Value Based Payment for Medicaid Child Health Services Part I: Setting the Stage for VBP Chad Shearer and Suzanne Brundage; United Hospital Fund Boris Vilgorin, Dan Ferris, Yvette Kelly; McSilver Institute for Poverty Policy and Research September 21, 2016

Agenda Context—Why Children, Why Now? Medicaid Utilization and Expenditures by Children Children’s Health System Transformation Today Social Determinants of Health Implications for Child-Serving Providers

Context

United Hospital Fund Mission: United Hospital Fund works to build a more effective health care system for every New Yorker. An independent, nonprofit organization, we analyze public policy to inform decision-makers, find common ground among diverse stakeholders, and develop and support innovative programs that improve the quality, accessibility, affordability, and experience of patient care.

Children’s Health Initiative and Medicaid Institute Publications Seizing the Moment: Strengthening Children’s Primary Care in New York (Jan 2016) You Get What You Pay for: Measuring Quality in Value-Based Payment for Children's Health

Care (June 2016) Understanding Medicaid Utilization for Children in New York State (July 2016) Value-Based Payment Models for Medicaid Child Health Services (July 2016)

McSilver Institute for Poverty Policy and Research The McSilver Institute for Poverty Policy and Research at New York University Silver School of Social Work is committed to creating new knowledge about the root causes of poverty, developing evidence-based interventions to address its consequences, and rapidly translating research findings into action. The McSilver Institute employs collaborative research methods via partnerships with policymakers, service organizations, consumers and community stakeholders. The McSilver Institute’s research efforts are guided by a recognition of the interrelatedness of race and poverty.

Value-Based Payment—Bringing Children to the Forefront Delivery system and payment reform efforts to date generally focused on adults, and more specifically high-cost, high-need adults ‘Value’ for children is very different from adults, especially given that children and adult health differ dramatically: Dollars, Diagnoses, Dependency, Developmental Stages, Diversity New York Medicaid is leading and moving quickly:

• All Albany Ready—Pilot collaboration with Albany Promise on pediatric primary care and kindergarten readiness • NYS Medicaid VBP Roadmap—Children’s VBP Subcommittee and Clinical Advisory Group

Children’s Utilization and Expenditures

Context—Children in NY Medicaid Medicaid covers 43.5% of all children under age 21 in New York State Children account for 37% of all NYS Medicaid Enrollees Most, but not all, children are in managed care VBP only applies to children in managed care

Enrollment Jan 2016 2,292,641

Managed Care 2,042,872

Fee For Service 249,769

Age Breakdown Under age 1 – 6% 1-4 – 22% 5-9 – 26% 10-13 – 18% 14-17 – 17% 18-20 – 11%

Sources: New York State Medicaid Program Enrollment by Month – Health Data NY; Census Bureau American Fact Finder ACS Demographic and Housing Estimates; United Hospital Fund Understanding Medicaid Utilization for Children in New York State.

Data Needs for Value-Based Payment Adult Comparisons—How are children different from adults Population Segmentation—Different analytic approaches are possible

• Existing Utilization—Determining current usage and investigating potential points of under- or over-utilization. Identify variation by: • Demographics—Age, race/ethnicity, geography • Utilization type—primary care, emergency department, inpatient • Diagnoses—Especially common conditions at different developmental stages • Expenditures—How are dollars spent—limited savings opportunities

Population Segmentation by Expenditure Quartiles

90% of Children average only $2400 per year in expenditures High-cost children have a range of conditions (e.g., DD, BH, complex chronic conditions) Not all high-cost in one year remain high-cost next year

Source: United Hospital Fund Understanding Medicaid Utilization for Children in New York State.

Utilization for Children Varies by Many Factors Children have high utilization in the early years, especially primary care and hospitalizations for asthma and gastroenteritis In the teen years utilization rises mostly due to behavioral health conditions Primary care utilization decreases with age

CE Children with at Least One Inpatient or ED Visit by Age Group, 2014

0%

1%

2%

3%

4%

5%

6%

7%

8%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Under 1 1–4 5–9 10–13 14–17 18–20

Enro

llees

with

an

Inpa

tient

Vis

it

Enro

llees

with

an

ED V

isit

Enrollees with at Least One ED Visit (%) Enrollees with at Least One Inpatient Visit (%)

Source: United Hospital Fund Understanding Medicaid Utilization for Children in New York State.

Children Are Not Just Small Adults Average expenditure per child $6,900 less than for average adult Children use much less inpatient care, and have shorter stays than adults Diagnoses driving emergency and inpatient utilization differ greatly

2014* Children Adults

Expenditures $7.52 Billion $23.8 Billion

Enrollees w/ Inpatient Visit

5.8% 12.3%

Length of Stay 5.32 days 8.17 days

Emergency Visits / 1,000 Enrollees

487 648

Source: United Hospital Fund Understanding Medicaid Utilization for Children in New York State.

