Appendix
5
Materials for Ohio Leadership Workshop
This
document was prepared for a Leadership
Workshop on Managed Care and Child
Health to be held on September 28,
2004 in Columbus, Ohio. The workshop
is based on work by the Center for
Health Services Research and Policy
at The George Washington University
(GWU), and conducted with support
from the Health Resources and Services
Administration, Maternal and Child
Health Bureau (HRSA-MCHB) and the
Managed Care and Health Services Financing
Technical Assistance Center (MCTAC).
Senior policy makers and professionals
attending the workshop will discuss
approaches to ensure that plan enrollees
receive the highest quality pediatric
care. This information was designed
to provide a framework for discussion,
offering options for solutions to
concerns shared by State agencies,
managed care organizations, and consumer
advocates. These documents have not
been endorsed by Federal or State
officials. Prepared by Kay Johnson,
Johnson Group Consulting and Jeff
Levi, The George Washington University
under contract with HRSA-MCHB and
MCTAC. |
I.
Planning and Financing for Child Development
Services
Promoting Early Childhood Development
in Medicaid and Medicaid Managed Care
While child health professionals agree
about the importance of early childhood
development services,1
2 3
financing child development services through
Medicaid is not simple. One reason is
that current Federal
guidance does not specifically define
"child development services."4
5 Despite
overlaps between coverage
for young children in Medicaid’s
Early Periodic Screening, Diagnosis, and
Treatment (EPSDT) program
and early child development services,
the final determination as to whether
Federal Medicaid matching
funds are allowable for a particular service
is made by the Centers for Medicare and
Medicaid Services
(CMS). A second reason is that Medicaid
was designed to finance health care, while
child development
services often are provided by education
or social service agencies. Third, each
State has flexibility to
make rules about which providers are qualified.
Finally, because some child development
services also
are funded by other public programs (e.g.,
early intervention, mental health, or
children with special
health needs), it may be difficult to
understand which eligibility rules apply
and who should pay for what
services.
At the same time, Medicaid managed care
offers clear opportunities to promote
early childhood
development. Medicaid managed care contracts
typically include prevention and early
intervention
through EPSDT, as well as treatment. States
can work with MCOs to improve care, using
their power as
purchasers to ensure the quality and appropriateness
of services provided. Researchers at the
George
Washington University have prepared purchasing
specifications to assist States in efforts
to finance child
development services through Medicaid
managed care. (This work was financed
by the Commonwealth
Fund. See http://www.gwumc.edu/sphhs/healthpolicy/chsrp/newsps/child/)
Benefits and Services to Promote
Early Childhood Development
-
Use the GWU purchasing specifications
on child development to develop contract
language that clearly communicates policies
on developmental services to managed
care
plans. While Medicaid has over
30 benefit categories, no category is
labeled "child development
services.” The purchasing specifications
identify a range of covered services
linked to child
development
-
Improve and clarify the description
of developmental assessment under EPSDT.
For
example, States may distinguish a routine
developmental screening conducted as
part of an EPSDT
screen from developmental exams or diagnostic
assessment (evaluation) conducted by
a medical
social worker, public health nurse,
or developmental pediatrician. States
also could encourage use of
professionally recommended screening
tools appropriate for young children.
- Encourage
pediatric provider sites to promote
healthy development. State
Medicaid
agencies could reimburse primary pediatric
practitioners for providing preventive
mental health care
and development services (see Bright
Futures). Medicaid also might pay for
developmental services
provided by social workers and child
psychologists co-located in pediatric
practices.
- Clarify
rules on Medicaid payment for services
delivered through other public
programs, such as IDEA Part C Early
Intervention, children’s mental
health, child welfare, and
Head Start.
For example, Medicaid can finance early
childhood mental health consultation
for
children in child care settings. Many
contracts require MCOs to sign memoranda
of understanding
with public agencies.
