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Tools for Insurers
Until we are committed to full-fledged collaboration
with parents, CSHCN (and their families) we're faceless and
voiceless. Today we know who these children are, what their
families face on a daily basis, and what needs to change to
use our financialresources
more effectively.— Robert Master, MD • Neighborhood Health Plan
CYSHCN: Reality
- Approximately 12.8 percent of children/youth
in the United States, or 9.4 million, have special health
care needs, based on the MCHB definition
- Approximately 1 out of 5 homes in
the United States has a child or youth with special health
care needs
Note: This does not include children and youth
at risk for a chronic condition. -MCHB/NCHS.
National Survey of Children with Special Health Care Needs.
2002
CYSHCN: Financial Reality
- CYSHCN account for 80% of
pediatric health care expenditures
- Annual Cost of Medical Care
for CYSHCN
61% Hospitalizations
15% Other
(Therapies, Pharmaceuticals, Outpatient Lab, ED, Disposables)
14% Specialists
5% Primary Care
5% Durable Medical Equipment
-Health Partners/Institute for Health and Disability 2/97
Benefits of Coordinated
Care in a Medical Home
Physician Directed Care Coordination
includes:
- A plan of care is developed by the physician,
CYSHCN, and family, and is shared with other providers
involved with the care of the patient.
- Care among multiple providers is coordinated through
the medical home.
- A central record or database containing all pertinent
medical information, including hospitalizations and specialty
care, is maintained at the practice. The record is accessible,
but confidentiality is preserved.
- The medical home physician shares information
among the CYSHCN, family, and consultant; provides specific
reason for referral; and assists the family and CYSHCN
in communicating clinical issues.
- Families are linked to support and advocacy groups,
parent-to-parent groups, and other family resources.
- The medical home physician evaluates and interprets
the consultant’s recommendations for the CYSHCN
and family and, in consultation with them and sub- specialists,
implements recommendations that are indicated and appropriate.
Cost/Quality Benefits Include:
Reduced hospitalizations
Reduced length of Stay in hospital
Reduced ED Utilization
Increased Family and Provider Satisfaction
-American Academy of Pediatrics
The
Medical Home. Supplement to Pediatrics. Pediatrics.
2004:113(suppl):1471-1548
 New
Toolkit on Enhancing Child Development Services in Medicaid
Managed Care
Enhancing Child Development Services in Medicaid
Managed Care, a new toolkit from the Center for Health Care
Strategies (CHCS), offers practical strategies to help health
plans and states identify and treat developmental delays
in children, age 0 to 3, at the earliest stage possible.
The toolkit is based on the experiences of 10 health plans
and one primary care case management organization that participated
in a Best Clinical and Administrative Practices (BCAP) workgroup,
which was made possible by The Commonwealth Fund. Strategies
outlined in the toolkit include increasing the use of standardized
developmental screening tools, improving outreach to members,
enhancing provider partnerships, and linking reimbursement
to developmental screening. Case studies illustrate how
plans applied the BCAP Quality Framework to improve child
development services in Medicaid managed care.
Visit www.chcs.org to
download the toolkit or request a free print copy. The website
also includes practical tools for organizations interested
in designing programs to improve child development services.
Please contact Lorie Martin for additional information at
609.895.8609 or lmartin@chcs.org
Children with Special Health Care Needs: Building
a Quality-of-Care Initiative by Rebecca
Nyman and Henry Ireys - Mathematica Policy Research.
This brief summarizes recent studies conducted by Mathematica
Policy Research, Inc., and the Center for Health Care Policy
and Evaluation at UnitedHealth Group for the federal Maternal
and Child Health Bureau in the U.S. Department of Health
and Human Services. These studies investigated utilization
and cost patterns among a large sample of children with
special health care needs (CSHCN) enrolled in two commercial
managed care plans. Available data allowed us to examine
the full spectrum of services and costs, including pharmacy
and ancillary services. Issue
Brief 
This issue brief addresses a critical concern
for health plans -- the health status of children and youth
who have been required to transfer to new health plans when
a health plan exits the market. Little information is available
on the experience of enrollees who involuntarily switch
health plans due to an exiting plan. The information that
is available on this topic focuses on the quality of health
care the children receive. However, the health plans' concern
is that financial losses due to caring for a disproportionately
high number of children with special health care needs (CSHCN)
might have caused the exiting health plan to withdraw from
the public health insurance markets Issue
Brief .
