As the nation responds to the COVID-19 pandemic, policy makers, community residents, and leaders from all sectors are being called upon to deal with multiple needs in their communities. In addition to the health consequences of the pandemic, the economic impacts have exacerbated and further exposed gaps in meeting basic needs, including housing, transportation, and education—all of which impact overall health and well-being. Children and communities of color are among those at greatest risk from gaps that have existed for generations but are deepened by the pandemic. For example, at the end of April, two in five households of mothers with children 12 and younger were food insecure. The economic, racial, and health disparities that existed at baseline in our health and social service systems for children are intensified as both systems are stretched to their capacity.
The road to recovery for our nation’s health system is through investing in US families and strengthening our communities. It will require transformation of our health care and social service systems. This transformation should include advancement of value-based payment and delivery models that address underlying social factors impacting the health of children and families to explicitly promote health equity. Such models have the potential to play an important role in mitigating the heightened health inequities seen in the pandemic for communities of color, and those living in rural areas and in poverty.
Our organizations—Nemours Children’s Health System and Duke University’s Margolis Center for Health Policy—examined ways in which local, state, and federal stakeholders are accelerating the development of holistic models and policies that address the health and social needs of children and families. This post presents the core recommendations from that work.
Federal And State Momentum
Value-based payment and delivery models have bipartisan support, although the vast majority of models have been developed and implemented for adults, often through Medicare. Momentum has been building for a greater focus on children in holistic value-based care arrangements. Notably, the Integrated Care for Kids (InCK) and the Maternal Opioid Misuse Model (MOM) from the Center for Medicare and Medicaid Innovation (Innovation Center) address the health and social needs of children, adolescents, and pregnant women. States are also taking action. From New York’s First Thousand Days Initiative to Oregon’s Early Learning Hubs, there is a growing recognition that long-term health care transformation requires a focus on children and families. Although these initial steps in a subset of states have been meaningful, the COVID-19 pandemic adds urgency to expanding the reach of this transformation.
A Path Forward
Nemours Children’s Health System and Duke University’s Margolis Center for Health Policy recently released two issue briefs with emerging examples and policy recommendations based on expert interviews and a convening on the building blocks for integrated, value-based care models that promote whole child and family health. Based on this work, we have developed actionable recommendations for how policy makers, payers, providers, community partners, and funders can accelerate efforts to address social factors impacting health and promote equity for children through enhanced multisector partnerships and pediatric value-based care models that address social drivers. These five core recommendations could catalyze progress to move from the current stage of early innovation to spreading and scaling the most effective models in the COVID-19 era.
Create Coordinating Bodies To Advance An Agenda For Children And Families
Government leaders can prioritize child and family well-being by establishing coordinating structures, specifically children’s cabinets. In states that have created such bodies, the groups have focused on child developmental issues to advance joint goals, identify shared metrics across sectors, and work toward common outcomes. Delaware, for example, relaunched its Family Services Cabinet Council to help break down silos and coordinate critical services for families in areas including job services, early childhood education, social service delivery, and public safety. Such multisector leadership can improve services and interventions for children and families, including those exposed to trauma. The need for emphasis on children and families is heightened as the COVID-19 pandemic has drained resources from child-serving public and private entities across sectors that are struggling financially to survive.
Support Cross-Sector Data-Sharing Infrastructure That Includes Child-Serving Partners
We need to better leverage technology to support seamless connections among health care, public health, mental health, schools, childcare, food banks, and other social service providers. This basic connectivity and shared infrastructure is a foundational capacity of many innovative pediatric value-based care models, such as accountable health communities and the InCK model. Multisector partners should align to coordinate cross-sector data-sharing, referral to community resources, and closed feedback loops to address the resource needs of children and families during the pandemic and beyond.
For example, the North Carolina Department of Health and Human Services partnered with the private sector to develop NCCARE360, the first statewide coordinated collaborative care network using a shared technology platform. NCCARE360 allows providers to electronically connect individuals with identified needs to community resources and to confirm receipt of service through a feedback loop. Additional federal support to assist states in developing cross-sector data-sharing and closed loop technology systems is also needed for a robust pandemic response.