*Data limited to children and adults continuously enrolled in New York Medicaid in 2014

Data Implications Compared to adults, children are generally a low-cost, low-utilization population and have more contact with primary care.

• ‘Well’ children less likely than adults to have avoidable hospitalizations that are often the target for value-based payment savings • Preventing ‘well’ children from becoming high-need in the future may require more and/or different services, especially during early childhood

A very small subset of children with heterogeneous needs account for a large proportion of expenditures.

• Some of these sub-populations are not yet in managed care, and all may require a different approach in value-based payment.

Children’s Health System Transformation Today

Transition of Children’s Services to Medicaid Managed Care

Managed Care is a healthcare delivery system aimed at increasing quality of care,

lowering costs, and integrating services. Providers serving Medicaid enrolled children will contract with Managed Care

Organizations (MCOs) and will bill them for services provided. The MCOs receive a monthly premium from the state to manage an individual’s care and benefit package.

NYC, Long Island, and Westchester: July 1, 2017

Rest of State: January 1, 2018

Children’s Health Homes Health Homes provide comprehensive care management to children with complex

healthcare needs and their families. Health Home principles call for care coordination and planning to be family-and-

youth driven, supporting a system of care that builds upon the strengths of the child and families.

Enrollment of children in Health Homes will begin statewide on December 1, 2016.

New Medicaid State Plan Services New York State has proposed six new state plan services to be available to all

Medicaid eligible children under the age of 21 who meet medical necessity criteria. These services, often referred to as “SPA” services, are designed to:

Improve the service system’s capacity to identify needs early Maintain children in their homes and communities Prevent the need for more expensive long-term services Support the use of evidence-based approaches Follow trauma-informed principles

New Medicaid State Plan Services These services, to be implemented statewide on January 1, 2017, include: Crisis Intervention Other Licensed Practitioner (OLP) Community Psychiatric Supports and Treatment (CPST) Psychosocial Rehabilitation (PSR) Family Peer Support Services Youth Peer Support and Training Services

Behavioral Health Home and Community Based Services (HCBS)

Children’s HCBS is designed to offer support and services to children in non-

institutionalized settings that enable them to remain at home and in the community.

Services are person-centered, recovery-oriented, integrated, data-driven,

evidence based, trauma-informed, and flexible and mobile.

NYC, Long Island, and Westchester: July 1, 2017 Rest of State: January 1, 2018

SPA vs. HCBS - What’s the difference? State Plan Services:

• Available to a larger population • Early intervention services, more preventative in nature • Provide comprehensive care to prevent escalation

Home and Community Based Services:

• Limits on eligibility; determined by results of the CANS-NY Assessment • Rehabilitative and habilitative in nature • For those who require a higher level of care

Next Opportunity? Social Determinants of Health and Pediatric Primary Care

What are the Social Determinants of Health?

World Health Organization (WHO):

The social determinants of health (SDH) are the conditions in which people are

born, grow, work, live, and age, and the wider set of forces and systems shaping the

conditions of daily life.

Social Determinants of Health Income

Education

Occupation

Housing

Social Class

Gender

Race/Ethnicity

What We Can Do 1. Assess for Social Determinants of Health

2. Build staff and client knowledge

3. Unpack personal biases

4. Build community based partnerships

5. Engage stakeholders outside of health

Overview of the Science Epidemiology of child health has changed, with developmental health issues on the rise Early childhood experiences have a long-term effect on educational, social, and health outcomes Brain science has revealed how brains are shaped over time The “active ingredient” in brain development is interaction with adults

“Nature dancing

with nurture”

Sources: United Hospital Fund, Seizing the Moment: Strengthening Pediatric Primary Care in New York; Harvard Center for Developing Child; Allen & Jones, IOM NRC, 2015

Social Determinants of Early Child Development Foundations of Healthy Development Caring, nurturing relationships with adults Adequate nutrition Non-toxic environments The right kinds of stress

Social and Environmental Factors That Can Negatively Influence Healthy Development (Examples): Toxins and inadequate nutrition Lack of stimulation and exposure to words Poor parental health, particularly maternal depression Residential instability Abuse and trauma

New York City Children (Under 5) by Poverty Level, 2013

Children in poverty are more likely to be exposed to threats to early childhood development, and less likely to be exposed to protective factors, than their more affluent peers

Sources: United Hospital Fund, Seizing the Moment: Strengthening Pediatric Primary Care in New York; Citizen’s Committee for Children, Keeping Track of New York City’s Children: 2015

SDH Can Have Long-Term and Multisector Implications Utilization: Poverty = more and longer

hospitalizations

Long-term health: Adversity linked to harmful health behaviors in teen years, chronic disease in adulthood, depression, and anxiety disorders

Social-emotional development: Disrupted brain growth can lead to shortened attention spans, weak inhibitory control, compromised working memory, etc. with implications for educational and social outcomes

Sources: J. Jonas et al. “Shifting the Care and Payment Paradigm for Vulnerable Children”. Policy Lap (CHOP); Harvard Center for Developing Child; Centers for Disease Control and Prevention http://www.cdc.gov/ace/prevalence.htm

We now have the science and proven early childhood interventions to improve life long health.

