A new value-based payment model for Medicaid has set its sights on improving pediatric care for children with complex medical and behavioral needs.
CMS announced on Tuesday the Accelerating State Pediatric Innovation Readiness and Effectiveness (ASPIRE) Model, a pilot program that will allocate $125 million to up to five state Medicaid agencies to coordinate and augment care for youth up to 21 years old with complex conditions and those at risk of developing them.
The Medicaid agencies will be able to use the funds to coordinate physical and behavioral health, as well as community support, over eight years. The model will also use incentive payments for care teams to bolster this care coordination, as well as preventive care and quality improvements.
“The problems ASPIRE seeks to address are the same ones plaguing American health care more broadly: the focus on reaction rather than prevention, the consistent failure to treat the whole person, the confusing lack of transparency and coordination, and the perverse financial incentives that perpetuate this dysfunction,” wrote CMS Administrator Mehmet Oz, M.D., and Deputy Administrator Abe Sutton, in an announcement in STAT.
Medicaid and the Children’s Health Insurance Program (CHIP) cover about half of all children in the U.S. with complex medical and behavioral health needs or who are at risk of developing them, Oz and Sutton reported.
However, the current fee-for-service payment model has limited holistic treatment of these populations, they explained.
CMS already administers the Integrated Care for Kids (InCK) Model, a voluntary model launched in January 2020 that also targets children with behavioral and/or complex health needs enrolled in Medicaid or CHIP. Six states participate in the model, which is set to expire at the end of this year.
The Trump administration announced last year that it was considering reducing the size of InCK, as CMS terminated four other CMS Innovation Center models early. Oz and Sutton said that ASPIRE will build on InCK by “standardizing a more robust value-based payment framework that will give pediatric providers an on-ramp to greater accountability and more substantial rewards for high-quality care.”
ASPIRE will also require state awardees to establish a 24/7 advice line staffed by medical professionals who can access all relevant information on children participating in the model.
This line will be designed to help caregivers navigate care and associated paperwork through a single point of contact for condition management. Conditions targeted by the model include behavioral health conditions, substance use disorders and chronic conditions, as well as some physical, intellectual and developmental disabilities.
Additionally, ASPIRE will emphasize the use of wraparound services for targeted conditions and long-term planning to support health, productivity and financial stability as children transition to adulthood. A portion of a state awardee’s funds must be used to build infrastructure or expand access to these services.
“The results, we believe, will be transformative: less time spent filling out redundant forms and repeating the same information to six different care providers, faster progress toward health and functional outcomes, and more time for families to enjoy their higher quality of life,” Oz and Sutton wrote.
CMS will begin the application process later this year for the 10-year model, with up to five states eligible to participate.
Jacqueline LaPointe is a graduate of Brandeis University and King’s College London. She has been writing about healthcare finance and revenue cycle management since 2016.