Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / Medicaid and Children with Medical Complexity: From Policy to Bedside

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Medicaid and Children with Medical Complexity: From Policy to Bedside · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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This is Pediatrics Now, brought to you by the Department of Pediatrics at UT Health San Antonio.
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Today, I'm bringing you Grand Rounds. Let's listen in. Hi, everyone.
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Welcome to Pediatric Grand Rounds.
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Today, it is my honor to introduce one of our own, Dr. Ryan Van Ramhorst.
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He is the Chief Medical Director for Medicaid and CHIP Services at the Texas
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Health and Human Services Commission, and he serves as the lead physician for
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the Texas Medicaid program.
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Which provides needed health services to over 4 million Texans.
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He supervises the Office of the Medical Director, which is responsible for providing
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clinical direction and oversight of managed care and fee-for-service programs.
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His policy interests include improving care for children with medical complexity,
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enhancing the behavioral health continuum of care, and addressing non-medical drivers of health.
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And he has held this role since February of 2019.
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Dr. Van Rambhorst completed his undergraduate studies in biology and Spanish
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at Chapman University in Orange, California. He went to medical school at the
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Baylor College of Medicine in Houston.
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And he completed his internship residency and chief residency in pediatrics
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at UT Health San Antonio.
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And then he completed fellowship in academic general pediatrics here as well.
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He also holds a master's degree in public health, which was completed here at
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the University of Texas School of Public Health.
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His work and experience includes practicing in underserved communities.
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On the south side of San Antonio as part of a National Health Service Corps,
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scholarship service commitment, and he completed an externship as a uniformed
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officer in the Commissioned Corps of the United States Public Health Service.
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There he served in the Office of Research Integrity for the U.S.
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Department of Health and Human Services.
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His professional interests include health policy, clinician leadership, and medical education.
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He is a board certified in general pediatrics and in healthcare quality and management.
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He is a fellow of the AAP, fellow of the American College of Healthcare Executives,
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diplomat of the American Board of Quality Assurance and Utilization Review Physicians.
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He also sees patients on a part-time volunteer basis here as adjunct faculty at UT San Antonio.
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He holds the rank of adjoint associate professor of pediatrics.
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He also teaches part-time, providing guest lectures on the U.S.
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Healthcare system and clinician leadership at the Long School of Medicine and
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the Army Baylor MHA MBA program and other forums.
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He's been married to his wife, Christine, for over 16 years.
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She is an OBGYN in private practice.
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His personal interests include spending time with his wife, their three cats,
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soccer, fitness, traveling, cooking, and I could get on board with this one.
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Anything to having to do with Star Wars. No wonder I like you so much.
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Today, he's going to be talking to us. His talk is about children with medical
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complexity, and the title is From Policy.
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To Bedside, Medicaid's Role in Supporting Children with Medical Complexity.
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So please join me in welcoming Dr. Ryan Van Rambhorst.
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Dr. Sutter, thank you so much. Ms. Calderon, thank you for all the support.
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Really appreciate the invitation to come spend some time with you on a wonderful Friday morning.
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I am more caffeinated than I normally am because I definitely got in my car
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this morning and pulled out of the garage, headed to the medical school campus
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when I reminded myself that this was virtual.
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So I think I'm on my fourth cup of coffee. I'm ready to go.
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So buckle up. Before I bring up my slides, I just want to say thank you.
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Whether you realize it or not, you are part of a community of roughly 120,000
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providers that serve vulnerable Texans that are covered by Texas Medicaid and CHIP.
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And that is a really important thing. So thank you for all that you do to serve
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children, to serve families, to serve our community members.
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And as you know, pediatrics has a really important role when it comes to Medicaid
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because so many children in Texas and in the United States receive coverage
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through Medicaid and CHIP.
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In fact, Medicaid and CHIP combined represents the single largest insurer of
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children in Texas and in the United States. So thank you for what you do.
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I also want to say that it's really a privilege for me to have trained at UT
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Health San Antonio, where,
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I received a wonderful background in general pediatrics training and subspecialty,
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but more than anything, received mentorship from some of these wonderful pediatricians,
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some of which were on the call,
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who gave me the flexibility and inspiration to pursue a career in advocacy with
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a lowercase a and health policy.