Assessing for unmet basic needs and connecting to community resources Reducing intergenerational transmission of trauma Coaching parents on positive parent-child interactions Addressing two-generational health challenges Promoting early learning and literacy Identifying developmental delay

Sources: United Hospital Fund, Seizing the Moment: Strengthening Pediatric Primary Care in New York; Institute of Medicine. 2015. Exploring Opportunities for Collaboration Between Health and Education to Improve Population Health: Workshop Summary. National Academies Press.

An Untapped Strategy is Strengthening Pediatric Primary Care

0-3 Years 4-5 Years 6-11 Years 12-18 Years

Child Care 10%

Primary Care

90%

Child Care Primary Care

Pre-School

20%

Primary Care

80%

Pre-School Primary Care

School 50%

Primary Care

50%

School Primary Care

School 70%

Primary Care 30%

School Primary Care

The Opportunity to Influence Health, Behavior, and Development Over a Child’s Lifespan

Over 90% of commercially insured kids and over 80% of publicly insured kids make 5 or more well-child visits in the first 15 months of life.

Sources: Briggs, R and York, D. ©2015; NY QARR 2014. Comparison of Commercial HMO, Commercial PPO, and Medicaid Managed Care Plan statewide averages;

Sample Primary Care Approaches Child Health and Development Issue Sample Primary Care Approaches seen in New York

Social determinants of health

Partnering with Health Leads, a non-profit organization that uses a volunteer workforce to assist patients with resource connections

Referring families to multi-sector centralized referral services for all early childhood development needs, including resource needs, through the Help Me Grow program

Intergenerational transmission of trauma

Automatically providing higher-intensity preventive services to a child based on the parent’s Adverse Childhood Experiences score

Parent-child interactions Modeling positive parenting techniques during reading sessions with child through Video Interaction Project

Two-generational health challenges Screening and providing in pediatric setting brief treatment for maternal depression

Cognitive growth Coaching parents on how to read to their children and providing books through the Reach Out and Read program

Developmental Screenings and surveillance

Conducting quality improvement activities to improve the consistency of developmental screening or referral success

Source: United Hospital Fund, Seizing the Moment: Strengthening Pediatric Primary Care in New York

Challenges and Implications The value timeframe: Low overall expense, multi-year payoff (not necessarily to health care system) and need for additional services to generate those payoffs may require additional up-front investment Hard to hold providers accountable for social determinants that are largely beyond clinician control – who is accountable for what? Challenges to scaling and sustaining innovations both practice-level and systems-level

“Given the increased recognition of how profoundly social determinants of health (including Adverse Childhood Experiences) affect childhood development and adulthood health and social productivity, payment models need to consider how to motivate and support attention in this area.”

–Bailit Health

Sources: Bailit Health. Value-Based Payment Models for Medicaid Child Health Services. Final Report. June 2016.

Resources Chad Shearer Vice President for Policy Director, Medicaid Institute cshearer@uhfnyc.org (212) 494-0793 @chadeshearer

Seizing the Moment: Strengthening Children’s Primary Care in New York http://www.uhfnyc.org/publications/881092 You Get What You Pay for: Measuring Quality in Value-Based Payment for Children's Health Care http://www.uhfnyc.org/publications/881134 Value-Based Payment Models for Medicaid Child Health Services http://www.uhfnyc.org/publications/881145 Understanding Medicaid Utilization for Children in New York State http://www.uhfnyc.org/publications/881143 New York’s Value-Based Payment Roadmap (June 2016 Update): http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/2016/docs/2016-jun_annual_update.pdf

Suzanne Brundage Project Director, Children’s Health Initiative sbrundage@uhfnyc.org (212) 494 - 0729 @suzbrundage

Resources McSilver Institute for Poverty Policy and Research www.mcsilver.nyu.edu mcsilver@nyu.edu

Community Technical Assistance Center (CTAC) www.ctacny.org ctac.info@nyu.edu

Children’s System Transition Timeline http://ctacny.org/news/childrens-system-transition-timeline-update-important-update-doh-ocfs-omh-and-oasas-regarding Q&A from Children’s System Transformation Trainings http://ctacny.org/sites/default/files/Kids%20Q%26A%20August%202016.pdf Information about Children’s Health Homes (DOH) https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/health_homes_and_children.htm SPA Provider Manual http://ctacny.org/sites/default/files/spa-service-manual-draft.march2016_0.pdf\ CTAC Children’s System Resources http://ctacny.org/systems-transformation