CMS Calls on Stakeholders for Pediatric APM Development Input

CMS recently put out a request for information for a potential Medicaid and Children’s Health Insurance Program (CHIP) alternative payment model targeting pediatric care, according to an official CMS blog post.

“Through the RFI [request for information], we are seeking input on approaches to improve the quality and reduce the cost of care for children and youth enrolled in Medicaid and CHIP,” wrote four CMS leaders, including Patrick Conway, MD, MSc, CMS Acting Administrator, and Diedre Gifford, MD, MPH, Deputy Director of the Center for Medicaid and CHIP Services.

“In particular, we are exploring concepts that encourage pediatric providers to collaborate with health-related social service providers (e.g., early childhood development programs, child welfare services, and home and community based service providers) at the state and local levels and share accountability for health outcomes for children and youth enrolled in Medicaid and CHIP,” they continued.

Medicaid and CHIP provided health coverage for more than one in three children in 2015, the Department of Health and Human Services (HHS) reported earlier this month.

The federal healthcare programs offer children a wide range of covered comprehensive and preventative care services. As a result, Medicaid- and CHIP-covered children “lead the nation in participation in preventative care and access to needed care,” stated the CMS leaders, citing a 2014 Mathematica Policy Research and Urban Institute report.

To further improve care quality and access for Medicaid and CHIP-covered children as well as reduce their healthcare costs, CMS plans to create a pediatric-focused Medicaid alternative payment model.

However, CMS has enlisted healthcare stakeholders to help with alternative payment model development. The federal agency is seeking feedback on the following model development aspects:

• Opportunities and challenges to expanding and improving integrated service model concepts, such as pediatric accountable care organizations (ACOs)

• Supports or waivers that providers and states may need to implement a pediatric alternative payment model

• State and provider methods for coordinating Medicaid and CHIP benefits and waivers with other health-related social services

The federal agency also expects to use several existing initiatives as the basis for the potential alternative payment model. The initiatives include Medicaid Health Homes, which aim to coordinate care for individuals with chronic conditions, and the Medicaid Innovation Accelerator Program, which supports state efforts to implement value-based care models.

The potential pediatric alternative payment model will also build on the Strong Start for Mothers and Newborns Initiative. The care delivery reform program aims to reduce premature births and improve patient outcomes for newborns and pregnant women. CMS also designed the program to decrease healthcare costs for pregnancy, delivery, and the first year of life.

If developed, the pediatric alternative payment model will be one of the only CMS Innovation Center projects targeting children in addition to the Strong Start program.

Pediatric-specific alternative payment models and quality improvement programs historically have not taken center stage. An executive at Allied Physicians Group in New York told RevCycleIntelligence.com in January that pediatric care reform models may not be as popular because the opportunity for cost savings is not as robust as in older patient populations.

“Pediatrics is not where the cost-savings are, generally,” said Robert Creaven, the healthcare system’s Executive Vice President of Operation. “Our population is not the most expensive population, so they don’t focus in on it. They just sort of attach whatever quality programs they have to everybody and it just doesn’t work that way.”

Healthcare systems like Allied Physicians Group oftentimes have to remind payers that quality measures designed to monitor care for 65-year-old individuals or older do not always mesh with the pediatric population.

Pediatric care is also not as simple as one patient coming into the office. Pediatricians and other pediatric specialists manage families as patients, especially when younger children cannot voice their own healthcare needs.

Federal healthcare programs have also shied away from pediatric care reform, especially since there is little overlap between Medicare and pediatric populations, an Ohio-based pediatric ACO President stated last February.

He added that states have done more work with developing pediatric-focused alternative payment models and care delivery reforms, such as pediatric Medicaid ACOs.

However, the recent request for information indicates that CMS plans to venture more into the pediatric field. More specifically, the federal agency intends to improve pediatric care while also moving the field more to value-based reimbursement.

“Investing in child health can provide lifelong benefits and improve the nation’s health,” CMS stated. “We look forward to front-end comments from our state partners and other stakeholders who share our dedication to improving the health of our nation’s children.”

Stakeholders can submit comments on pediatric alternative payment model development by March 28.