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I know that Dr. Lukifer is on this call, which, as you know,
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was a longstanding member of our Child Abuse Pediatrics Division,
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who took me to Austin for the very first time as part of a Texas Pediatric Society
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Advocacy Day, where we met with our state representatives and state senators
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about Medicaid payment rates for pediatrics.
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And so it's been a journey, but I see so many faculty on this call that had
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been so impactful in my career and, again, would not be here without y'all.
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And then the last thing I'll say before I pull up the slides and we get into
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the meat of the presentation is, I certainly hope that there's residents and
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medical students tuning in.
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I hope that this is somewhat inspirational to you, that it'll make you want
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to learn more about the health system, more about health policy,
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and how the system at large impacts your ability to take care of your future
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patients and what we all can do better to make things a little bit easier for children and families.
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So let me pull up the slides and like I said before, buckle up.
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All right. So, the focus of today's presentation is about what Texas Medicaid
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does to serve, largely in collaboration with providers like you,
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children with medical complexity.
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But first, I'll say as a good faculty member that I don't have any financial
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or commercial conflicts to disclose. We're not going to be discussing the off-label
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use of products that are not approved by the FDA.
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And here's really our learning objectives. We'll start with an overview of the
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Medicaid program. Again, I know the focus is going to be on children.
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We'll talk about the managed care service delivery model and how that compares
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with the older, what some of you know as traditional Medicaid or fee-for-service model.
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And then we'll spend kind of the second half of the presentation kind of zooming
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in on services for children with medical complexity and how we all can work
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together to streamline that care and make sure that our kids are living their best lives.
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All right. So what is Medicaid? Medicaid is a jointly funded state and federal
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health care program that serves low income individuals, individuals with disabilities
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and otherwise vulnerable citizens.
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CHIP is a very similar program with a somewhat different legislative history
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that we may have time to get into that was really designed in the late 90s.
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Medicaid came into existence around 1965. We just celebrated our 61st birthday.
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So happy birthday, Medicaid.
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CHIP actually came into existence in the late 90s when
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healthcare was really being discussed at a national level, and this program
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was created to serve children who live in families that made too much money
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to qualify for Medicaid, but for whatever reason were not able to obtain
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private or commercial insurance, either because of finances or they worked at
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a place that didn't offer health insurance.
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Now, why is Medicare on here?
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You're probably thinking, saying, Dr. Van Ramshorst, Medicare is for elderly
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individuals, and you would be correct.
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But we do have a population of individuals served by Texas Medicaid that are
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what we call dually covered, are dually enrolled.
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So they receive coverage from both Medicare, which is a federal health care
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program, and Medicaid. And these are some of our most vulnerable and complex individuals.
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Most of them are over the age of 21 and, again, receive some services from either program.
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So this is just an impact perspective. So as of fiscal year 2025,
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our program covers over 4 million Texans.
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That's 13% of all Texans.
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You're probably familiar with the statistic that over half of births in the
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state of Texas are covered by Medicaid.
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40% of kids are covered by Medicaid or CHIP.
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And something that I really didn't realize until I started to work at the Health
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and Services Commission is the high percentage of individuals that are in nursing
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facilities that are also covered by Medicaid.
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And we'll talk about our eligibility and who qualifies in just a few slides.
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So we're not going to take too much of a deep dive here. As we say in the policy
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world, this gets really, really wonky, really, really quick.
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But what I wanted to point out here is our relationship with the federal government.
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Just like our agency has a role in regulating managed care organizations,
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which we'll talk more about, the Center for Medicare Medicaid Services,
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of which the current administrator is Dr. Oz, regulates Medicaid and CHIP programs for states.
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And so we have a partnership, a collaboration with CMS, as it's called,
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the Center for Medicare Medicaid Services, that really provides oversight of
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our agency and our program's operation.
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And so as an example, if we want to change a benefit, if we want to create a new waiver,
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We have to ask CMS for permission, answer their questions, thinking through
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things like how is it going to be administered, what are the financial implications,
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what are the program requirements.
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But at the base of it all, Medicaid programs have what is called a state plan.
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And this is kind of our base contract with the federal government that outlines
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the basic services that all individuals enrolled in Medicaid are entitled to receive.
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So in terms of funding, as I mentioned before, Medicaid and CHIP are partnerships
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between the federal government and states.
