Paying for Care Coordination

1. Paying for Care Coordination Starting assumptions How are states paying for limited care coordination at present What does that teach us about making this universal

2. 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

3. 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

4. The current situation?

5. 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

6. 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

7. 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

8. But we have learned a few things… To go to scale, we need models that • Bring down the cost • Get partners to share the cost and • Build political will for financing of care coordination

9. Strategies to bring down the cost • Leverage practice-wide improvement • Leverage state systems improvement • Use less costly personnel

10. 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

11. 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

12. 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

13. Strategies to get others to share the cost • Maximize reimbursement • Make the most of Medicaid waivers • Make the most of state partnerships

14. 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

15. 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

16. 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

17. Build political will • Show effectiveness • Show cost savings • Build a constituency

18. 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

19. Show cost savings • Reduced ER use: NC • Reduced hospitalization: RI • Earlier referral to appropriate resources: RI

20. Build a political constituency Requires • Data: MN, CMHI, NC • Case studies: RI and • A grasp of systemwide parameters • Evidence of feasibility

21. 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

22. 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

23. One parallel model • MA blended funded for Part C • Broad eligibility • Mandated benefit • State certifies vendors • Generic service (rather than specific discipline) is reimbursable

25. 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