As we move toward a system of value-based care where the focus is on high quality, cost-effective care of populations, payors are setting rates per member per month that are designed to maximize the preventive health aspects of a care team rather than the costs of acute illnesses. Yet nowhere are preventive strategies more needed and yet often neglected due to more acute illnesses that arise than in children with medical complexity (CMC). To remedy this need to prioritize keeping CMC healthy, community health care teams have been created made up of interprofessional health care providers whose goal is to work together to improve wellness in these patients while controlling total cost. Unfortunately, because these children require far more services than might be anticipated in setting a monthly rate, members of the care team often go above and beyond to better coordinate the care of these children—with efforts that are important but currently non-billable because of their uniqueness for an individual child. So just how many of these services are non-billable? Ronis et al. (10.1542/peds.2017-3562) answer that question with their study of 208 CMC and their 53,148 unique non-billable care coordination activities that various staff documented in terms of time spent in these activities. While dieticians accounted for the most non-reimbursed costs (26%), MDs, NPs, RNs, and social workers also incurred such costs to the tune of a median non-reimbursable 2.3 hours of work per child per month. The amount of time spent in non-reimbursable work was greater for CMCs in their first month of needing care-coordination services (6.7 hours per month) and accounted for a cost of $145 to $210 per child per month.
So what can we do to improve the reimbursement of these care-coordination activities? We asked Drs. Ryan Coller and Mary Ehlenbach, experts on caring for children with medical complexity at the University of Wisconsin to provide an accompanying commentary (10.1542/peds.2018-2958). They point out that the estimates provided in the Ronis study are really the “floor” with other indirect and unaccounted for costs adding to the unfunded efforts of the care coordination process which also need to be accounted for. In addition, the quality of the care coordination should also be taken into account in considering costs—and the formation of dedicated and fully-reimbursed teams (based in children’s hospitals or in communities with agencies working together to provide the needed support CMC) may be a win-win for those who have expertise in complex care coordination, as well as for the primary care offices that may not or do not have the time to provide such coordination. Turning care over to these expert teams, this might free up more time in primary care offices to provide more time to patients without medical complexity who may not be getting the services needed because of the unfunded mandate that those with CMC require in primary care medical homes to keep them out of the hospital. Both the study and commentary offer some important insight that may help you better negotiate for your time spent caring for CMC, which in the short- and long-run will mean better care delivery to this important population of patients.