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And the way that I like to think of it is for, at least in Texas,
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for every Medicaid dollar, the federal government puts in 60 cents and the state
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of Texas puts in 40 cents. And so that dollar is really split.
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Now, that way that it's split is called the FMAP, the federal medical assistance percentage.
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This is different for every state, but it has to do with the per capita personal
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income and other factors.
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Many states are around that 60% mark, and you can see that there's a slightly
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higher match rate for the CHIP program.
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Actually, when CHIP was first authorized, the match rate was over 90% to try
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and incentivize states to enroll children in CHIP.
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I also want to call out here that we do have a few other programs that are actually part of Medicaid.
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Or are very similar to Medicaid in that they're administered by our agency,
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the Health and Human Services Commission, the Family Planning Service,
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Medicaid for Breast and Cervical Cancer, as well as our Community First Choice
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Program, which is Attendant Care Services.
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Now, I also want to take a moment here and just talk a little bit more about dollars and cents.
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One of the most difficult jobs that our state representatives and state senators
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have to do is pass a balanced budget.
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In fact, that is the only law that they must pass during a Texas legislative
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session, of which the 90th is going to begin in January of next year.
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Medicaid makes up between a third to a quarter of the entire state of Texas
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budget, depending on the biennium.
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That's largely because we cover so many vulnerable Texans.
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But if you're an appropriator, if you have to make those difficult decisions,
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Medicaid is always something that's going to be considered just because of the
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impact that it has on our state budget.
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When you look at spending in Medicaid at a national level, in 2024,
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national Medicaid spending was around $920 billion, with a B.
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And in Texas for that same year, it was around $50 billion.
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I also want to pause here and talk a little bit about the enrollment nationally.
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We said a few slides ago that in Texas Medicaid, we have around 4.1 million individuals.
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When you look nationally, 88 million individuals across the country are covered by Medicaid.
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And when you look at Medicare, there's 66 million individuals that are covered.
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So I said the word entitlement a few minutes ago, and sometimes that's said
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and it is kind of a bad word.
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And it's not. What that means here is that if someone is eligible for the program,
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they are going to receive the services.
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And so Medicaid is an entitlement program. So again, if someone meets the eligibility,
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they must be enrolled in the program and receive services.
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And again, this has a tremendous impact on state budgets.
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If all of a sudden a national disaster were to occur or a natural disaster,
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and many, many individuals lost their jobs and became eligible for Medicaid,
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they would all potentially be enrolled.
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And again, that has a large budgetary impact. So that's what we mean when we
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say that Medicaid is an entitlement program.
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CHIP is not an entitlement program, but it operates very similarly.
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I mentioned in the last slide that the match rate is a bit higher,
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but funds are technically capped.
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The way that I like to think of this is the federal government gives states
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kind of a bucket of money to spend on CHIP.
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And when that money is gone, there's no additional federal matching dollars.
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And so states would then have the ability to say, we're not going to enroll any more CHIP clients.
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We're going to change the benefits. And those are things that we have not done
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in the state of Texas, but just the nuance between the funding of those programs.
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So let's talk about eligibility. I feel like some of the most common questions
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that we get from providers, advocates, and clients alike are eligibility.
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So Medicaid, again, was passed into federal law as part of the Social Security Act back in 1965.
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That's where kind of a bulk of the provisions live in terms of what defines eligibility.
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Really two buckets of things. There's the financial criteria,
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which we'll talk through shortly.
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That has to do with the federal poverty level. And then there's non-financial
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criteria like age, residency, citizenship, or alien status.
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And you can see at the bottom the categories of individuals that we cover in Texas.
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Now, it's not on the slide, but I wanted to pause and take a moment to talk
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about H.R.1, otherwise known as the One Big Beautiful Bill Act.
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I think one of the other very common questions that we get is,
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will Texas be implementing work requirements for our Medicaid program?
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As you know, Texas is one of nine or 10 states that elected not to expand Medicaid.
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So our eligibility is a bit different than it is in expansion states.
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Texas does not have to implement work requirements as called for by One Big Beautiful Bill Act.
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You've probably read articles in the national media or Kaiser Family Health
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News about this, But that is something that Texas does not have to do,
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in case you were wondering.
