Paying for Care Coordination

Starting assumptionsHow are states paying for limited

care coordination at presentWhat does that teach us about

making this universal

Starting assumptions --before you get to what it costs

Children with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally

The family of any child or youth with special health care needs may need care coordination at some time

Starting assumptions --before you get to what it costs, cont.

An organized, statewide system of care coordination is the only way to assure universal availability (and quality)

The medical home is the best option for a statewide system of care coordination

Care coordinators in the medical home Can serve children and adolescents with a range

of disabilities or chronic conditions effectively Can serve children and adolescents with a range

of disabilities or chronic conditions efficiently Can leverage practice-wide change that reduces

the need for jerry-rigging solutions

The current situation?

More precisely Almost all Title V programs pay for some care

coordination Who they serve

Some serve a defined group who receive care in state-run or funded clinics

Some serve a subgroup group defined by diagnosis, need and/or coverage status

Some serve a patchwork of children through categorical programs

Whom they employ Most rely on state or county employees Some contract with hospitals to provide care

coordination Some contract out to community-based vendors, which

may include counties

How they pay Generally a mix of state and federal Title

V funds May also include Part C funds if Title V is the

lead agency Some categorical add-ons

Federal and private grants State appropriations

Some states have significant Medicaid involvement, others little or none

Some states integrate some services with other state agencies

So…

No Title V program currently assures availability of care coordination to all CSHCN This reflects

Lack of funding (~ $1 billion to serve all CSHCN in 59 jurisdictions)

But also Lack of infrastructure

Which are both linked to lack of political will

But we have learned a few things…

To go to scale, we need models that1. Bring down the cost2. Get partners to share the cost

and3. Build political will for financing

of care coordination

Strategies to bring down the cost

Leverage practice-wide improvement

Leverage state systems improvement

Use less costly personnel

Leveraging practice-wide improvement

Chapel Hill Pediatrics Pre-visit Contact Care Coordinator does Pre-visit Contacts for 10 docs/1,000 CYSHCN Care coordinator screens schedule for upcoming CSHCN physicals based

on registry The child’s MD assesses child’s complexity and requests PVC Care Coordinator makes call to parent. Parent concerns are identified Labs (and pain control!) are anticipated and scheduled for Consultant notes are available, ED and specialty visits are noted New issues/special needs are anticipated 93 % of Families find PVC’s helpful:

Less reviewing, more looking forward”. . . “it shows you care about my child”. . . It “makes my visit more useful and efficient

Even “late adopter” MD’s like PVC’s and love care coordination

The lesson practice-wide change expands reach of single care coordinator

Leveraging state systems improvement

Massachusetts Consortium as a vehicle to address diaper crisis Massachusetts care coordinators identified a decline

in quality of diapers Statewide network makes clear it’s a shared

problem -> instead of solving over and over one, child at a

time, seek systemic solution We don’t have a broad, statewide network of

medical home care coordinators, but Consortium served as proxy

The lesson: statewide network reduces need for individualized solutions -> increased care coordinator efficiency

Using less costly personnel Rhode Island Pediatric Practice Enhancement Project

20 parents employed as practice-based care coordinators 10 in primary medical home sites 10 in NICU, specialty clinics

Parents are employees of parent organization (RIPIN) Title V oversees contract RIPIN provides intensive training and supervision

Payment is to the organization, which pays parents New payment sources are emerging

Practices Private insurers

The lesson: parent experience is a huge potential resource to the system

Strategies to get others to share the cost

Maximize reimbursement Make the most of Medicaid waivers Make the most of state partnerships

Maximize reimbursement

Chapel Hill Pediatrics Has retrained pediatricians on coding to

maximize reimbursement for their own potentially covered activities

Has gotten raised reimbursement rate based on cost savings

Decreased ED use Replaced by after-hours use of practice Define as P4P to payers

The lesson: education of physicians and payers about care coordination is key

Make the most of Medicaid waivers

Florida Uses a waiver to serve targeted

populations Reserves Title V-funded care

coordinators for children ineligible for waiver

The lesson: creation of a universal system requires a central intelligence

Make the most of state partnerships

Minnesota alliance of Title V with Mental Health Child Welfare Medicaid child health policy unit State-mandated community teams

The lesson: as long as you are all discussing the same model, it doesn’t matter if it means different things to different people

Build political will

Show effectiveness Show cost savings Build a constituency

Show effectiveness:Establish medical home (including care coordination) as standard of care

Documentation of improved outcomes Parent, provider satisfaction: NC, MN,

Center for Medical Home Improvement Reduced days out of school, work Reduced preventable hospitalization Need new tools for this purpose

Show cost savings

Reduced ER use: NC Reduced hospitalization: RI Earlier referral to appropriate

resources: RI

Build a political constituency

Requires Data: MN, CMHI, NC Case studies: RIand A grasp of systemwide parameters

Evidence of feasibility

Estimating cost for WA

375 FTE care coordinators Distributed among 750 FTE

physicians Each caring for about 530 children To serve the state’s population of

200,000 CYSHCN

System costs for 375 care coordinators with benefits @ .25

Advanced practice RN $34,125,000 Social worker $24,375,000 Certified paraprofessional $14,625,000

Plus Estimate $2,000,000 in system oversight cost

-> Cost is between $16 and $36 million

One parallel model

MA blended funded for Part C Broad eligibility Mandated benefit State certifies vendors Generic service (rather than specific

discipline) is reimbursable

The Catalyst Center on Financing and Coverage for CYSHCN

Our priorities Medical debt among families of CYSHCN Cover more kids through Medicaid buy-in Reduce gaps through Catastrophic Relief Enhance quality through financing of care

coordination Our team

Carol Tobias, Susan Epstein, Sally Bachman, Meg Comeau, Deborah Allen

Find us at http://www.bu.edu/hdwg/ Contact me at dallen@bu.edu