Opportunities identified by NASHP
With the support of the Commonwealth Fund,
the National Academy of State Health Policy
(NASHP)
has defined some examples of activities
that a State might use to improve the
health, mental health,
development, and well being of young children
and their families.6
These included the following:
-
Managed care contract provisions
that specify coverage of child development
services and parent
education, as well as require local
interagency coordination agreements;
-
Incentives (in pay-for-performance
or other arrangements) for pediatric
providers to screen children
and families for risk factors and provide
appropriate guidance and counseling;
-
Structured capitation payments
to plans, enhanced primary care case
management (PCCM) fees,
and/or payment to providers for the
inclusion of certain child development
services; and
-
Adopt benefits definitions and
billing codes for diagnostic assessment
and intervention services
to reduce risk factors that
can impede healthy development, such
as family depression or other
mental illness, smoking, substance abuse,
potential for child abuse and neglect,
injury hazards, lead
poisoning, inadequate nutrition, developmental
delays, or behavioral problems.
Other
no cost / low cost opportunities
-
Collaborative planning –
States that have established more comprehensive
and/or coordinated
approaches appear to do a better job
at serving vulnerable and at-risk children
(e.g., FL, HI, IN, MI,
MN, and NC). In 2003-04, States have
used Title V discretionary grant funds,
called Comprehensive
Early Childhood Care Systems (CECCS),
to support planning efforts (e.g., CT,
IL, MA, and NM).
-
Maximize use of Federal entitlement
funds and State/local dollars available
for matching –
Whether Medicaid, SCHIP, CCDBG, or IDEA,
designation of State and local dollars
is an essential
step for drawing down available Federal
funding.
-
Clarify the definitions of children
at risk
– While no State can afford to
extend eligibility to all
children at-risk, use of broader and
clearer definitions can help include
more young children in need
of early interventions to help them
achieve school readiness.
Clarify and Adopt Billing Codes for Early
Childhood Development Services
Without clear billing codes and payment
rates, providers are less likely to deliver
developmental services.
Some States have found that billing codes
tailored to young children’s conditions
(using the Diagnostic
Classification for Children 0 –
3 - DC:0-3)7
helped to reduce unnecessary spending,
minimize fraud, and
maximize early intervention. For example:
- In
North Carolina, Child Service Coordination
is case management services to children
at risk for or
diagnosed with special needs. Diagnosis
codes that support medical necessity
for Coordination
include: V11.9 -Unspecified mental disorders;
V15.86 - Exposure to lead; V15.9 - Unspecified
personal history presenting hazards
to health; V17.2 - Other neurological
diseases.
-
A workgroup report from King County
(WA) studied the potential role of the
DC:0-3 and emphasized
the importance of training and a standardized
“crosswalk” between the
two sets of codes.
-
Florida has developed guidelines and
a tool for professionals to use with
the DC:0-3. For example, in
a “crosswalk” between the
two codes: DSM-IV 700 “Disorders
of Relating and Communicating”
is
clarified in DC:0-3 as “Psychoses
with origin specific to childhood (299.0
– 299.9)” and/or
“Developmental disorder NOS (319.5).”
II. Screening and Assessment for
Young Children
In clinical practice, the terms screening,
assessment, and evaluation have general,
but not precise
meanings. Professionals do not use these
terms consistently. Because these terms
are confused in
Medicaid/EPSDT guidance to States, it
is important to reach agreement on what
they mean in this
context.
Screening is used to identify possible
problems and presumes follow-up with additional
tests if a problem
is suspected. Screening tools can be general,
be specific to a disorder or be focused
on an area of
development (e.g., language or motor skills).8
Ideally, developmental screening tools
should: identify
children with or at risk of problems,
be quick and inexpensive to administer,
be of demonstrated value to
the patient, provide information leading
to follow-up, and be sensitive and specific
enough to avoid
mislabeling many children.9
10 Screening
does not result in diagnoses.
When a possible problem is identified
through screening, the next step is assessment
(also sometimes
called evaluation). Assessment is more
in depth and helps child health professionals
to determine the
nature of the condition and to consider
possible treatments. Assessment tools
or (more often) processes
might be considered diagnostic. An assessment
may be comprehensive or measure a child’s
condition on
an area such as physical, cognitive, or
behavioral development.11
How does this fit with Medicaid and EPSDT/
screening?
In this context, the word “screening”
also reflects the definition in Medicaid’s
Early Periodic, Screening,
Diagnosis, and Treatment (EPSDT) program.12
EPSDT screening (a comprehensive
well-child checkup),
diagnostic assessment, and treatment for
any health problems found during the checkup
including
medical care, mental health services,
vision, hearing, and dental care. By law,
an EPSDT screen is
comprehensive and includes age-appropriate:
health history, physical exam, developmental
tests, blood
and urine lab tests, immunizations, and
health education/anticipatory guidance.