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Certainly, there are other provisions of One Big Beautiful Bill Act that will
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have an impact on things like directed payment programs. But as it goes for
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work requirements, again, not something that Texas will have to do.
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So this is kind of the breakdown of eligibility, and we will pause here for a second.
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So on the Y-axis, you have the percentage of federal poverty level,
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and I think ballpark federal poverty level 100% is around $30,000 for a family
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of four, and so 200% or 198% is $60,000 for a family of four.
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And obviously, the federal poverty level changes according to family size.
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The larger your family, the larger the number.
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And so, again, our eligibility is largely determined by an individual's percentage
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of federal poverty level.
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And so let's walk through the categories on the bottom of the slide.
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These are the groups that you saw on the prior slide that we cover.
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So to the far left are pregnant women and infants, which are children up to one year of age.
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The dark blue is the federal minimum. Again, Medicaid, joint federal-state partnership,
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the federal government dictates kind of the basics.
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Texas, in the gray coverage, has elected to provide more generous coverage to
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pregnant women and infants in this category.
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I'll also mention that a few years ago, our legislature directed our agency
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to extend postpartum coverage from 60 days to a full year.
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So for those of you that are doing well-child visits and that baby is insured
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with Medicaid I think it's a best practice to remind that mother that she will
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have full-fledged Medicaid for an entire year after that baby's delivery.
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And it's full-fledged Medicaid ranging from behavioral health services to prescription drugs to checkups.
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But I know that was very, very impactful for our program and something that
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advocates had been looking for for a very long time.
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Next categories are children between ages one to five and six to 18.
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You're probably wondering why is the percentage different there?
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I don't have a great answer. I just know that healthcare is complicated.
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We'll come back to those two middle categories. And then on the far right are
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those individuals being served in nursing facilities.
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And here you can see that this is some of the most generous coverage that we
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offer all the way up to 222% of federal poverty.
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And you can see that some of our lowest eligibility, if you will,
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is for parents and caretaker relatives.
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So able-bodied working adults, as some people refer to them,
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are not eligible for Medicaid in Texas.
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Again, we are not an expansion state, but parents and individuals who are caring,
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for example, for an ill or disabled relative are able to get Medicaid so long
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as their income is at or below 13% of federal poverty,
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which is roughly $300 for a family of three, just to put a number on that.
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The last thing that I'll bring up here is where is CHIP? So if you look at the
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children ages one through five and six to 18, CHIP takes that coverage up to
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198% of federal poverty.
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So when you're getting asked questions about eligibility or wondering if a patient
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or a family member is eligible, this is ultimately what that is based on.
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So let's talk a little bit more about spending. So caseload simply means that
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the individuals that we currently have, so that larger bucket of 4 million Texans,
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and then you can see spending on the right.
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Now, this should make sense, especially to this audience. So that's 73% of our
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caseload. Most of our caseload are healthy, typically developing, low-income children.
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And we have smaller categories of non-disabled adults and those with disabilities, including kids.
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And not surprisingly, the kids that are in the bulk of the caseload only account
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for about a third of the spending.
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And we know why. It's because healthy, typically developing kids really don't
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need a lot when it comes to health care. Of course, they need checkups.
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They need those routine immunizations. They need developmental screenings.
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All of the things that our general pediatrics division does a great job at teaching
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our medical students and residents, but they're generally not expensive to cover.
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But when you start thinking about a child with complex medical needs that's
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on multiple medications, that receives G-tube feeds, that might be on a ventilator,
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obviously the cost is higher.
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And so that is why the bulk of spending is on individuals with disabilities.
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So let's talk for a second about what is covered. And so I am always surprised
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by the breadth of services that Medicaid covers, especially as compared to commercial insurance.
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And we'll speak a little bit more about that in a second. So we cover acute
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care services, which is policy speak for things like doctor's visits,
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hospital services, laboratory radiology.
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We cover what are called long-term services and supports, sometimes abbreviated LTSS.
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I know when I was a trainee, this was not something that I was familiar with
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in terms of the name, but I was familiar with the service.
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And these services are generally unique to Medicaid. These are things that commercial
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insurance policies do not cover.
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These are things like attendant care to help someone with disabilities do basic
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activities of daily living.
