In 2015, New York State’s Medicaid Redesign Team (MRT) issued a “Roadmap for Medicaid Payment Reform” that laid out a path for dramatic and innovative change in the way the state financed and administered healthcare. Initially, MRT took on a volume-based approach to health care through the introduction of QARR and HEDIS Measures on patient experience and outcomes. Over time, MRT began to reward value, identifying it at the nexus of improved health outcomes and cost.
As a result of the work of the MRT, payers, health systems, IPAs, CBOs and behavioral health providers have come together to better understand root causes, access, engagement and the whole health principles that lead to dramatic shifts in how health care should be delivered. Evidence of these changes can be seen in State Department of Health and hospital investments in housing, the presence of recovery coaches in emergency departments to improve engagement in Medication-Assisted Treatment (MAT), DSRIP Max Series and in projects such as the new ICL/CHN East New York Health Hub offering behavioral and physical health care under one roof through an integrated approach. This work is far from fully scaled but the direction of healthcare for adults in New York is heading in the right direction.
Unfortunately, the MRT has not created the same changes in services to children and youth. MRTs analytics looked at the total cost of care and resulted in a profoundly new understanding of who high-need, high-cost individuals were. This led to the development of new service models and innovative partnerships that incorporate how social determinants of health, traumatic experiences and substance use disorders all play a role in health outcomes. For the adult population, total cost of care is overwhelmingly found in the health and behavioral health sectors. For children and their families this is not so. Children are not just smaller adults. I am convinced that if the same MRT analytic strategy were applied to troubled children and families, one would need to also look at child welfare, juvenile justice, behavioral health and most certainly education. If we want to improve lives today as well as for the next generation, we need the same kind of innovation and system reform that the MRT delivered for adults.
A Promising Path Forward
I believe there is a path that could be forged right now, like the MRT Roadmap, but focused this time on the unique needs of children and their families. A “Children’s Redesign Team” (CRT) could establish a vision and roadmap for achieving value for children and families. This unique and forward-focused plan would bring together stakeholders from relevant, child-facing agencies in New York State to focus NOT on coordinating what each agency is doing or could do individually, but to coalesce around common outcomes that can then be used to drive value for our next generation.
The CRT would start with an understanding of the fact that all children are served by more than one state agency, that no single agency is ever exclusively responsible for the well-being of a child. Any viable plan must consider the interrelatedness of areas like education, juvenile justice, and child welfare with health and behavioral health.
The need for better cross-agency collaboration to improve both the quality and cost (the value) of care might be best understood by looking at school-related Medicaid funding. In FY 2016, almost $262 million in New York Medicaid spending was spent on school-based services. The deep connection between education and health is clear – agencies are often serving the same child, in the same location, separately attending to the same or interrelated issues. The reality is that these child-serving health and education entities, for the most part, have grown and developed wholly independent of each other.
Given this significant interplay between children’s education and health needs, it seems only logical that adequately supporting children requires better coordination of services between school settings and care provided elsewhere. There is much we know and many basic tools to get started. We could organize the work using the priorities outlined by the New York State Council on Children and Families “Kids Well-being Indicators Clearinghouse” (KWIC). There the Council identified a common set of measurable indicators to improve child and family outcomes—“Touchstones”—that focused on: Economic Security, Physical and Emotional Health, Education, Citizenship,
Family, and Community. These areas are integrally related and can form a set of goals and objectives that cut across all service systems to allow organizations with diverse missions to come together to improve conditions for children and families. These Touchstones are useful today to inform the CRT’s work of building collaborative services that enhance the lives of children and support families.
Some argue that coordinating care across child-serving agencies is just too great a task, that these agencies are simply not organized to encourage this type of collaboration. This was the argument used against the MRT when it began 5 years ago. The impact on adult health care outcomes tells a different story – one getting closer to value.
Applying the concept of value to the children’s system will be difficult, will require a long-term investment and will require perseverance. We can build on the successes and knowledge gained from the Decade of the Child in the 1990s, the Children’s Plan, the First 1000 days of Medicaid, Close to Home and Community Schools, to name a few. These actions have made a difference, but they have not resulted in a fundamental shift in how we deliver and measure the impact of our collective work.
New York State has proven time and again to be one of the most innovative and forward-thinking states with some of the brightest policy minds and most effective leaders. There is no reason to think that the state cannot apply that same innovative thinking to improving care by better coordinating the work of the agencies serving children.
I am ready to join the effort to make this happen. Are you?