CMS Seeking Feedback on Pediatric Alternative Payment Model

March 01, 2017 - The Centers for Medicare & Medicaid Services (CMS) recently issued a request for information seeking input on designing an alternative payment model focused on improving care quality and cost (APM) that specializes in pediatric care.

The CMS Innovation Center and Center for Medicaid and CHIP Services (CMCS) are requesting feedback from child and youth-focused stakeholders about improving health outcomes for Medicaid and the Children's Health Insurance Program (CHIP) beneficiaries through value-based reimbursement.

“The aim of this model is to facilitate strategies for timely and appropriate delivery of family-centered, community-based, linguistically and culturally appropriate, cost-effective, and integrated services to all children and youth covered by Medicaid and CHIP with an emphasis on those with or at-risk for developmental, social, emotional, or behavioral health challenges, intellectual or physical developmental delays or disabilities, and/or those with complex and/or chronic health conditions,” the RFI states.

This research into drafting a pediatric care model concept follows care redesign and innovation efforts, such as the State Models Innovation Initiative and the Strong Start for Mothers and Newborns Initiative, focused on addressing threats to children’s health.

CMS insures one-third of American children and is therefore positioned to demonstrate the value of an alternative payment model to large pediatric population which includes high-risk patients. The RFI is first step toward designing a workable pediatric APM.

“Some children and youth enrolled in Medicaid and CHIP, especially those that are high-need and high-risk, may experience barriers to accessing the optimal combination of child-focused programs and services that are available to address these critical factors,” CMS officials said in an official blog post. “Through the RFI, 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.”

In the RFI, CMS seeks comments across four categories as well as other comments:

• Integrated pediatric health care and health-related social service delivery model.
• Operation of integrated service model
• Integrated pediatric service model payment and incentive arrangements
• Pediatric quality measures

CMS asks stakeholders to suggest ideas for opportunities that could reproduce integrated services for adult-centered accountable care organizations (ACOs) in pediatric settings. Individuals or groups submitting information are asked to suggest flexibilities and support necessary for states and providers to offer a pediatric APM.

Submitted information should also include approaches for states and providers to coordinate Medicaid and CHIP benefits with other health-related social services for children. A major focus of the RFI included an emphasis on incorporating support in the community and local level benefactors to pediatric health.

“We know there is more to health than health care alone, and for children, factors such as sound nutrition, safe living environments, responsive adult caregivers, and nurturing social relationships are especially critical for healthy growth and development. Inadequate or inconsistent access to these factors can have physical and behavioral impacts that reverberate throughout a child’s life course as he or she grows into adulthood,” CMS officials observed.

CMS leadership, including Acting Administrator Patrick Conway, MD, MSc, highlighted three concepts critical to the task of providing value-based care to pediatric populations for which stakeholder feedback would prove beneficial:

• Opportunities and impediments to extending and enhancing integrated service model concepts like accountable care organizations (ACOs) to the pediatric population;
• Flexibilities and supports states and providers may need in order to offer such models of care to a state’s pediatric population; and
• Approaches for states and providers to coordinate Medicaid and CHIP benefits and waivers with other health-related social services for children and youth.

“Investing in child health can provide lifelong benefits and improve the nation’s health. 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,” they concluded.

A week ago, CMS continued soliciting support for another APM, the Comprehensive Primary Care + program. This and other advanced APMs are one pathway that eligible clinicians in the Quality Payment Program can receive positive Medicare payment adjustments (and avoid negative ones) under MACRA.