Screening visits may be
based on the State established (periodicity)
schedule or on an interperiodic basis,
as necessary. Hearing,
vision, and dental screening also are
required and have their own periodicity
schedule. Children age three
and older must be referred to a dentist.13
Developmental screening is a basic component
of an EPSDT screen for a child or adolescent
of any age
and, thus, should be part of a comprehensive
screen. If developmental problems are
suspected or detected
as part of a screen, a more thorough developmental
assessment by a trained professional should
occur as
soon as possible. While measurement tools
vary, developmental screening and diagnostic
assessment/evaluation should include measurement
using standardized tools of the following
domains:
gross and fine motor, cognitive, language,
psycho-social, and activities of daily
living skills.
III. Early Childhood Mental Health Services
Research has shown that early child health
and development services can effectively
address the needs of
many children who are considered at risk
of cognitive, social, or emotional problems.
14
15 While
effective early interventions and treatments
do exist once a child is identified, the
challenge is to identify
those children in need. Surveys indicate
that care for the social-emotional-behavioral
development of
children lags behind that of other preventive
and developmental services recommended
by the AAP.16
Financing early childhood mental health
services poses particular challenges.17
Challenges related to Serving Young Children
-
Definitions of eligibility
for the child –
Our silo approach to programs for children
and families
creates gaps and overlapping authority.
This particularly affects IDEA Part
C, Part B Preschool, Head
Start, child welfare, and Medicaid/SCHIP
programs.
-
Lack of eligibility for parents
–Promoting or repairing a child-to-caregiver
relationship is
fundamental for child mental health,
especially if the parent is battered,
abusing substances, or
depressed. This requires treating parent
and young child together.
-
Difficulties in distinctly diagnosing
conditions among young children
–
Can the child’s
condition be specifically diagnosed?
Is the condition considered a medical,
social, or educational
problem? Is the appropriate provider
trained in medicine, social work, mental
health, or child
development?
- Dilemmas
of primary care providers about where
to refer children for diagnostic
assessment and treatment. Surveys
of pediatricians indicate problems with
the number of
referrals, the willingness to refer,
and the linkages to referral resources.
These data suggest systemic
barriers for children.18
Opportunities to Promote and Protect
Socio-Emotional Development
-
Clarify State Medicaid guidance
on screening, assessment, and treatment
related to early
childhood mental health development.
Specifically, States might clarify benefits
covered, better
define developmental screening and assessment,
put protocols into place for developmental
services,
and define a set of providers qualified
to receive reimbursement.
-
Encourage pediatric provider sites to
promote healthy mental development.
State
Medicaid
agencies might reimburse primary pediatric
practitioners for providing preventive
mental health care
and development services as defined
under the Bright Futures Mental Health
Guidelines.19
Alternatively, Medicaid might designate
specific payment rates for social workers
and child
psychologists co-located in pediatric
practices and clinics to promote healthy
emotional development
through assessment, referrals, and treatment.
-
Eliminate treatment barriers
created by requiring providers to diagnose
young children as
having a mental or behavioral health
condition in order to obtain intervention
and
treatment. Such requirements
are established at the State level.
States might review State mental
health or Medicaid mental health rules
that require a diagnosis prior to Medicaid
mental health
financing and identify opportunities
to finance early interventions that
promote healthy mental
development.
-
Use the revised Child Abuse
Prevention and Treatment (CAPTA) law
as a stimulus.
Congress revised the CAPTA legislation,
which now requires each State to submit
a plan for early
intervention referrals among children
ages birth to three with confirmed cases
of child abuse and
neglect. Some States are using this
opportunity to restructure the linkages
between child welfare, Part
C early intervention, and Medicaid.
-
New protocols for screening.
One starting point is to provide
more uniform and
appropriate early childhood assessment
for children entering foster care
based on
protocols developed by professionals,
as well as approved for financing
by Medicaid.
Such protocols could be used as
the basis for enhanced EPSDT screening.
-
New professionals in Part C.
In most States, the sites conducting
early intervention
assessments are not well equipped
or trained in providing assessments/evaluations
for
children with a history of abuse
and neglect or in providing treatment
for infants and
toddlers with high levels of social-emotional
need.