Health Care Use Patterns and Expenditures of Children
with Special Health Care Needs (CSHCN): Using National
and State Program-level Data to Inform Decisions About Identification,
Financing and Reimbursement.
The purpose of this report is to provide a detailed, user-friendly
compendium of available data sources that can be used to
develop profiles of children with special health care needs
(CSHCN) and to analyze their healthcare use and expenditures.
The data sets are grouped into two major categories: national
data sets and state program-level data sets.
As an initial step in developing recommendations for identification,
financing and reimbursement strategies, we have assembled
information on a wide range of potential data sources that
can be used to address these questions. The goal is to provide
information about each source, and via the conceptual and
organizational framework provide guidance that can aid in
deciding which sources are of most use for which purposes.
Report
Additional reports and briefs from The National
Center on Financing for CSHCN are available at:
www.cshcnfinance.ichp.ufl.edu
Focusing in on the
Workplace
Purchaser’s Guide to Clinical Preventive Services (for large employers)
The Purchaser's Guide to Clinical Preventive Services is developed in collaboration between the Centers for Disease Control and Prevention (CDC) and the National Business Group on Health. The guide provides large employers with information that can be used to help select, define, and implement preventive medical benefits. Each section includes summaries about the economic impact of the relevant condition and what is known about costs and benefits of the interventions being recommended. For more information, http://www.businessgrouphealth.org/prevention/purchasers/guide/fullguide.pdf
Employee Benefits Study
The
Employee Benefits Study for Children with Special Health
Care Needs
A project of the Center for Child and Adolescent Health
Policy Mass General Hospital for Children with a goal to better understand how systems
of care for children with special health care needs and
their families can be improved through employer-sponsored
benefit systems.
Guides and Toolkits
The Shared Responsibilities Toolkit: Tools for Improving
Quality of Care for Children with Special
Health Care Needs (CSHCN) is available on the New
England SERVE website. This publication (2002, 75 pages)
is designed to focus the attention of health plans on CSHCN.
The Toolkit includes an 8-page introductory booklet, and
fifteen additional tools that can help plans identify CSHCN
and collaborate with families, providers and Title V programs
to improve systems of care.
The Shared Responsibilities tools are designed to be easily
adapted for use by:
- any health plan;
- provider group;
- purchaser; or
- state agency working in partnership with health plans.
The Identify section of the Toolkit includes a rationale
for why health plans should invest in identifying this population.
Four sample tools for identifying children with special
health care needs are included, as well as references on
how to get additional information and support in using these
tools.
The Collaborate section of the Toolkit includes survey formats
and resources designed to assist health plans to build partnerships
with families, providers, and state organizations that are
also involved in providing care for this group of children.
The Improve section of the Toolkit includes examples of
best practices at the health plan level, a checklist for
health plan policies and procedures that can support serving
CSHCN, and a set of measures that can be used to assess
a health plan’s readiness to focus on this population.
Shared
Responsibilities Toolkit: Tools for Building Partnerships
to Improve Health Care Financing for CSHCN 
Susan G. Epstein. May 17, 2003.
Pediatric Managed Care Training Module Now Available
The George Washington University Medical Center's Center
for Health Services Research and Policy (CHSRP) recently
developed a pediatric managed care training module for use
by all payers, providers, state and local health departments,
and advocates who are concerned with the health care of
children. The module is a learning course to help interested
parties learn about managed care contracting for pediatric
services, as well as write and negotiate contracts to ensure
that children, particularly Medicaid and SCHIP children,
receive quality care.
