Improving Child Health Outcomes: Addressing Policy Barriers to Caring for Parents in the Pediatric Setting explores a financing mechanism known as “dual reimbursement” as a potential solution to barriers that limit the availability of healthcare services for parents that could improve health outcomes for their children. Following this summary is an update on a major breakthrough that has occurred since the submission of this report which has significant implications for both the policy recommendations put forth in the report and the future of Medicaid reimbursement across the country.
A growing body of evidence documents that children’s health outcomes are directly affected by the physical and mental health of their parents or caregivers [hereafter referred to as “parents”]. In order to ensure positive health outcomes for children, it is critical for parents to receive the services they need to maintain their own health and well-being.1-4 Unfortunately, many parents, particularly in low-income families, face significant barriers to accessing healthcare services due to lack of insurance coverage, transportation and child care challenges, conflicting demands on their time, and social stigma often associated with some health issues such as mental health conditions. Many low-income parents with Medicaid-enrolled children prioritize attending the child’s visits to a pediatrician, but often do not seek out healthcare services for themselves.
Intergenerational family services in healthcare, sometimes referred to as “dual-generation” or “two-generation” services, are a potential solution to address many of these barriers to care for parents. Intergenerational family services include screening and treatment services that address conditions or behaviors of the parent that can impact the health of their children. One method of delivering this type of care is by providing direct screening, treatment and referral services to parents in the pediatric setting during their children’s healthcare visits. This practice could be used to capture the often missed opportunity to improve the well-being of entire families by eliminating some of the accessibility and stigma barriers, and reaching parents in healthcare settings where they are more likely to go.
Some of the services that could be provided to parents in the pediatric setting, which are known to have an impact on children’s health outcomes, include:
- Tobacco Screening and Cessation Services
- Immunization Services
- Obesity Screening and Treatment
- Substance Use Screening and Treatment
- Mental Health Screening and Treatment
Barriers to the implementation of direct care intergenerational family services exist at multiple levels within the health system. First, many parents do not have the same access to health coverage as their children, and some pediatric providers report concern about lack of reimbursement for the time and administrative costs of providing care for a child’s parent. Second, providers and health networks cite a number of practice-level challenges that prevent the implementation of this strategy. For instance, some pediatric providers report concerns about their ability to recognize and treat conditions for adults, uncertainty about effective referral systems, and other clinical and administrative issues.5
This report focuses exclusively on the financial obstacles to providing intergenerational services. Specifically, it explores dual reimbursement—allowing providers to bill certain services for adults under the child’s health insurance—as one potential solution to the reimbursement challenge, particularly for families on Medicaid. The practice-level barriers are beyond the scope of this paper. Researchers, providers and administrators at the Children’s Hospital of Philadelphia (CHOP), like several other health systems, are working to address these challenges and develop best practices for the implementation of intergenerational family services. This paper therefore serves as a companion piece to this ongoing body of work and is intended to help inform and make possible the provision and payment of intergenerational family services in the pediatric setting.
Renewed emphasis on preventive healthcare within the Affordable Care Act and recent attention to the importance of maternal depression screening at both the federal and state levels create a window of opportunity for taking steps to improve access to intergenerational family services. This report utilizes a case study of state Medicaid plans that have implemented dual reimbursement methods for maternal depression screening in order to identify ways this reimbursement method can be expanded to apply to additional types of services in more states.
Seven states—Illinois (2006), Minnesota (2010), Virginia (2010), North Dakota (2011), South Carolina (2013), Colorado (2014), and Ohio (2016)—allow and encourage the use of dual reimbursement for maternal depression screening for pediatric Medicaid providers. In these states, providers are able to provide this screening service for new mothers during their child’s healthcare visits, and can bill the service to the child’s Medicaid ID.
This method of reimbursement:
- Eliminates the challenge of offering the service to mothers who are uninsured or covered by a plan that is not accepted in the pediatric setting;
- Helps to reach mothers who would not otherwise be able or willing to seek out care for themselves; and
- Alleviates provider concerns about being adequately reimbursed for the time and resources expended in order to offer this service.
The decision to utilize this financing mechanism lies with the state. Some state laws clearly provide the authority to do so, and these state Medicaid agencies can issue Medicaid guidelines through administrative rules and regulations to establish the specific services (screenings, tests, treatments, and other products or services) and billing procedures that are to be included under the benefit. In other cases, legislative action may be needed to add new benefits to the Medicaid fee schedule that had not previously been covered by the state Medicaid program. Given this structure for establishing specific Medicaid benefits, the process of adding dual reimbursement for parental healthcare services in the pediatric setting will vary depending on the existing legislative authority for benefits, and specific rules for providing and paying for those benefits, in each state.
