How Do Medicaid Programs Cover Pediatric Curative, Hospice Care?

States use Affordable Care Act flexibilities in innovative ways to set definitions for curative care, implement reimbursement models, and care coordination in Medicaid pediatric care for children with terminal illnesses, a Health Affairs study found.

Each year, over 55,000 US children die, largely as a result of a chronic or complex condition. While these children are largely enrolled in Medicaid, very few receive hospice care, even though states are required to cover curative and hospice services under section 2302 of the Affordable Care Act.

“Advocates of pediatric hospice care recognized that the strict choice between curative and hospice care was a significant barrier to enrollment in pediatric hospice services at the end of life,” stated the researchers. “To overcome this barrier, in the 2000s several states demonstrated innovation in financing and care models and developed alternative pathways to enrollment in pediatric hospice that allowed children to continue to receive curative care.”

Thirty-two states came up with a variety of models under section 2302 of the Affordable Care Act to accommodate pediatric concurrent care, in which Medicaid covers both continued curative care—which encompasses therapies such as dialysis, chemotherapy, and medications—and hospice care for children.

However, section 2302 incorporates very little oversight. There are no deadlines, penalties, nor even any federal appropriations set aside for this policy. Thus, states are largely left to their own devices and policymakers have little way of knowing how to most effectively leverage section 2302 to provide for pediatric concurrent care.

The study set out to fill in these knowledge gaps.

Researchers discovered that over one-third of all states implemented section 2302 to expand on the definition of curative care (35.29 percent). Another around three in ten states used the section of the Affordable Care Act to reform reimbursement of concurrent care (29.41 percent). Another 27.45 percent refined care coordination guidelines.

States that chose to redefine curative care did so in a variety of ways. Curative, life-prolonging, and disease-directed care were often considered interchangeable terms. Some indicated that therapies, treatments, and medications were curative treatments, while others included palliative care.

“There was no standard definition for the services related to terminal illness under concurrent care among the states,” the study found.

For reimbursement, strategies were similarly wide-ranging.

Fifteen states changed provider reimbursement, for example by billing hospice and curative care separately (Iowa) or shifting concurrent care reimbursement from managed care to fee-for-service reimbursement (Texas).

When it came to care coordination, states that used section 2302 to address this element of concurrent care were fairly non-descriptive in their expansion on the matter.

“Most states discussed the importance of care coordination by the hospice team,” the study stated. “Rarely did states discuss how hospice and nonhospice providers coordinate care, which is especially important in the context of concurrent care.”

Four states had specific rules around care coordination beyond that it should exist. Perhaps this is not surprising, given that for patients with certain chronic conditions public payers are known to have worse coordinated care strategies than private payers.

Like the other section 2302 uses, care coordination for concurrent care varied greatly by state.

Based on these findings, the researchers supported state Medicaid programs establishing innovative guidelines around concurrent care. Adding a set of criteria to section 2302—similar to the criteria for section 1332 of the Affordable Care Act—may be a way to ensure quality guidelines.

“Second, the framework we created to extract information could serve states as a basic guide to identify gaps in concurrent care guidelines: common definitions, payment information, staffing guidelines, care coordination requirements, eligibility criteria, or clinical guidance,” the researchers noted.

Strong pediatric care is critical to moving the industry forward, both in the public and private payer spaces.

“Children’s health is the most powerful lever we have to influence the health of the next generation, and, ultimately, to influence the economy of this country,” Larry Moss, MD, president and chief executive officer of Nemours Children’s Health System, told the audience at Xtelligent Healthcare Media’s Fourth Annual Value-Based Care Summit.