Promoting the Well-Being of Childrenin Foster Care: The Role of Medicaid

Sheila A. PiresHuman Service Collaborative

Three Branch Institute on Child Social and EmotionalWell-Being: Meeting for State Teams

July 25, 2013Philadelphia, PA

Most children in foster care are Medicaid-eligible

Most children remain eligible for Medicaid whenthey leave foster care

• WI study – 85% remain eligible

Child welfare was not intended to be a health orbehavioral health care delivery system

Why Medicaid is Essential

Children in Foster Care Are a High Cost Medicaid Population

Represent 3.2% of children in Medicaid but 15% of childrenusing behavioral health services

Have the highest penetration rate for use of behavioralhealth services than any other aid category of children(32% of children in foster care use behavioral health services compared to 26% of children on SSI, and 4.9% TANF)

Have the highest mean behavioral health expenditures of anyaid category of children ($8,094 per child compared to $7,264 forchildren on SSI)

Have overall Medicaid mean expenditures (physical and behavioralhealth care) of $12,130 per child – costs are driven by behavioral health care

Children in foster care who use behavioral health services have costs thatare 7x higher than for Medicaid children in general

Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid: Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ;Center for Health Care Strategies

Children in Foster Care Use More Restrictive,More Expensive Services in Medicaid

More likely to use: inpatient psychiatric services,residential treatment and therapeutic group care, emergencyroom services, and psychotropic medications

Children in foster care are only one-fifth the size of theTANF population but use nearly the same amount of dollarsfor residential and group care and ER visits and 3.5 timesmore for therapeutic foster care

Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid: Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ;Center for Health Care Strategies

Children in Foster Care Have High Rates ofPsychotropic Medication Use

Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid: Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ;Center for Health Care Strategies

Are 3.2% of Medicaid child population, but nearly 13% ofMedicaid children using psychotropic medications

23% of children in foster care use psychotropic medicationspaid for by Medicaid (compared to 27% of children on SSI and4% of TANF children)

Are more likely to receive 2 or more concurrent psychotropicmedications than other aid categories of children (49% FC,46% SSI, 26% TANF)

Of children getting anti-psychotics, 42% are in foster care(42% are on SSI, 18% are TANF)

Have highest mean expenditures for psychotropic medications of any aidcategory of children ($934 FC, $916 SSI, $475 TANF)

Health Reform

Renewed interest in:Managing care for populations withchronic conditionsIntensive care coordination modelsManaging the total cost of careMoving dollars from “deep end” tohome and community basedEvidence-informed approachesData-informed approachesUse of technology“Integrated” care through capitated managed care

Pires, S. 2011. Washington DC: Human Service Collaborative

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Medicaid Re-Design and Integration Caveats

Our experience has been that –

• When physical and behavioral health dollars are integrated, there is a risk of behavioral health dollars being absorbed by physical health services

• When adult and child behavioral health dollars are integrated, there is a risk of child behavioral health dollars being absorbed by adult services

This occurs in the absence of appropriate customization.

Pires, S. 2011. Washington DC: Human Service Collaborative

Regardless of Medicaid managed care design (integrated, carve out), certain design elements and contractual specifications enhance value for foster care population

See virtually all of these elements/specs looking across the states but not all in any one state (has been incremental process)

Tend to see more in states with behavioral health carve outs than integrated designs• Documented initially in 10-year Health Care Reform Tracking Project

(1997-2003)• Examples in “Making Medicaid Work for Children in Child Welfare” (2013)

Customization within Medicaid Adds Value for Children in Foster Care

A word about a “special benefit” for foster care population through a foster care carve out –

TANF and SSI-enrolled children need the same service array as foster care population (while prevalence rate for behavioral health is higher for children in foster care than TANF population, there are many more TANF children)

Children don’t stay in foster care forever (median LOS in 2011 was 13.2 mos.) but tend to remain Medicaid-eligible and in need of services

Can lead to unintended consequence of parents having to relinquish custody to access care (especially an issue for children with serious behavioral health challenges)

Service Coverage: Change the Trajectory of High End Service Use

Cover a broad array of behavioral health in-home andcommunity-based services (May 7, 2013 CMCS and SAMHSA

Informational Bulletin)AZ: In-home services; respite; life skills training; family andyouth peer support; therapeutic foster care; case management;

supported housing; supported employment; mobile crisisintervention; crisis stabilization; transportation; Wraparound

process

MA: In-home services; family peer support; mobile response; therapeutic mentoring; behavior management therapy and

behavior therapy monitoring; intensive care coordination usinga Wraparound approach

NJ: Mobile response and stabilization; therapeutic group home care;treatment homes/therapeutic foster care; intensive care management;

Wraparound process; behavioral assistance; intensive in-home/communityservices; transportation; youth support and development

Service Coverage:Change the Trajectory of Use of Inappropriate Care

Cover evidence-based practices (May 7, 2013 CMCS and SAMHSA Informational Bulletin)

e.g. Trauma-Focused Cognitive Behavioral TherapyMultisystemic Therapy, Functional Family Therapy,

Multidimensional Treatment Foster Care, Parent-Child Interaction Therapy, Integrated Co-Occurring Treatment