This report offers recommendations for state- and federal-level actions that can help to increase the use of dual reimbursement methods to improve access to healthcare services for parents in the pediatric setting and ultimately improve child and family health outcomes.
State Medicaid agencies should work to incorporate dual reimbursement mechanisms for maternal depression screening into their fee schedules. After assessing the existing state Medicaid authority:
- Medicaid agencies in states with existing legislative authority should issue administrative rulings and establish guidelines explicitly including reimbursement for maternal depression screening, and instruct pediatric providers to bill for the service under the child’s Medicaid ID when the screening is provided during the child’s visit.
- State Medicaid agencies should collaborate with local American Academy of Pediatrics chapters for support in developing new and amended guidelines, and point to dual reimbursement methods in other states as models for implementation.
- States without the existing authority to cover maternal depression screening in the context of improving child health outcomes should consider establishing such legislative authority, making sure the focus is on improving child and family health outcomes.
State Medicaid agencies should ensure adequate reporting of maternal depression screening in order to inform future policy efforts. Guidelines should direct providers to record the use of screening tools and their outcomes in electronic health records during the visit, or report screening rates directly to the state, to support data gathering efforts that may be used to establish best practices and help providers improve health outcomes moving forward.
State Medicaid agencies should explore other adult services that could be provided in the pediatric setting using the dual reimbursement model to directly benefit children’s health outcomes.
The Centers for Medicare and Medicaid Services (CMS), the federal agency that administers Medicaid, should recommend the standardized use of dual reimbursement to all states.
- Issue a CMS letter to all state Medicaid directors providing information about the dual reimbursement models already in place, explicitly stating that no federal laws exist to prevent states from using this model, and encouraging the practice of maternal depression screening—and any other services deemed appropriate—for parents in the pediatric setting.
On May 11, 2016, CMS issued an informational bulletin titled “Maternal Depression Screening and Treatment: A Critical Role for Medicaid in the Care of Mothers and Children.” This bulletin explicitly clarifies that “since the maternal depression screening is for the direct benefit of the child, state Medicaid agencies may allow such screenings to be claimed as a service for the child.”
Discretion of whether to include maternal depression screening as a covered service for children, and whether to allow dual reimbursement to pay for it, remains with each state Medicaid agency. However, states no longer need to take the legislative step of establishing a new benefit category, as it is provided in this bulletin from CMS for all states.6
1. Sherryl H. Goodman and Ian H. Gotlib, eds., Children of Depressed Parents: Mechanisms of Risk and Implications for Treatment (Washington, DC: American Psychological Association, 2002).
2. “Parental Depression: Indicators on Children and Youth,” Child Trends Data Bank (August 2014), accessed November 1, 2016, http://www.childtrends.org/indicators/parental-depression/.
3. Eliane Siegenthaler, Thomas Munder, and Matthias Egger, “Effect of preventive interventions in mentally ill parents on the mental health of the offspring: systematic review and meta-analysis,” J Am Acad Child Adolesc Psychiatry, 51, no. 1 (2012): 8-17 e18, doi: http://dx.doi.org/10.1016/j.jaac.2011.10.018.
4. “The Health and Well-Being of Children: A Portrait of States and the Nation, 2011-2012,” U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Rockville, Maryland (2014), accessed November 1, 2016, http://mchb.hrsa.gov/nsch/2011-12/health/.
5. Marian F. Earls, “Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice,” Pediatrics, 126, no. 5 (November 2010): 1032-1039; doi: 10.1542/peds.2010-2348.
6. “Maternal Depression Screening and Treatment: A Critical Role for Medicaid in the Care of Mothers and Children,” CMCS Informational Bulletin (May 11, 2016), accessed November 1, 2016, https://www.medicaid.gov/federal-policy-guidance/downloads/cib051116.pdf.
Jennifer Gable is currently a policy associate with PolicyLab at the Children's Hospital of Philadelphia. In this capacity, she supports the development and implementation of the center’s policy agenda, and works to ensure that PolicyLab research is well-positioned to influence policy decisions at the local, state and federal level to improve the health outcomes of children and families. Jennifer completed her graduate education at the University of Pennsylvania where she earned a master of Public Administration degree at the Fels Institute of Government and a master of Bioethics degree at the Perelman School of Medicine.