Paying for Care Coordination

1. Paying for Care Coordination Deborah Allen, ScD Boston University School of Public Health Josie Thomas Parent’s Place of Maryland

3. State-at-a-Glance Chartbook The Catalyst Center • Educational and inspirational tool for state policymakers and other stakeholders • Key indicators of health care coverage for children and youth with special health care needs by state • Descriptions of promising practices in improving coverage and financing

5. For more information, contact Meg Comeau, MHA Director The Catalyst Center Health and Disability Working Group Boston University School of Public Health 617-426-4447, ext. 27 mcomeau@bu.edu www.hdwg.org/catalyst

6. Paying for Care Coordination Why it matters Strategic approach

7. Why it matters • To Families • Consistent findings that families place a high priority on care coordination • Consistent findings that there is unmet need in this area • To State Title V Program Staff • Reflects Title V expertise • Reflects Title V philosophy/systems approach • Links public health to direct care and families • To Providers • Central to medical home model • Most expensive component of medical home and thus, hardest to assure • In relation to national 2010/New Freedom agenda • May be most direct, concrete manifestation of family-centered, comprehensive, coordinated care • Key test of system success

8. Starting assumptions --before you get to what it costs • Children with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally • Any child or youth with special health care needs may need access to care coordination at some time • An organized, statewide system of care coordination is the only way to assure universal access • The medical home is the best option for a statewide system of care coordination • Care coordinators in the medical home • Can serve children and adolescents with a range of disabilities or chronic conditions effectively • Can serve children and adolescents with a range of disabilities or chronic conditions efficiently *See Chapel Hill Pediatrics presentation at http://www.medicalhomeinfo.org/model/MHLC.html

9. What have we learned from states • No state has achieved universal access to medical home care coordination yet • There may not be a single, universal formula for success • But there has been enough progress to offer lessons related to two strategic objectives • Bring down the cost • Get partners to share the cost

10. Estimating the cost of care coordination

11. Why conduct the exercise • Highlights key components of a system • Drives debate within the field about optimal approach to system • Makes statewide implementation a real possibility for policy makers

12. Relevant variables • The number of children with special health care needs in the state • Depends on population and percent CSHCN • The caseload per FTE medical home care coordinator per year • Depends on model • The salary per FTE care coordinator per year • Depends on model and local labor market

13. Case example: Washington • 2000 Census: 1,513,843 under age 18 • National CSHCN Survey: 13.7% reported to have special health care needs • That means 207,396 children with special health care needs • For purposes of estimation: 200,000 CSHCN

14. The caseload per FTE care coordinator • Depends on model and case mix • For purposes of estimation: • Washington has 500 pediatricians; about 250 family practitioners see children ->Average primary care caseload is 1.5mil/750=2,000 • If assume 1 FTE care coordinator serves typical panel of 2,000 ->Each care coordinator serves about 275 CSHCN ->System requires 750 care coordinators • If assume 1 FTE care coordinator can actually serve 600 children and that a care coordinator can work with more than one provider -> System requires 375 care coordinators

15. So let’s roughly estimate • 375 FTE care coordinators • Distributed among 750 FTE physicians • Each caring for about 530 children • To serve the state’s population of 200,000 CYSHCN

16. Washington labor market salaries For nurse manager $37.75* For staff nurse $30.54 For health educator $24.22 For medical/public health social worker $23.45 For child and family social worker $17.62 For trained paraprofessional $14.67

17. Annual salary • At hourly rate of $35 $72,800 • At hourly rate of $25 $52,000 • At hourly rate of $15 $31,200

18. System costs for 375 care coordinators with benefits @ .25 • Advanced practice RN $34,125,000 • Social worker $24,375,000 • Certified paraprofessional $14,625,000 • Plus Estimate $2,000,000 in system oversight cost\ • -> Cost is between $16 and $36 million

19. How are costs spread across system • Cost of care coordination for CYSHCN per CYSHCN • Range is $80 to $180/year • Cost of care coordination for CYSHCN per child • Range is $11 to $24/year • 24% of Washington CYSHCN are enrolled in Medicaid • Assume FFP covers ½ of 24% of total cost • State cost would be reduced by $2-$4 million

20. Does care coordination produce savings? Compare costs of care coordination to family costs • 12% of Washington families of CYSHCN exceed $1,000/year out of pocket • Assume each of those families spends exactly $1,000/year • Then those families ALONE spend $24 million/year Possible sources of savings due to care coordination • Inpatient care • Number of hospitalizations or LO • Cost of hospitalization/CSHCN almost four times cost/child nationally • Specialty visits • Cost for physician services for CSHCN more than two times cost/child nationally

21. Sources for estimating cost of statewide care coordination • Census http://www.census.gov/prod/2006pubs/07statab/pop.pdf • Percent CSHCN http://cshcndata.org/Content/States.aspx • Salary per carecoordinator http://www.bls.gov/oes/current/oessrcst.htm

22. The Catalyst Center on Financing and Coverage for CYSHCN • Our priorities • Medical debt among families of CYSHCN • Cover more kids through Medicaid buy-in • Reduce gaps through Catastrophic Relief • Enhance quality through financing of care coordination • Our team • Carol Tobias, Susan Epstein, Sally Bachman, Meg Comeau, Deborah Allen • Find us at http://www.bu.edu/hdwg/ • Contact me at dallen@bu.edu