The link to the Training Module is provided below, and
for more information on CHSRP's work on managed care contracting,
please visit the managed care section of CHSRP's Web site
at: www.gwumc.edu/sphhs/healthpolicy/chsrp/managed_care.html
Planning Culturally and Linguistically Appropriate Services:
A Guide for Managed Care Plans
To address shifting demographic trends in health care, this
guide offers health plans an approach to defining the needs
of multi-ethnic members and developing culturally and linguistically
appropriate services for them.
The Centers for Medicare & Medicaid Services commissioned
this guide, developed by a contractor of the Agency for
Healthcare Research and Quality. www.ahrq.gov/about/cods/planclas.htm
Parents Partnering with Managed Care: A Discussion Guide
on Services for Children with Special Health Care Needs Guide
-Developed by Family Voices
Improving Managed Care for Children with Special
Needs - A Best Clinical and
Administrative Practices Toolkit
As health plans across the country increase enrollment of
Medicaid and SCHIP
beneficiaries, the challenges of providing consistent, high
quality care and the need
for defined and measurable quality improvement expand significantly.
The Best
Clinical and Administrative Practices (BCAP) initiative
was created by the
Center
for Health Care Strategies (CHCS) to develop, document,
and spread best practices
among Medicaid health plans. This toolkit reflects the experiences
of the Improving
Managed Care for Children with Special Needs workgroup,
a group of 11 health plans
and a primary care case management (PCCM) program that collaborated
over 24
months to develop, pilot, and refine best practice models
for serving this population.
Model Programs
Partnership HealthPlan of CA Improves Managed Care
for Children with Special Needs. A BCAP Pilot Project: Case
Study
Published: September 2004
Partnership's overall BCAP objective was to create a medical
home to streamline care for CSHCN and provide comprehensive
resources for families of these children.
Partnership HealthPlan of California is a Medicaid health
plan serving 82,500 members in Solano, Napa, and Yolo counties
in Northern California. Partnership case manages children
classified as “special members,” including those
with chronic conditions, children in Title V, and out-of-county
foster care. Fifteen percent of all children in the health
plan are children with special needs and of these, approximately
32 percent are “special members.”
Aim:
 Survey
35 percent of families of CSHCN to better understand the
barriers to quality and coordination of care.
Measure:
Percent
of CSHCN completing a member needs assessment.
# of CSHCN with a completed needs assessment
# of CSHCN sent member surveys
Change:
Develop/adopt
member needs
assessment tools modeled on the 2002 CAHPS survey.
Select
a sample of CSHCN and send survey.
Compile
results of needs assessments, report to CSHCN coalition
and pilot practice sites, stratify, and develop interventions
based on issues identified.
Sections
Introduction
Identification
Stratification
Intervention
Outreach
Supporting Improved Communication
between Health Plans and their Members with CSHCN
- The
Alliance for Health Care Improvement
A Collaboration of Massachusetts Health Plan Medical Directors
Goals:
- To improve the quality of health care in the communities
that they serve;
- To assist member organizations in quality improvement
initiatives;
- To streamline administrative requirements so providers
can focus on health care; and
- To enhance appropriate dialogue, education and collaboration
regarding care management, clinical quality, patient rights
and other areas of benefit to patients.
Why was the Alliance formed?
The idea for the Alliance emerged out of a common belief
among the member health plan Medical Directors that certain
critical health care and health outcome improvements could
best be achieved through collaboration among health plans
and other key stakeholders.
The Alliance participates in two specific work groups
that are focusing health plan attention on CSHCN:
the Identification and Screening Work Group, as well as
a Work Group that is revising the Department of Public Health’s
Directions Manual, an
information resource for families (see section B below).
Various members of the Alliance are also part of the Consortium’s
Care Coordination, Family Participation and Medical Coverage
Decision-Making Work Groups.
Last Updated
July 15, 2008
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