-
New referral patterns.
For staff in local child welfare
agency, TANF, Medicaid, and
Part C programs, an aggressive response
to the intent of new CAPTA rules
will be a big
change in practice. The State agencies
can help by providing suggestions
or guidance
about how and when children should
be referred between programs.
-
Target other at-risk populations
already eligible for Medicaid benefits.
This includes groups
such as children in protective services/foster
care or in IDEA Part C Early Intervention
Programs.
Specific efforts might involve activities
such as:
-
Better linking EPSDT and IDEA.
Some Medicaid agencies require the
signature of a
primary care provider, as prior
approval on each child’s IFSP
under the IDEA Part C
program. Since these populations
already use services, this is an
opportunity to reduce
long-term costs and improve children’s
mental health outcomes.
-
Focusing on children with special
health care needs. Children with
special health
care needs (CSHCN) can be defined
as children under 21 who have or
are at risk for a
chronic physical, developmental,
behavioral, or emotional condition,
and require health
and related services of a type or
amount beyond that which is required
by children
generally. However, not all CSHCN
programs include children with social-emotionalbehavioral
needs.
Other no cost / low cost opportunities
-
Conduct joint training of
professionals - Facing
shortages of professionals trained to
provide
appropriate mental health services to
young children and their caregivers,
some States – such as
Florida, Indiana, Louisiana, Michigan,
and Vermont – have aimed to provide
training to “grow their
own” crop of professionals. Training
dollars are available in many programs.
-
Monitoring children at risk
- Children at-risk are more likely to
fall into the cracks between
various service systems (and associated
eligibility definitions). Several existing
mechanisms could be
used by States to monitor or track children
at risk. Children whose EPSDT periodic
screening exams
indicate high risk for social-emotional
or developmental delays may receive
more frequent
“interperiodic” screening
to assess their progress and need for
treatment.20
IV. Financing for home visiting
– Medicaid and funding streams
Home visiting is a long-standing, well-known
prevention strategy used by States and
communities to
improve the health and well-being of women,
children, and families, particularly those
who are at risk.
One home visitation program evaluation
found that children in participating families
made 35 percent
fewer visits to the emergency department,
had 40 percent fewer injuries, and 45
percent fewer behavioral
and parental coping problems noted in
their physicians’ records than children
in the comparison group.21
Mothers visited by nurses provided home
environments that were more conducive
to child development.22
Overall, comprehensive home visitation
or pediatric programs can save society
money in the long run,
due to reduced welfare dependency, teen
parenthood, and violence.23
Characteristics of effective home
visiting projects
-
Provide specific services, social supports,
and referrals.
States are using home visiting to help
transition families from welfare to
work, strengthen early childhood development
programs, and
provide support to first-time families.
Matching services to goals is essential.
-
Quality services.
Recent national evaluation research
underscores the importance of improving
the
implementation and quality of home visiting
services. Staff training is a fundamental
element of
quality. Ongoing monitoring and evaluation
helps to ensure that quality is maintained.
-
Integrated strategy.
Effective home visiting efforts must
be connected to other child and family
services and supports. For the many
home visiting programs designed to provide
care coordination
and social support linkages, this is
a critical aspect of the program.
-
Maximize Federal funding
streams. A variety of
Federal funding streams are available
to support
home visiting - including Medicaid,
the State Children's Health Insurance
Program (SCHIP), the Title
V Maternal and Child Health Services
Block Grant (Title V), and Temporary
Assistance to Needy
Families (TANF) - some of the largest
and most common sources of Federal support.
Blended
funding is associated with long-term
program survival.
The Status of Home Visiting Policies
From Alaska to Florida, States have advanced
home visiting programs and policies. At
the beginning of
Fiscal Year 2003, a total of 21 States
had laws establishing home visiting programs.
