December 1, 2006
Melinda K. Abrams, Neva Kaye, Jennifer May, M.P.H.
N. Kaye, J. May, and M. Abrams, State Policy Options to Improve Delivery of Child Development Services: Strategies from the Eight ABCD States, National Academy for State Health Policy and The Commonwealth Fund, December 2006
Early childhood experiences influence brain development, establishing neural connections that provide the foundation for language, reasoning, problem solving, behavior, and emotional health. Developmental delays are prevalent in young children, especially low-income children, and are significantly under-detected. Many young children are not identified with developmental problems until school entry or until they demonstrate school failure. Although more than 95 percent of young children see a child health care clinician in the first three years of life, most of these clinicians are missing opportunities to detect developmental problems, counsel parents of young children about developmental issues, or refer children to needed services in the community. Fortunately, there are health care delivery and policy options that can be adopted to increase the detection of children with developmental problems as well as facilitate access to assessment and treatment services for those children and families in need of follow-up care.
Since 2000, the National Academy for State Health Policy (NASHP) and The Commonwealth Fund have conducted two state learning consortia dedicated to improving the delivery of child development services to young children who are Medicaid beneficiaries. The work of the eight Assuring Better Child Health and Development (ABCD) states has shown that state policies, especially Medicaid policies, can effectively promote improvements in the quality of preventive and developmental services provided to young children. This paper provides a starting point for states seeking to identify and implement policy improvements to achieve two main objectives:
- improve the identification of young children with or at risk for developmental delays through promoting use of an objective, standardized screening tool; and
- improve families' access to follow-up services, including assessment, referral, and care coordination.
The policies that govern the operation of any state program can be divided into three groups—policies that define what services the program will cover for which people (coverage), those that establish how much the program will pay for a qualified service (reimbursement), and those that establish how services will be delivered (performance). The paper presents specific policy improvements that emerged from efforts of the eight ABCD states that can serve as models and inspiration for states interested in improving developmental services for young children. An overview and some examples of policy changes in the three areas are listed below.
Improving program coverage (eligibility and benefits). Most of the policy improvements focused on changes to covered benefits instead of eligibility. The most frequently reported improvement to benefit coverage was to clarify the state's expectations to individual providers (including pediatricians) to encourage the use of formal, valid screening tools as part of an Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) screen. The most frequently reported eligibility improvement was to clarify that children with specific mental health problems were eligible for the state's Early Intervention (Part C) program. Some specific examples include:
- Minnesota, Utah, and Illinois changed their Medicaid provider manuals to encourage clinicians to use a standardized developmental screening instrument during well-child visits.
- North Carolina Medicaid changed its EPSDT requirements to require primary care providers to use a formal, validated developmental screening tool at selected well child visits.
- Illinois Medicaid modified its contracts with managed care organizations to require that providers use developmental screening instruments (general developmental, social-emotional, and maternal depression) at age-appropriate preventive care visits.
- Iowa and Washington developed encounter forms to facilitate structured surveillance of young children for developmental problems.
- Illinois' Part C program clarified that a child can receive Early Intervention Services if his or her parent, or other primary caregiver, has been diagnosed with a severe mental disorder, including perinatal depression.
Improving Reimbursement. Improvements to reimbursement policies to promote developmental services include both how much the program pays for a service, as well as how payment is structured. The most frequently reported reimbursement policy improvement among the ABCD states relates to clarifying that providers (including primary care clinicians) can bill for conducting a developmental screen with a formal and valid screening instrument. Some specific examples include:
- Illinois, Iowa, and Minnesota have clarified that primary care physicians who use a standardized developmental screening tool may bill for that service under CPT code 96110.
- Minnesota Medicaid plans to pay a financial incentive to contracted health plans in 2007 for increasing use of objective general developmental screening tools (for children under age 7) and mental health screening tools (for children under 21 years of age.)
- Illinois clarified that pediatricians may bill Medicaid for screening mothers for perinatal depression and, if the mother is not herself eligible for Medicaid, Illinois allows the screening to be billed as a risk assessment for the infant, under the infant's identification number for up to one year postpartum.
Improving Performance. States can change a number of policies to promote improved performance by physicians and others who provide developmental services to young children. These changes range from requiring managed care organizations to embark on quality improvement projects on developmental screening, to developing processes to ensure feedback from follow-up service providers to the primary pediatric clinician. Many states also implemented policies to support measuring performance in delivering child development services. Specific state examples include:
- In Minnesota, three agencies—Medicaid, Children's Mental Health, and Early Intervention—jointly established standards for developmental and behavioral health screening of young children. The standards call for use of common screening instruments across systems and are publicly announced on the state's website.
- Illinois and Utah Medicaid both required contracted health plans to conduct Performance Improvement Projects (PIPs) designed to support children's referral to follow-up services (Illinois) and coordination of care (Utah).
- Minnesota, Illinois, and North Carolina all 'unbundled' the procedure code for standardized developmental screening from the well-child visit so that state officials can track an overall screening rate as well as the screening rate of individual health plans or providers.
Several factors led the ABCD states to implement policies to improve developmental services for young children. The most common and critical factors associated with each state's success are:
- a strategic plan (clarity about goals, objectives, and policy priorities);
- broad stakeholder participation (making sure that leadership from all potentially affected agencies are actively engaged from the beginning);
- grounding proposed improvements in experience (pilot-test new ideas with local physician practices, collect data to show progress over time), and
- creating opportunity (build on complementary state and local initiatives).
Collectively, the ABCD states changed state statutes, state regulations, contracts, provider manuals, Web sites, and other documents that define state policies designed to improve the delivery of child development services. They have also changed eligibility and claims processing systems to implement the policies described in the documents, conducted quality improvement projects designed to assess performance and foster change, and helped providers better understand new and existing policies. The ABCD experience has yielded a plethora of policy models that can serve as examples or inspiration for other states interested in improving preventive care for young children.