Transcript 2007 Medical Home Updates

Healthcare Financing:
Investing in Healthier
Communities
Your Name, MD, FAAP
Name of Practice
City, AL
How are healthcare providers
paid?
 Cash
 Third-party insurers
 Government programs
 Self-insured corporations
Government programs
 CHIP (ALL Kids in Alabama)
 Medicaid (federal-state partnership)
– Poor children 100% poverty level ($35k family of
4)
– Pregnancy
– Elderly poor/nursing home care
– Disabled who qualify
– Adult extreme poverty
 Medicare (federal program for the elderly,
certain disabled adults and kidney disease)
CHIP
 ALL Kids
– Funding began in 1997
– Provides child-friendly benefits package
– Administered by ADPH
– ADPH contracts with BCBS to provide
benefits & services through its provider
network
– Co-pays and premiums based on family
size and income
Medicaid
 Alabama Medicaid is a minimum federal
standards program
 Pays providers to care for children under a
managed care, medical home model
 Covers vision, dental, medications
 50% of babies born in Alabama are born to
mothers covered by Medicaid
 Boosts economic development – paying
providers in excess of $20 million annually in
more than two-thirds of the state’s counties
by drawing down federal $$ in 3:1 match
Cash
 Choose no coverage and pay cash
 Choose catastrophic coverage and pay
cash for visits
 Do not qualify for insurance at work
and do not meet income requirements
for Medicaid or CHIP
Group Insurance
 Many companies write policies for large
groups of employees
 Premiums paid by employer and
employee
 Benefits vary from poor to complete
coverage
Underinsured
 Insurance that provides some benefits,
frequently vaccines are NOT covered
– This is most costly part of care for
children
 ADPH has two-tiered system for vaccines
– Medicaid and no insurance are covered
by the Vaccines for Children Program
– Underinsured cannot get most
expensive vaccines through this
program at their doctors’ office
Corporate self insurance
 Company official decides what services
and care will be covered and at what
rate
– May subcontract for medications to mailorder pharmacy
– Restrict providers, pharmacies, etc.
HSA (Health Savings Account)
 Usually high-deductible plan
 Best for young adult with no
dependents
 Due to check-ups and vaccines, not a
good option for children
Innovations
 Some companies have HSAs to cover
medications, durable medical
equipment, etc.
 Providing well care with no co-pay to
reward well care, health maintenance
Where we need to go
 Large insurers need to know that health
maintenance—preventive care--and
medical homes save money and provide
better care.
Why is Preventive
Care Important?
For the first time in the history of civilization,
infectious diseases are no longer the number
one cause of death in the world. Now it is
heart disease and cancer! Children who are
frequently counseled about the
consequences of tobacco are less likely to
smoke. Hypertension, obesity and asthma
identified and treated early prevents or delays
heart attack, end-stage kidney disease,
diabetes and chronic lung disease.
Well Child Care
 Well-child care truly is one of the greatest
values in medicine. The cost of AAPrecommended preventive pediatric care for
a healthy child from the first birthday to
the second, for example, is about $600 for
the year. This is a bargain. It includes
three well-child visits, physical exam,
growth charting, blood pressure
screenings, vision and hearing screenings,
developmental/behavioral assessments,
and vaccines.
The Case for Health Promotion &
Preventive Care: Immunizations
 Vaccines are cost-effective and cost-
saving.
 Routine childhood vaccination program
saves nearly $10 billion in direct
medical costs and $43 billion in
societal costs for every birth cohort
 Lack of coverage and adequate
payment for vaccine and its
administration are impacting access.
The new children’s diseases
 Child abuse and neglect
 Early dental caries
 Obesity
 Mental health disorders – 20-25%
 School failure
 Adolescent pregnancy
 HIV and AIDS
 Substance abuse including tobacco
 Juvenile crime/violence
The Case for Health Promotion &
Preventive Care: Developmental
 Developmental disabilities can occur at
any time in childhood and can result in
delayed learning, autism, and other
physical or mental impairment
 Approximately 17% of children 17 years
or less in US have at least one
developmental disability
 Children with developmental disabilities
who are identified and treated early
have better long-term outcomes.
The Case for Health Promotion
and Preventive Care
Benefits for preventive care should also include:
 Screenings for developmental delays, hearing,
vision, blood lead levels
 Pediatric obesity services including, but not
limited to, clinical assessment, prevention,
evaluation and treatment of obesity by the
primary care physician to avoid more expensive
future costs for treatment of adult obesity and
related health risks.
 Counseling, coordination of care, and
consultations to enable pediatricians and other
primary care providers to provide primary
mental health services
Bright Futures Guidelines
 Comprehensive health supervision
guidelines
 Developed by multidisciplinary child
health experts
 Provide framework for well-child care
from birth to age 21
 Present single standard of care based on
health promotion and disease prevention
model
 Replaces former American Academy of
Pediatrics Guidelines for Health
Supervision
Bright Futures Guidelines
 Bright Futures recommends 31
visits between birth and 21 years of age
to include comprehensive health
assessments, age-appropriate screening,
counseling, preventive medication and
treatment, parent/child education and
anticipatory guidance.
 Bright Futures also recommends a
prenatal visit
 Ideally, care is provided in the medical
home.
The Medical Home
 The American Academy of Pediatrics
(AAP) believes that the medical care of
infants, children, and adolescents ideally
should occur in a medical home in which
care is accessible, continuous,
comprehensive, family centered,
coordinated, compassionate, and
culturally effective.
 It should be delivered or directed by
well-trained physicians who provide
primary care and help to manage and
facilitate essentially all aspects of
pediatric care.
The Medical Home
 The physician should be known to the
child and family and should be able to
develop a partnership of mutual
responsibility and trust with them.
 In contrast to care provided in a
medical home, care provided through
emergency departments, walk-in clinics,
and other urgent-care facilities, though
sometimes necessary, is more costly
and often less effective.
Business Case for
Preventive Care
 The National Business Group on Health
(NBGH) developed Plan Benefit Model
 Adapted clinical guidelines from
professional medical organizations,
healthcare groups and federal health
agencies, including Bright Futures
 Applied actuarial analysis to the Plan
Benefit Model components, including
preventive care
 New movement to embrace PatientCentered Medical Home
Patient-Centered Primary Care
Collaborative (www.pcpcc.net)
Coalition of:
Major employers
Consumer groups
Primary care physicians
Mission: To advance the patientcentered medical home
Business Case for
Preventive Care
 Preventive services can prevent or
reduce the need for treatment
 Screening is less expensive than
treatment, resulting in saving
healthcare dollars
 BOTTOM LINE: Early investment in
child healthcare reaps larger returns
for financers of healthcare.
Business Case for
Preventive Care
AND…
 The added time and stress associated with
caring with a child with a medical
condition may result in employees
experiencing:
 Higher medical claims for parent and child
 Lower productivity at work (parent) and
school (child)
 Increased absenteeism
 Early exit from the workforce
Contact Information
Pediatrician Name, MD, FAAP
Street Address
City, AL Zip
Email Address
For more information:
Alabama ChapterAmerican Academy of Pediatrics
334/954-2543
[email protected]
www.alchapaap.org
Thank you
for your attention!