Leverage Medicaid Managed Care Organizations As Key Partners For Addressing Social Needs
The requirements and incentives included in contracts that states negotiate with Medicaid managed care organizations (MCOs) are powerful levers to accelerate transformation to pediatric value-based models. Strategies include requiring specific numbers or types of performance metrics related to children, health equity (for example, reducing disparities in infant mortality) and social factors impacting health (for example, food insecurity). Many states and their MCOs are developing approaches to address social needs, such as Arizona requiring MCOs to make investments in the community. Massachusetts and Minnesota are testing ways of risk-adjusting MCO premium payments to account for issues related to social determinants of health among their covered populations. Expansion of these types of holistic efforts to additional states will be needed as the pandemic threatens the ability of families to meet their children’s basic needs.
Align Investments To Support Children’s Health And Development And To Promote Health Equity
Achieving maximal impact from invested resources requires coordination and alignment among partners. A dedicated, pooled funding source can aggregate the resources of payers, health systems, businesses, and philanthropy for a common purpose. In some communities, competition among partners for limited resources and “wrong pocket” issues (in which investments from one sector result in benefits or cost savings to another) are barriers to integrated models in which partners collectively make progress on joint goals. The development of children’s trusts that braid funding from multiple sources and invest in evidence-informed programs that will achieve impact in the short, medium, and longer term can help to address these barriers. These pooled funding mechanisms can amplify the impact of pediatric value-based payment models that address health-related social factors and ensure targeted investments in promoting health equity.
Promising models exist. In Oregon, Yamhill Coordinated Care Organization’s Wellness Fund supports evidence-based community prevention programs via a steering committee and has secured more than $1 million in blended and braided funds (county prevention funds, grants, and funds built into agency contracts). In Imperial County, California, the MCO California Health and Wellness contributes monthly per-member fees totaling up to $90,000 and annual revenue sharing of up to $1 million a year to a Local Health Authority Commission that oversees a wellness fund. That commission is funded by both the county public health department and the California Accountable Communities for Health Initiative.
Support State And Provider Capacity To Innovate For Children
Child-serving providers from all sectors are struggling financially because of the pandemic. In the health care sector, as patients delay and cancel non-urgent visits, the fee-for-service payment model has created huge revenue shortfalls. The financial pressures faced by health care providers may create new opportunities to develop holistic care for children.
The Centers for Medicare and Medicaid Services (CMS) can support health care providers in efforts to redesign how they deliver care during the pandemic and beyond. CMS can leverage various tools (such as guidance, waivers, technical assistance, and demonstration authority) to enhance states’ and providers’ readiness to test additional models that better coordinate resources and create value-based payment models that address social factors impacting health. New Innovation Center models could build upon the InCK and MOM models, with a sharper focus on promoting equity.
Congress could play an important role as it has done for other crises. For example, the SUPPORT for Patients and Communities Act of 2018 authorized Medicaid planning grants for states to address the opioid epidemic. As part of COVID-19 relief efforts, Congress could authorize CMS planning grants to states and providers that support capacity-building and the design of value-based models that address the multisector needs of children and families. For providers ready to move forward now, Congress could authorize upfront provider relief payments to support implementation of new models—these awards would help providers strengthen their response to COVID-19 while building a foundation—including health information technology updates, telehealth platforms, staff training, cross-sector convening, and care coordination—for more sustainable and holistic care models in the future.
Concluding Thoughts
Responding to the immediate needs exacerbated by COVID-19 and addressing the social factors impacting the health of children on a national scale will require vision, sustained commitment, investment, and creativity from community-based partners, policy makers, providers, payers, and businesses. Multisector, multipartner collaboration is complex but achievable, using early lessons to inform comprehensive, integrated models. We should not delay in these efforts. The current public health crisis has demonstrated that interventions are more urgent, more necessary, and more possible than ever.
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July 21, 2020 at 07:11PM
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Caring For Kids In The COVID-19 Era: Addressing Social Drivers And Paying For Health - Health Affairs
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