Among these 21
States, 31 laws were in effect, with the
authority typically assigned to Departments
of Public Health (33
percent) or to Departments of Education
(23 percent). Just over half of these
laws mentioned a specific
program model, and nearly half specified
a funding source.24
Other States operate home visiting
programs without specific legislative
authority. Most State home visiting programs
are adaptations of preexisting
program models, including Healthy Families
America (HFA), the Nurse-Family Partnership
(Olds model), Early Head Start, Home Instructional
Program for Preschool Youngsters (HIPPY),
and
Parents as Teachers (PAT).25
Home Visiting Policies and Financing
-
A survey of 30 State-based home visiting
programs conducted in 1999-2000 found
that: 26
-
State dollars were used to fund
home visiting programs by virtually
all of these 30 States,
with nearly half using State general
revenue funds and others using categorical
funding
streams.
-
Both large and small States have
made substantial public investments
in home visiting.
The largest reported State spending
was in Florida, Illinois, Michigan,
New York, Ohio,
Oklahoma, and Washington; however,
on a per capita basis, small States
such as
Delaware, Hawaii, and Rhode Island
are spending well above the average.
-
A more recent survey of home visiting
programs in 37 States found that: 1
-
State funds were the primary source
of funding for home visiting programs.
-
Federal dollars accounted for about
45 percent of home visiting budgets.
-
Local public and private dollars
also were being used as matching
and supporting funds.
-
Leading sources of funding from specific
Federal programs include the following:
-
Medicaid State-Federal
matching funds, particularly to
finance targeted case
management and care coordination
delivered through home visits.
-
States have found a fit between
home visiting and Title IVB (of
the Social Security Act)
program, with goals to address child
abuse and neglect and promote safe
and stable
families.
-
Temporary Assistance for Needy Families
(TANF) Federal dollars and State
maintenance of effort dollars have
been used to fund home visiting,
which fits with
program purposes.
-
Early Head Start
has launched a major initiative
to enhance home visiting.
-
Maternal and Child Health
Block Grant dollars from
Federal set-aside funds, Federal
block grant allocations to States,
and State matching funds are being
used to support
home visiting.
-
Part C Early Intervention Program
of the Individuals with Disabilities
Education Act
(IDEA) Federal, State, and local
dollars for children birth to age
three with disabilities.
-
Other Federal grant dollars
from various programs such as the
Social Services Block
Grant, Adolescent Family Life Grant,
Americorps, and domestic violence
prevention.
Opportunities through Medicaid
and Medicaid Managed Care
Medicaid is used to finance home visits
in more than a dozen States. A number
of States -- including
Illinois, Michigan, Kentucky, Oklahoma,
and Wisconsin -- are using some version
of Medicaid case
management to finance home visiting services
to at-risk families. Medicaid may finance
all or part of the
cost of home visiting services. Some States
are using "target case management",
which would require
Federal approval and is matched as a medical
assistance service. Others are using "Administrative
Case
Management", which does not require
special Federal approval and is matched
at the 50/50 administrative
rate. A few States use fee-for-service
payments for various services. States
use various resources for
matching; for example, Kentucky uses a
combination of Medicaid and tobacco dollars.
-
The Illinois Medicaid Family
Case Management program provides
intensive service coordination
for pregnant women and infants, using
Medicaid's administrative case management
approach. The
target group includes pregnant women
and mothers with infants. Local agencies
under contract
include health departments and community-based
organizations. Program guidelines are
set out in
State regulations.
-
In Michigan, the Medicaid
Maternal and Infant Health Advocacy
Services (MIHAS) program
provides outreach, health education,
and care coordination to pregnant women
and their infants. To
qualify for services, a pregnant woman
must be Medicaid eligible and have one
or more risk factors
(i.e., single marital status, social
isolation, younger than age 20, history
of abuse or neglect, maternal
depression, low intellectual functioning
or educational level, and HIV/AIDS risk).
Services include
case management and assistance with
making and keeping prenatal care appointments,
referrals to
other needed services, transportation
assistance, needs/risk assessments,
and health education related
to pregnancy and parenting.
1
Institute of Medicine. From Neurons
to Neighborhoods: The Science of Early
Childhood Development. Jack P.
Shonkoff and Deborah A. Phillips, (Eds),
Washington, DC: National Academy Press,
2000.
2
Brown B, Weitzman M, et al. Developmental
Needs of Many Children Not Being Met Early
Child Development in Social Context: A
Chartbook. New York, NY: Commonwealth
Fund, 2004.
3
VanLandeghem K, Curtis D, and Abrams
M. Reasons and Strategies for Strengthening
Childhood Development Services in the
Healthcare System. Portland, ME:
National Academy for State Health Policy,
2002.