Dollars needed for training, capacity-building, quality and fidelity monitoring

Trauma-Informed EPSDT Screening and Early Intervention:Change the Trajectory of High End Service Use

(3/27/13 CMCS and SAMHSA Informational Bulletin and 7/11/13 SMD Letter)

Incorporate state child welfare requirements for physical, behavioral and dental health screens within specified

timeframesAZ: Urgent response requiring behavioral health

screen within 72 hrs of entering care and “fast track”linkage to services

Mandate use of standardized screening tools and inclusionof behavioral and developmental (not only physical health) screens

MA: Enhanced screening rate

Require inter-periodic screens when child enters foster care, orchanges placement, or tied to length of stay in foster care

Psychotropic Medications:Change the Trajectory of Inappropriate Use

(August 24, 2012 CMCS Informational Bulletin and November 23, 2011 Tri-Agency Letter)

Track and monitor outlier use, e.g. too young, too many, too much, (growing number of states) –

interface with Drug Utilization Review Board

Consultation to prescribers, including primary care providers (MA, VT)

Orient MCOs to state’s informed consent and assent policies in child welfare

Provide coverage and training for treatment alternatives (aggression, sleep disorders)

Primary Care: Medical Home

Every child has an identified primary care provider

Annual well-child visit

Metabolic monitoring if on psychotropic medications

Asthma protocols

Electronic health record – health passport

Analysis of Medical Home Services for Children with Significant Behavioral Health Conditions

“All behavioral health conditions except ADHD associated with difficulties accessingspecialty care through medical home”

“The data suggest that the reason why services received by children and youth with behavioral health conditions are not consistent with the medical home model

has more to do with difficulty in accessing specialty care than with accessingquality primary care”.*

*Sheldrick, RC & Perrin, EC. “Medical home services for children with behavioral health conditions”. Journal of Developmental Pediatrics, 2010 Feb-Mar 31 (2) 92-9

Need for more intensive care coordination approaches forchildren with significant behavioral health conditions

Medicaid-Related Opportunities/Challenges in the Affordable Care Act

• Coverage of young adults in foster care to age 26 (2014)Addiction and mental health treatment accounted for 42% of hospital claimsfor 19-25 year olds enrolled in their parents’ health plans in 2011 through ACA (Employee Benefit Research Institute, April 2013)

• 1915 i home and community-based services (lessstringent than institutional level of care criteria of 1915 chome and community-based waiver)

• Section 2703 Health Homes (“chronic conditions” caninclude significant behavioral health challenges; cannotlimit by age, but can customize approach for children)

For Family Members Who Are Not Medicaid-Eligible

• Access to insurance coverage through HealthExchanges• Elimination of annual and lifetime limits on benefits• No denial of coverage for pre-existing conditions• No cost-sharing/co-pays for certain preventive services(based on IOM recommendations; important for Medicaid populations as well)

• Well-woman visits• Gestational diabetes screening• HPV DNA testing• Counseling for sexually transmitted infections• HIV screening and counseling• Contraception and contraceptive counseling• Breastfeeding support, supplies and counseling• Interpersonal and domestic violence screening and counseling

Lessons from States: Customization for Children in Foster Care in Medicaid

Medicaid service delivery and payment models need to reflect attention to state child welfare, Medicaid and behavioral health system policies and goals –

Collaborative planning, design, implementation needed

Explore potential for Medicaid match from child welfare –most children are Medicaid eligible; many services paid for bychild welfare are Medicaid-allowable (NJ, AZ, MI)

State agencies need to approach implementation in partnership with managed care entities

Example: Addressing Parental Substance Abuse

Medicaid• Cover substance use disorder services (adults who are eligiblefor Medicaid can access)• Cover evidence-informed interventions for Medicaid child that incorporate family engagement, education and support• Cover 1:1 crisis stabilizers for child (WI)• Cover family and youth peer support

Child welfare• IV-E waiver (for adults who are not Medicaid-eligible and fornon-Medicaid covered services)

Mental Health and Substance Abuse• May manage Medicaid match for BH services• Block grant funding for adults not Medicaid-eligible or servicesnot covered by Medicaid

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System Re-Design

Child Welfare

Alternative to out-of-home care high costs/poor outcomes

Juvenile Justice

Alternative to detention-high cost/poor outcomes

Medicaid

Alternative to IP/ER/PRTF; multiple psychotropic meds

Education

Alternative to out-of-schoolplacements, high special ed costs

Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

Aligning Incentives Across Agencies

At 12, Jacob was removed from his father’s home due to neglect and was placed with an aunt in another town. Jacob began using drugs and skipping school. His aunt talked to her child welfare case worker about getting Jacob substance abuse counseling and also thought that a male adult mentor would be good for him. However, traditional Medicaid did not cover substance abuse services or therapeutic mentors, and the child welfare system’s budget had been cut, making access to these services through child welfare also difficult. Jacob became increasingly angry and aggressive toward his aunt, and after threatening her with a knife, was held at the juvenile detention center. While there, Jacob attempted suicide. He was hospitalized in an adolescent psychiatric unit for a week, placed on psychotropic medications, and discharged to a residential treatment center after his aunt refused to take him back without community-based services. Jacob remained in the residential facility for nine months, and was then discharged to a foster home. The one-year cost of his detention, hospitalization, medications and residential stay totaled $67,900, $48,000 of which was paid for by Medicaid.

Contrast Jacob’s story with that of Jeremy, also removed from home at age 12 and placed with a relative, and having a similar history of substance use, skipping school, anger, aggression, and alternating threats to kill his grandmother or himself. Jeremy, however, was enrolled in a Medicaid waiver program allowing access to substance abuse treatment, therapeutic mentoring, and a Wraparound process that provided him with a care coordinator and his grandmother with a family partner to provide peer support. They were both involved in a structured, strengths-based Wraparound process to find community-based approaches and solutions to the problems Jeremy was experiencing. The waiver services Jeremy and his grandmother received over the course of a year – therapeutic mentoring, substance abuse counseling, and Trauma-Focused Cognitive Behavioral Therapy for Jeremy, family peer support for his grandmother, care coordination, and use of a small amount of flexible funds to pay for a boxing gym membership paid for by child welfare totaled $21,740 in costs to Medicaid. Jeremy remains in the community with his grandmother.

*Note. These are not actual case vignettes; they are representative to illustrate the differences for children as a result of state efforts to strengthen Medicaid for children in child welfare.

At 12, Jacob was removed from his father’s home due to neglect and was placed with an aunt in another town. Jacob began using drugs and skipping school. His aunt talked to her child welfare case worker about getting Jacob substance abuse counseling and also thought that a male adult mentor would be good for him. However, traditional Medicaid did not cover substance abuse services or therapeutic mentors, and the child welfare system’s budget had been cut, making access to these services through child welfare also difficult. Jacob became increasingly angry and aggressive toward his aunt, and after threatening her with a knife, was held at the juvenile detention center. While there, Jacob attempted suicide. He was hospitalized in an adolescent psychiatric unit for a week, placed on psychotropic medications, and discharged to a residential treatment center after his aunt refused to take him back without community-based services. Jacob remained in the residential facility for nine months, and was then discharged to a foster home. The one-year cost of his detention, hospitalization, medications and residential stay totaled $67,900, $48,000 of which was paid for by Medicaid.

Contrast Jacob’s story with that of Jeremy, also removed from home at age 12 and placed with a relative, and having a similar history of substance use, skipping school, anger, aggression, and alternating threats to kill his grandmother or himself. Jeremy, however, was enrolled in a Medicaid waiver program allowing access to substance abuse treatment, therapeutic mentoring, and a Wraparound process that provided him with a care coordinator and his grandmother with a family partner to provide peer support. They were both involved in a structured, strengths-based Wraparound process to find community-based approaches and solutions to the problems Jeremy was experiencing. The waiver services Jeremy and his grandmother received over the course of a year – therapeutic mentoring, substance abuse counseling, and Trauma-Focused Cognitive Behavioral Therapy for Jeremy, family peer support for his grandmother, care coordination, and use of a small amount of flexible funds to pay for a boxing gym membership paid for by child welfare totaled $21,740 in costs to Medicaid. Jeremy remains in the community with his grandmother.

*Note. These are not actual case vignettes; they are representative to illustrate the differences for children as a result of state efforts to strengthen Medicaid for children in child welfare.

Illustrating the Impact of State Efforts: Jacob and Jeremy*

Federal Medicaid Guidance

7/11/13 State Medicaid Director’s Tri-Agency Letter onTrauma-Informed Treatment http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-07-11.pdf

5/7/13 Informational Bulletin on Coverage of Behavioral Health Services for Children,Youth and Young Adults with Significant Mental Health Conditionshttp://www.medicaid.gov/federal-policy-guidance/downloads/CIB-05-07-2013.pdf

3/27/13 Informational Bulletin on Prevention and Early Identification of MentalHealth and Substance use Conditionshttp://www.medicaid.gov/federal-policy-guidance/downloads/CIB-03-27-2013.pdf

8/24/12 Informational Bulletin on Resources Strengthening the Management of Psychotropic Medications for Vulnerable Populationshttp://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-08-24-12.pdf

11/21/11 State Medicaid Directors Tri-Agency Letter on Appropriate Use ofPsychotropic Medications Among Children in Foster Carehttp://www.medicaid.gov/federal-policy-guidance/downloads/SMD-11-23-11.pdf

Resources

Making Medicaid Work for Children in Child Welfare:Examples from the Fieldhttp://www.chcs.org/usr_doc/Making_Medicaid_Work.pdf

Customizing Health Homes for Children with SeriousBehavioral Health Challengeshttp://www.chcs.org/usr_doc/Customizing_Health_Homes_for_Children_with_Serious_BH_Challenges_-_SPires.pdf

Psychotropic Medications Quality Improvement Collaborative:Improving the Use of Psychotropic Medications Among Children in Foster Carehttp://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1261326

CHIPRA Care Management Entity Quality Collaborativehttp://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1250388

For further information, contact:

Sheila A. Piressapires@aol.com