Pediatricians often are frustrated by problems posed by managed care organizations (MCOs) that cover children and youths.
The AAP Committee on Child Health Financing determined that a collective sense of dissatisfaction could not produce constructive change unless it articulated specific changes pediatricians want to see. To meet that need, an updated AAP policy statement offers 46 recommendations in four areas of managed care arrangements to best support patients, families, clinicians, payers and society:
- access to appropriate primary care pediatricians and pediatric specialty services,
- eligibility and treatment authorization,
- quality improvement and management, and
- financing and payment.
The policy Guiding Principles for Managed Care Arrangements for the Health of Newborns, Infants, Children, Adolescents and Young Adults is available at https://doi.org/10.1542/peds.2022-058396 and will be published in the August issue of Pediatrics.
The principles not only guide the Academy’s federal and state advocacy, they also model what AAP chapters and pediatric councils can aim for when dealing with state and territory managed care plans, both Medicaid and commercial.
The AAP-endorsed principles also can be used by pediatricians who have influence with local or regional health insurers, such as those who are members of a large physician group that cares for a large number of a plan’s patient base or those who have a large share of the local market.
Bringing pediatric expertise into all the aspects of the managed care system is the theme of these principles.
Access to services, resources
Families covered by an MCO should be able to find pediatricians who are paid well enough to deliver comprehensive medical home services, including telehealth, and their staffs are paid enough to coordinate with the community resources to meet the needs of children affected by adverse experiences, social factors or special health care needs.
An MCO network needs to include subspecialists, mental health providers and hospitals with pediatric expertise even if it means contracting with providers beyond its usual geographic boundaries. Formularies of covered medications, products and devices need to be designed for the therapeutic, habilitative and rehabilitative needs of children, especially those with special health care needs.
Streamlined, transparent policies
MCO workings must be streamlined and understandable. To help families choose an insurance plan and maximize its use, MCOs should provide accurate, easy-to-understand information on the pediatricians and specialty care services families can access. Families should have input on how this information is presented. They also should have coverage for and access to urgent care without administrative delays.
All providers need understandable information on how they will be paid and what coverage their families have. Their ability to become credentialed with an MCO should be streamlined.
Pediatric expertise critical
Panels of individuals with pediatric expertise should create and review MCO policies on medically necessary services and authorization for health care services.
In light of families’ growing needs for mental health services, MCO payment policies should take into account pediatricians’ skills as well as the need for a stronger, adequately paid workforce of child psychologists, psychiatrists and counselors. MCOs should avoid “carving out” mental and behavioral health services to providers who are harder to access or have less experience with children and youths. It is necessary to provide payment parity between mental health and physical health services, reduce barriers to care, and promote collaboration, interprofessional consultation and integrated care models.
MCOs spend a lot of effort devising ways to identify “quality care” and creating payment-related rewards and consequences, but this effort has focused on adults, largely ignoring the special circumstances of children and youths. MCOs should involve pediatricians in the design, implementation and ongoing evaluation of quality measures appropriate for children.
Children and youths — and society in general — have the most to gain in the long term from sound policy, especially on prevention and early detection of problems. They also have the most to lose from unintended consequences of policies that pose administrative and payment barriers to families and physicians.
Children and adolescents are about 23% of the population but 100% of the future.
The recommendations in the policy statement are meant to strengthen advocates who are working to improve the ubiquitous managed care systems for a generation of children and youths.
Dr. Price is a co-author of the policy and immediate past chair of the Committee on Child Health Financing.