4
Rosenbaum S, Proser M, Schneider A, and
Sonosky C. Room to Grow: Promoting
Child Development Through
Medicaid and CHIP. New York, NY:
Commonwealth Fund, 2001.
5
Perkins J. Medicaid Early and Periodic
Screening, Diagnosis and Treatment as
a Source of Funding Early
Intervention Services. Los Angeles:
National Health Law Program, 2002.
6
Johnson K and Kaye N, Using Medicaid
to Support Children’s Health Mental
Development. Portland, ME:
National Academy for State Health Policy,
2003.
7
Zero to Three: National Center for Infants,
and Toddlers and Families. Diagnostic
Classification of Mental Health and Developmental
Disorders of Infancy and Early Childhood
(DC:0-3) (1994) and DC:0-3 Casebook.
Washington, DC: Zero to Three Publications,
1997.
8
Centers for Disease Control and Prevention,
National
Center for Birth Defects, Developmental
Disability, and Disability Health.
9
Bergman D. Screening for Young Children.
Portland, ME: National Academy of State
Health Policy, 2004.
10
Glascoe FP and Shapiro HL. “Developmental
Screening,” from the web site
of Developmental-Behavioral
Pediatrics Online Community, 5/5/2004
11
American Academy of Pediatrics Committee
on Children with Disabilities “Developmental
Surveillance and
Screening of Infants and Young Children”
Pediatrics 2001;108:192-196.
12
Rosenbaum S and Sonosky C. Federal
EPSDT Coverage Policy. Prepared by
the George Washington University Center
under contract to the Health Care Finance
Administration, 2000.
13
States’ Medicaid Manual Part 5:
Early and Periodic Screening, Diagnosis,
and Treatment. Centers for Medicare and
Medicaid Services (CMS).
14
U.S. Department of Health and Human Services.
Mental Health: A Report of the Surgeon
General, 1999.
15
Op cit. Neurons to Neighborhoods.
Washington, DC: National Academy of Sciences,
2002.
16
Bethell C, Peck C, Abrams M, Halfon N,
Sareen H, and Scott-Collins K. Partnering
with Parents to Promote the Healthy Development
of Young Children Enrolled in Medicaid:
Results from a Survey Assessing the Quality
of
Preventive and Developmental Services
for Young Children Enrolled in Medicaid
in Three States. New York, NY:
The Commonwealth Fund, 2002.
17
Johnson K, Knitzer J, and Kaufmann R.
Making Dollars Follow Sense: Financing
early childhood mental health services
to promote healthy social and emotional
development in young children. New
York, NY: National Center for Children
in Poverty, 2002.
18
Rushton J, Bruckman D; Kelleher K. “Primary
Care Referral of Children with Psychosocial
Problems,” Archives of Pediatric
and Adolescent Medicine 2002;156:592-598
19
Jellinek M, Patel BP, and Froehle MC.
eds, Bright Futures in Practice: Mental
Health. Arlington, VA: National
Center for Education in maternal and Child
Health, 2002.
20
Johnson K and Knitzer J. Finance and
Policy Strategies to Promote Socio-Emotional
Development for School
Success. New York, NY: National Center
for Children in Poverty. In press. November
2004.
21
Olds, D.H., Henderson C., and Kitzman
H., “Does Prenatal and Infancy Nurse
Home Visitation Have Enduring
Effects on Quality of Parent Caregiving
and Child Health at 25 to 50 Months of
Life?” Pediatrics 1994;93:
89-98.
22
Kitzman et al., “Effect of Prenatal
and Infancy Home Visitation by Nurses
on Pregnancy Outcomes, Childhood
Injuries and Repeated Childbearing,”
Journal of the American Medical Association
1997;278: 637-643.
23
Karoly, L.A., Greenwood, P.W., Everingham,
S.S. et al, Investing in Our Children:
What We Know and Don’t
Know About the Costs and Benefits of Early
Childhood Interventions, Santa Monica,
CA: RAND, 1998.
24
Home Visiting Legislation and Funding:
Lessons from Healthy Families America.
Healthy
Families America, April, 2003.
25
Home
Visiting Forum, 2003.
26
Johnson K. No Place Like Home. New
York, NY: Commonwealth Fund, 2000. |