA Services. Focusing on details is important, but keeping your eye on the prize is essential.

Any significant change or invention requires leadership and a clear and compelling purpose. The Children’s MRT had and I would argue still has, deep commitment and vision to see a health care system that is wise in investing in early detection and intervention to help families raise their children to achieve their fullest potential. A healthcare system that is also expert in treatment and support of families and children with the most complex and intensive needs. One that has secondary gains in reducing the number of children in juvenile justice facilities and improving graduation rates for children with serious emotional disturbances.

The work of the MRT to craft a vision has been bolstered through the work of several child-focused experts. The United Hospital Fund (UHF) is expanding on our collective “why” through release of several documents. Seizing the Moment: Strengthening Children’s Primary Care in New York documents the hope and possibility before New York to “improve the overall health and well-being of its youngest residents through a renewed focus on strengthening primary care to make it responsive to the healthy development challenges children face today.” The report knits evidence-based practice, value-based payments, the importance of building solutions for social determinants and the need for child-specific outcomes together into a call for action.

UHF also authored a data brief and chartbook to provide supporting data on children served in the New York State Medicaid system. In Understanding Medicaid Utilization for Children in New York State: A Data Brief and Understanding Medicaid Utilization for Children in New York State: A Chartbook we are grounded by the following findings:

  • Children account for nearly 40 percent of New York State Medicaid enrollees, but less than 20 percent of the program’s expenditures.
  • Nearly 90 percent of children averaged $2,400 in annual expenditures (compared to $11,154 for adults between the ages of 21 and 64 who were continuously enrolled in Medicaid).
  • A relatively small group of 185,625 continuously enrolled children, approximately 10 percent of all continuously enrolled children, account for half of Medicaid expenditures on continuously enrolled children.
  • Nearly 85 percent of continuously enrolled children had at least one outpatient evaluation/management or preventive care visit.
  • Black and Hispanic children have much higher rates of inpatient hospitalizations and emergency department utilization than white or Asian and Pacific Islander children.
  • Inpatient hospitalizations and emergency department utilization also vary by age, diagnosis, and geography.
  • Children under age 4 have inpatient and emergency department utilization driven by respiratory system diseases, including asthma; teenagers and older adolescents have a much higher portion of inpatient utilization driven by behavioral health conditions.

The United Hospital Fund and Schuyler Center for Analysis and Advocacy published Value Based Payment Models for Medicaid Child Health Services written by Bailit Health in July 2016. The document makes a strong case for separate value-based designs for children. First and foremost, children do not have the significant medical cost spend that adult do. Value and savings are in making investments in the future in terms of child growth and development and long-term health cost avoidance. Secondly, the smaller percentage of children with high medical costs are a diverse population and their health status is significantly impacted by social determinants of health that may be out of the scope of the clinicians and managed care plans. The report offers an analysis of value based payment approaches through a child-specific lens and highlights the lack of readiness for value-based payments across the provider system.

Re-Energizing the New York Child-Serving Sector for Implementation

There are two key areas where each of us -State official, Provider, Advocate, Family Member or Consultant can work to improve implementation of children’s reform in New York.

The first is to remember the “why.” Perhaps we need a collective visual or mantra. Maybe it is as simple as creating a children’s transformation statement for your Agency. For example, “With everything we do we seek to improve the health/lives of children and their families. We challenge the status quo and offer safety, health care, social supports and connections that are easy to access and deliver results.” This is not fluff. It is our shared commitment and sense of purpose that will keeps us focused on the end goal.

If we can reconnect with the vision or “why” we need to rethink the “what” and “how.” This is about working SMARTER together – State, Provider, Advocates and Interested Parties, not simply working HARDER. The impact of periods of development followed by implementation delays has created a sense of implementation fatigue that is beginning to take its toll. Working smarter could include thinking of ways to create a steadier progression for the children’s transition. One where, for example, 95% of the milestones are met on time. In order to build more realistic milestones, the BANDWIDTH of State Agencies to develop child-specific rates, outcomes and systems not to mention bandwidth to advance real regulatory reform will need to be extended. Providers similarly need to focus on keeping the current system running while we convert to an entirely new operating system. Children’s Providers need to develop an operational vision and framework for delivering healthcare in ways which comport with a competition-based, product-driven market. Or as I like to say, becoming a Millennial Nonprofit®. An architecture within your agency for moving to the value-based world connects and inspires people inside the organization and beyond. Agency leaders need to articulate a clear vision of what “value-based” means to them from the beginning, breaking it down into clear action steps, communicating what it will look like at mile-markers along the journey, and translating it into a story that can be told and retold.

As zealots who have dedicated years of service in helping children to heal, grow and thrive we have to both reconnect with a vision of what the New York Children’s System can be and be wise in our work to get there.

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