1. Chapter 41 Health Care Delivery Systems and Financing Issues
Overview
Defining children and youth with special health care needs (CYSHCN)
U.S. services and supports for these children
Medical home and care coordination for CYSHCN
Insurance coverage in the provision of health care
Public health care programs and benefits to CYSHCN and their families
Chapter 41 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved

2. Introduction
CYSHCN: those who have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions and require special health and related services
14% of U.S. children
22% of U.S. households
CYSHCN includes
Diverse group of all races, ethnicities, ages, family incomes, and levels of functional abilities
Some children with developmental disabilities as well as some typically developing children with complex medical problems
Coordinating health care for CYSHCN presents unique challenge to family and health care providers
Chapter 41 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved

3. The Concept of a Medical Home
All children should be provided comprehensive health care within a medical home: “ongoing comprehensive, coordinated, family-centered care in the child’s community” (U.S. Department of Health and Human Services, 2007)
47% of CYSHCN received care that met medical home criteria:
Personal doctor or nurse; usual source of sick and well-child care; no problems obtaining referrals
Satisfaction with doctors’ communication with each other, school, related systems; help coordinating care
Sensitive, listening doctor spends adequate time with child
Parents feel they are partners in child’s health care
See the textbook Children with Disabilities, Seventh Edition, for full citation and reference information.
Chapter 41 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved

4. Importance of Coordination of Care
Each child’s needs are complex and may involve many agencies, institutions, and professionals who must work together for comprehensive care plan
Benefits of coordination of care:
Avoid excessive and deficient services
Increased chance of receiving family-centered care
Cost savings
Decreased hospital stays
Chapter 41 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved

5. Importance of Coordination of Care (continued)
Case management programs
Much time coordinating care is not reimbursed by insurance, so insurers, hospitals, public agencies, and private agencies have developed case management programs
Purpose and scope of programs vary
Important to provide care coordination at community practice (medical home) level; although more expensive, produces better outcomes
Medical home index (MHI): higher scores associated with increased organizational capacity, care coordination, chronic condition management, significantly fewer hospitalizations
Chapter 41 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved

6. Changes in Financing Health Care for Children and Youth with Special Health Care Needs
Retrospective payment system
Fee-for-service model
Little incentive for preventive services
Too many acute care services
Prospective (prepayment) system
Appropriate utilization
Well and preventative services
Avoid unnecessary services
CYSHCN have health care costs as high as three times that of children in general population
Chapter 41 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved

7. Changes in Financing Health Care for Children and Youth with Special Health Care Needs (continued)
Accountable care organizations (ACOs):
Group of physicians, hospitals, other providers accept shared responsibility for broad set of medical services to defined set of patients across age spectrum
Held accountable for quality and cost of care through alignment of incentives
“Teamlet” model: practitioner and medical assistant/health care coach provide care collaboratively with patients
Chapter 41 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved

8. Insurance Coverage: Public and Private
When employer-sponsored insurance declines, public forms of coverage must increase; if this doesn’t happen at the same rate, more children are left uninsured
Federal government-funded insurance programs include Medicaid and Children’s Health Insurance Program (CHIP)
Some federal and state funding and services for health care also provided by Supplemental Security Income, Maternal and Child Health Bureau’s Title V programs, and Individuals with Disabilities Education Improvement Act (IDEA) of (PL )
Insurance issues and programmatic variability complicate care plans for CYSHCN
Decreasing trend for CYSHCN to have private insurance
Chapter 41 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved

9. Insurance Coverage: Public and Private (continued)
Adequacy of insurance coverage varied as function of insurance type
Parents often face financial strains as direct result of having CYSHCN
Concern that managed care organizations reduce access to specialty services (especially high-cost procedures)
Chapter 41 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved

10. CCS http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
IHSS
Chapter 1 materials in Children with Disabilities, Seventh Edition, Online Course Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

11. Wagner’s Chronic Care Model
Wagner video
Care in context of patient- and family-centered medical home
Processes and incentives to improve care delivery system
Information technology and clinical decision support for clinicians
Focus on effective self-management training and support
Evidence-based guidelines utilized
Increased communication between primary care and specialty care providers
Chapter 41 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved

12. Additional Services for Children and Youth with Special Health Care Needs
Centers for Medicare & Medicaid Services has set of safeguards promoting attention to unique aspects of caring for CYSHCN
Some states have “carve-outs” in which child is handled separately from general populations
Medicaid waivers can allow home- and community-based services as alternative to institutionalization or continued hospitalization
Chapter 41 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved

13. Looking Toward the Future
Measuring outcomes and demonstrating high-quality results increasingly important in justifying services for CYSHCN; requires rigorous collection and analysis of data
Affordable Care Act of 2010 should improve access and quality of care for CYSHCN while reducing costs
Various innovations hold promise for primary care:
ACOs
Health insurance exchanges
Innovative infrastructure (teamlets, care coordination)
Chapter 41 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved