Children’s health and well-being are affected by their surroundings – the schools they attend, the places they play, the food they eat, and their relationships with the adults around them. In 2021, Nemours Children’s Health founded the Whole Child Health Alliance to help advance the concept of “whole child health.” Learn how this group of children’s hospitals, health insurance companies, think tanks, advocacy organizations, and others work together to address the multi-faceted needs of kids through health care delivery and financing approaches that keep the “whole child” in mind.
Guests:
Daniella Gratale, MA, Associate Vice President, Federal Affairs, Nemours Children’s Health
Joshua Traylor, MPH, Executive Director, Center for Health and Research Transformation
Jim Perrin, MD, Professor Emeritus of Pediatrics, MassGeneral Hospital and Harvard Medical School
Host/Producer: Carol Vassar
Announcer:
Welcome to Well Beyond Medicine, the world’s top-ranked children’s health podcast produced by Nemours Children’s Health. Subscribe on any platform at nemourswellbeyond.org or find us on YouTube.
Carol Vassar, host/producer:
Each week we’ll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor’s office. I’m your host, Carol Vassar, and now that you’re here, let’s go.
Music:
Let’s go…well beyond medicine.
Carol Vassar, host/producer:
It may be obvious, but if you talk to any parent or caregiver, they’ll tell you that raising a child is not easy, never has been. The child’s health and well-being are always at the forefront of a parent’s mind. Is my child eating right? Are they healthy? Are they safe? Are they doing well in school? Are they getting along with others? Are they happy? Not only are these the kinds of questions that keep parents up at night, but they’re also the kinds of questions debated, discussed, and acted on by members of the Nemours Whole Child Health Alliance. Founded in 2021, The Whole Child Health Alliance is a group of children’s hospitals, health insurance companies, think tanks, advocacy organizations, and others working together to address the multifaceted needs of kids through healthcare delivery and financing approaches that keep the whole child in mind.
This episode begins a two-part series focused on whole child health and the Whole Child Health Alliance. We’ll also hear about a couple of on the ground examples, one from Massachusetts and one from Washington State, demonstrating the art of the possible for whole child health. Joining me right now are two members of the founding Whole Child Health Alliance Steering Committee, Daniella Gratale, the Associate Vice President of Federal Affairs at Nemours Children’s Health, and Josh Traylor, the Executive Director of the Center for Health, Research, and Transformation.
And we begin our conversation with a fundamental question, what is whole child health? Here’s Daniella Gratale.
Daniella Gratale, Nemours Children’s Health:
So to me, whole child health really means children and youth having the opportunity to reach their full potential and thrive, and that encompasses a number of domains, so certainly physical health, but I think especially over the past two years, we’ve been very thoughtful about mental, emotional, and behavioral health for children and youth. It’s also reaching their developmental milestones and key educational milestones, addressing social needs, so that could be everything from access to nutrition to high quality child care, and then finally promoting positive relationships with caregivers, so it’s really thinking holistically about all those domains and how we can help to support them.
Carol Vassar, host/producer:
Now as we look at the Whole Child Health Alliance, I’m curious as to why was this established to begin with back in 2021?
Daniella Gratale, Nemours Children’s Health:
So the Alliance came together as a group of multi-sector stakeholders that really wanted to be thoughtful about how can the healthcare sector work with other partners like schools, community-based organizations, food banks, to create a context in which families are supported and children do have this opportunity to thrive. So the Alliance is really focused on the nexus of the way we deliver care and then how we pay for it and how we coordinate across all the sectors to really achieve alignment and synergy so that we can help children and families have this opportunity to thrive.
Carol Vassar, host/producer:
How does this manifest? In other words, what have you been working on most recently?
Daniella Gratale, Nemours Children’s Health:
The Alliance big picture is thinking about how do we disseminate innovation and best practices that is already occurring, and then how do we inform policy to create new opportunities to support whole child health?
So we started out with defining the core elements of whole child health and then thought, “We have to make this more real.” So we’ve done case studies. So we started with four case studies on the state side, and we’re very lucky to be able to hear from Washington and Massachusetts as part of this podcast, and right now we’re working on three provider case studies as well. So that’s in that kind of the category of disseminating innovation. On the category on policy and advocacy, the Alliance itself does not endorse legislation, but individual members do come together. So we’re doing meetings on Capitol Hill with individual Alliance members who choose to participate on the Kids Health Act, for example. And I know we’ve done a podcast on that as well. It’s bipartisan, bicameral legislation. So we’re really trying to think about how can we identify what whole child health is, bring out examples of it, and then try to inform policy moving forward to help support it?
Carol Vassar, host/producer:
Now Josh, you come from a background in payment transformation. Talk about what brought you to the Whole Child Health Alliance.
Josh Traylor, Center for Health and Research Transformation:
I’m a public health person by training in MPH, and I think that working in the pediatric health or child health base is really interesting because it highlights a lot of the challenges with doing reform efforts in healthcare at large. And in particular, we have so much research, and we know so well the positive impacts of investment in child health on the long-term development and well-being of kids and the families and communities, but it’s really hard to focus on doing innovative work with this population because so much of our energy and effort tends to be focused on other groups, folks with acute needs and multiple chronic conditions.
And sometimes I think it is difficult to figure out where investments in pediatric health fit and to address the wrong pocket problem, namely an investment in pediatric health often pays off in other areas like education or job attainment or reduced involvement with the juvenile justice system, especially for behavioral health situations, but that doesn’t ultimately accrue back to the healthcare system, so I think there are some really clear challenges that working in the pediatric health space highlights, and I’m excited to be invited to join this Whole Child Health Alliance effort because the folks sitting at this table are taking a very holistic view of the impacts that investments in pediatric health can have both on children directly, but also on their families and their communities.
Carol Vassar, host/producer:
Now, if I’m hearing you correctly, you’ve outlined some of the challenges in applying what is known as value-based care or innovative financing approaches to pediatrics. Are there other challenges that you wanted to highlight here?
Josh Traylor, Center for Health and Research Transformation:
Yes, there are many. The attention when we talk about innovative work, payment reform, and care delivery form in healthcare often is focused on the most acute and high need patients, and children tend, by and large, to be viewed as young and healthy and relatively straightforward cases. We know that that’s not universally true. There are certainly many children that have complex needs, but trying to justify the focus and the investment on the population of kids who are generally healthy and well can be challenging, especially for state Medicaid programs that have so many competing demands on their time and on their staffing and on their resources. And so I think that’s one big challenge here.
The other one is that oftentimes there’s excellent data and studies that talk about the impact of investments in early childhood especially, and the return on investment for lack of a better term there, but those studies are not necessarily parsing out the returns from the point of view of the healthcare system versus the educational system versus employment success later on in life, and I think that is an ongoing challenge.
A third area I’ll highlight is data, and having good reliable data on children and especially on children and their families is pretty difficult. So in the Medicaid space in particular, that data is collected, in many states, by Medicaid managed care plans and often commercial insurers who are working with the state to implement a Medicaid program. That data then goes to the state level and then the states report that data to the federal level. In thinking about working on this at the federal level, oftentimes you can have a several year lag in data. I think that’s getting better now, but there can be a lag in data, there can be incomplete data, and if we think about a multi-generational approach to investment in pediatric health, you really need to think about not just the child, but also their mother, their father, their broader family, and sometimes we don’t have the information to appropriately be able to link and model those broader impacts.
So much of our policy work is driven by some sort of data analytic effort and not having all of that data that you need or not having the most up-to-date data is another barrier.
Carol Vassar, host/producer:
Daniella, Josh has laid out some pretty big challenges in this area, applying value-based care approaches to pediatrics. Why is it important that we work on these, overcome these challenges?
Daniella Gratale, Nemours Children’s Health:
I think it’s important to really think about what is the end that we seek to achieve, and that’s definitely healthy children who can grow up to be healthy adults. And the healthcare sector and making sure that there are financially sustainable integrated approaches that the healthcare sector and its partners are taking are really important to do that because there are so many points of contact that families have with the healthcare sector in their early years from the well visits, for example.
The healthcare sector is important because we’re also employers in the community, and we have deep relationships with all these other organizations. So the healthcare sector is very well positioned to think about how do we support children and families, but we need to make sure that we have financially sustainable approaches to do that. And it’s particularly important in pediatrics because we have such a unique opportunity there to have impact across a lifetime, across a child’s whole trajectory. So when you think about all those years of life that you can be impacting by starting with the early years, it really is a tremendous opportunity. So as we’re thinking about these integrated and aligned approaches, we really can make a difference, and these types of holistic integrated approaches are what we have highlighted in the case studies and what we’re really trying to hope to support through policy change.
Carol Vassar, host/producer:
Daniella Gratale is the Associate Vice President of Federal Affairs at Nemours Children’s Health. We also heard from Josh Traylor, the Executive Director of the Center for Health and Research Transformation.
Next, we’ll hear about a real world example of a whole child health approach that comes to us from the Commonwealth of Massachusetts. Stay with us.
Dr. Jim Perrin is a Professor Emeritus of Pediatrics at Mass General Hospital and Harvard Medical School and an advisory council member for the Whole Child Health Alliance. Dr. Perrin has been involved with developing and implementing an innovative payment model to advance whole child health in the Medicaid primary care setting. He and others involved with this project have been able to do this under what’s known as an 1115 Medicaid waiver. 1115 refers to a provision of the Social Security Act allowing states to implement pilot projects to improve Medicaid.
First, though, we spoke with Dr. Perrin about why the primary care setting is so crucial in pediatrics. Here’s Dr. Jim Perrin.
Jim Perrin, MD, Professor Emeritus of Pediatrics, Mass General Hospital and Harvard Medical School:
Primary care, both in pediatrics and medicine of course, provides an entry point, really important and ongoing entry point for children, youth, and families to healthcare and to getting themselves really in a pattern of doing well by their health and improving their health and well-being. It provides a remarkable entry point, especially in the first few years of life.
Carol Vassar, host/producer:
Now, my understanding is that the state of Massachusetts uses a tier payment model for the pediatric population. Describe, if you will, how the model works and how that differs from say, a typical fee-for-service payment model.
Jim Perrin, MD, Professor Emeritus of Pediatrics, Mass General Hospital and Harvard Medical School:
Sure. So I think actually there are two especially important innovations in the Massachusetts model that came to our 2022 1115 Medicaid waiver. The first really is this notion of tiers. So basically if a practice expands to include mental and behavioral health or to add other personnel such as school liaison staff or community health workers of the like, they actually get increased per-member per-month payment, and the state’s tried to make additional tiering funds enough to allow people actually to afford to increase that kind of staff. So the more you do that really is comprehensive and family-oriented and preventive and health promoting, the more money you get.
The other really important innovation in Massachusetts was to move from a fee-for-service methodology to instead a partial capitation model of payment. Now, what does that mean? That’s a kind of complicated idea, but it basically says that for most things or many things that you do routinely in healthcare, we’re going to provide you a global payment, a capitated rate rather than have you bill us for each individual service. That’s not true for some services, so for some services that both we in the provider community and pediatric community and the state wanted to emphasize or incentivize, we’ve kept them in a fee-for-service arrangement, and we think this is a really good way to try to innovate change in practice while making sure that children and families get the care they need.
Carol Vassar, host/producer:
When you talk about value-based care, which is what we’re talking about here in this capitation model, where is the value? How is that quantified? Where do you prove that this is working?
Jim Perrin, MD, Professor Emeritus of Pediatrics, Mass General Hospital and Harvard Medical School:
Well, I think it’s two or three things to say here. One is that when we’re talking about people under age 21, the value is not very much reflected in costs or cost savings. There are very few cost savings for children in Medicaid. There are a few here and there, but they’re really pretty minor, so mainly we talk about moving toward certain aspects of health provision, but also health outcomes over time. And we’re trying to work with the state to improve the kind of measures that are used to show those kinds of improvements in the health of populations or the child population over time.
But it’s very, very, very important to realize that when we talk about value-based care for children, it’s very different from talking about value-based care for older populations. Older populations, yes, there are substantial opportunities to save money, to provide more efficient care, and to provide better care. For children, there are many opportunities to provide better care and to make care more efficient, but there are very few opportunities to save money.
Carol Vassar, host/producer:
So the value really is in the outcomes, the positive outcomes, that families and patients, children, are ultimately seeing. Is that what I’m hearing?
Jim Perrin, MD, Professor Emeritus of Pediatrics, Mass General Hospital and Harvard Medical School:
That’s absolutely correct. That outcome, of course, may not be immediate. It may not come in 18 to 36 months, and we need to be prepared to allow consideration of outcomes that are longer in time.
Carol Vassar, host/producer:
Any early lessons? I know it’s only been in place a year, maybe a year and a half, but any early lessons? Or what are some of the barriers you’re encountering aside from payment from the larger Medicaid providers that you mentioned that might be impeding its movement forward?
Jim Perrin, MD, Professor Emeritus of Pediatrics, Mass General Hospital and Harvard Medical School:
Sure. So I think first of all, the good news is that many of our practices across the Commonwealth are actually seeing more income from their primary care services, and they’re seeing more income based on their tiers, so the tiers really do incentivize the practices to transform into serious multi-specialty or multi-disciplinary team care, including community health workers. So we do see that in many parts of the Commonwealth.
On the other hand, the way Massachusetts pays directly to its accountable care organizations, which really carry out this, varies a lot from one accountable care organization to another. So the larger ones, Boston Medical Center, University of Massachusetts Medical Center, Massachusetts General Hospital, Brigham, those ones are very big, and they’re paid essentially at the sort of large corporate level, doesn’t provide the corporate level incentives necessarily to make sure that on the ground the primary care practices are reaping the benefit of this increased investment in primary care and these new strategies, so we’re working to see that we can really make that happen at that point so that we translate these really great ideas down to the community where children and families are.
Carol Vassar, host/producer:
As other states look to implement something similar, a value-based payment model for their pediatric population in the whole child health realm, what advice would you give them, and is this model that you’ve implemented in the Commonwealth of Massachusetts scalable? Can it be brought to other states?
Jim Perrin, MD, Professor Emeritus of Pediatrics, Mass General Hospital and Harvard Medical School:
I think there’s no question that can be brought to other states, and I think we’ve seen a lot of innovation in many state Medicaid programs, and I know that this group, the Whole Child Health Alliance, has done a great job of keeping track of some of those more impressive and interesting innovations. So yes, I think as a nation in general, moves increasingly away from fee-for-service strategies to new strategies and alternative payment mechanisms. This is definitely one to look at. This is one that we think works well for children and youth as well as adults too. This is not just implemented for children and youth in the Commonwealth, it’s being used for adult patients too. We think it’s a real good strategy for moving forward and highly scalable.
Carol Vassar, host/producer:
Let’s look at what the federal government can do. What can they do to help promote, support your Commonwealth, the states in the United States in advancing whole child health model such as this or something similar?
Jim Perrin, MD, Professor Emeritus of Pediatrics, Mass General Hospital and Harvard Medical School:
So I think there are at least two ways. One is through the 1115 waiver mechanism which does provide states the opportunity to innovate, and states really can try to innovate in their payment arrangements that way. Another way, though, is in 2022, 40% of Medicaid funds nationally went in non-direct fee arrangements. That is to say there are a whole bunch of indirect Medicaid subsidies that the old one that many of us know about are the disproportionate share hospital subsidies. But most recently, the one that’s really grown are the managed care directed payment subsidies. That gives states a lot of opportunity to innovate in how they distribute funds, and they can do it to call for alternative payment mechanisms through their managed care organizations, or they can do it by asking the managed care organization to support a particular type of provider, could be a nursing home, could be a pediatric practice, could be a children’s hospital, a variety of strategies that exist at that level. Those are ones also that we ought to be looking at and thinking about how to make the best use.
Carol Vassar, host/producer:
As we talk about the turn away from fee-for-service, which has been a very difficult thing to implement across all of healthcare toward value-based care, where do you see value-based care models such as this in a year, 5 years, 10 years?
Jim Perrin, MD, Professor Emeritus of Pediatrics, Mass General Hospital and Harvard Medical School:
It’s hard to say. I mean, I think we’ve been talking about moving away from fee-for-service for many years, and if you look for example, at many of the larger Medicaid managed care organizations, most of them say that they’re doing some variation on value-based payments and moving out of fee-for-service, but we’re not sure that that’s actually being translated down to the actual provider group, the physicians and nurses and families in the ground, so I think it’s still very much a work in progress at that level, and I do think we’re facing that.
What I think is most important for children and youth is that the adult models frankly don’t work well for children and youth, and it’s partly because of this difficulty in getting short-term financial improvement in a population of people under age 21. So I think there will be a good deal of diversity and alternative payment mechanisms. Much of the innovation right now is in Medicare. It’s very hard to, frankly, use the Medicare innovations for younger populations. They just don’t work, frankly.
I do think that one of the important things as we move forward together is going to be to get the adult population to stop talking only of Medicare and commercial and the child population from talking only about Medicaid and commercial and start to realize that in the Medicare and Medicaid space, there are some really very important common opportunities for how we can move toward value-based payment.
Carol Vassar, host/producer:
Dr. Jim Perrin is a Professor Emeritus of Pediatrics at both Mass General Hospital and Harvard Medical School, and an advisory council member of the Whole Child Health Alliance.
Music:
Well beyond medicine.
Carol Vassar, host/producer:
Thanks to Dr. Perrin, Daniella Gratale, and Josh Traylor for joining us on this episode of the Nemours Well Beyond Medicine Podcast. And thanks to you for listening.
Our two-part series on whole child health continues on our next episode when we travel, virtually, across the nation to hear how a collaboration in Washington State is positively impacting pediatric mental health delivery there. Please join us.
The Nemours Well Beyond Medicine Podcast has more than 30,000 loyal subscribers. Are you one of them? If you are, thank you. If you’re not, subscribe today at nemourswellbeyond.org. You can also hear previous episodes and leave a review of the podcast or a topic idea too. That’s nemourswellbeyond.org. The podcast team for this episode includes Cheryl Munn, Susan Masucci, Lauren Teta, Steve Savino, Hannah Wagner, and Daniella Gratale. I’m Carol Vassar. Until next time, remember, we can change children’s health for good, well beyond medicine.
Music:
Let’s go…well beyond medicine.