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This could be a private duty nurse that, again, is supporting that child with
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complex medical needs, addressing their ventilator, assisting with gastrostomy
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feeds, and a variety of other services, again, that we call LTSS.
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And again, these are generally services that are not covered by commercial insurance.
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We cover what I think is an increasingly broad array of behavioral health services.
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Now, why do we say behavioral health? Behavioral health in health policy world
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means mental health services as well as substance use disorder services.
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So we cover a range of things. On one end of the spectrum would be inpatient
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psychiatric hospitalization.
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You probably have cared for patients that do require that level of care.
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And then we cover all of the things on the other side of the spectrum,
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like outpatient visits with a psychiatrist, medication management.
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Now, we don't do as good of a job at covering the things that are in the middle
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of that continuum, things like partial hospitalization and intensive outpatient,
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but our program has made some really good strides in the right direction,
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and we'll have time a little bit later to talk about that.
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We cover transportation services. I know that one of the biggest barriers for
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our families is transportation, and so all of the managed care companies and
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our fee-for-service members have the ability to get a ride to doctor's appointments, etc.
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And I feel like there's lots of opportunity there for providers to remind families of that benefit.
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And then as you know, we do cover a broad array of prescription drugs with a
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formulary that is likely larger than what most commercial insurances would ever consider offering.
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So, two service delivery models. So, on the right, again, is what some might
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call traditional Medicaid.
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And this is the Medicaid that existed kind of pre-1994 and still exists to a
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small extent. And this is where a provider simply has a contract with the state
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of Texas to deliver health services.
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If you do 10 well-child checks, you're going to get paid for 10 well-child checks.
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If you order more tests, if you prescribe more medicine, if your visit is more
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complex, you're going to get paid for that.
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And so this is kind of a basic fee-for-service process that really all types
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of payers are kind of shifting away from over time, shifting to things like
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the managed care model, value-based payment, alternative payment models, etc.
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Now, we still have about 3% to 5% of our enrollees that are in our fee-for-service
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program, and those are largely
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newborns that have not yet been assigned to a managed care organization or MCO
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or individuals that are transitioning between programs, but it is an increasingly
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small percentage of our program.
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The bulk of our enrollees, in fact, the bulk of all individuals enrolled in
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Medicaid across the U.S. are in a managed care organization.
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The finance model is important. I've talked a bit about the Texas budget and
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state budgets and the impact of Medicaid.
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The way that this works is instead of the state contracting directly with providers,
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the state has contracts currently with 16 different health insurance companies
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or HMOs or managed care organizations,
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and we pay those health insurance companies a capitated rate.
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Capitated rate is sometimes referred to as a per member per month.
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And so let's say that you have a health insurance company, you're participating
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in Texas Medicaid, and you cover 100 healthy kids, and the state of Texas is
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going to pay you $50 for each of those kids per month.
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And I think, if I'm doing math correctly, that's going to be 50 times 100 is $5,000 for a month.
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Now, if the cost of healthcare services for that group of kids is more than
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$5,000, that's a loss for that health insurance company.
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But if the cost is less than $5,000, that would represent a profit.
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And we have controls baked into our program that help make sure that if profits
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are above a certain percentage that some of that actually has to be shared back with the state of Texas.
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But this model gives state budgeters certainty, if you will,
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because that capitated rate, while it does change over time,
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it is helpful for two-year budgeting cycles, again, giving programs certainty.
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And so we own the contracts with the MCOs. One of our agency's primary job is
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to provide oversight of those MCOs, make sure that they're
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doing right by providers, making sure that the clients enrolled in their programs,
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their members are getting the services that they need.
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Um, uh, one of the unique features of, uh, managed care is service coordination.
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So, um, a great example, our individuals, kids in our star kids program,
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which we'll talk about shortly,
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those kids should be receiving service coordination where at least once a year,
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depending on the child's complexity, they should have an in-person visit from
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a service coordinator from their managed care plan to identify their needs and
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make sure those needs are being met.
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And there's a few other nuances with managed care. They're able to provide things
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that we call value-added services.
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You may have seen billboards or emails about MCOs giving new families a baby
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shower, infant car seat, bicycle helmets. These are all value-added services
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that traditional Medicaid just wouldn't be able to offer.
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Okay, so why managed care? Managed care emphasizes preventive care,
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which we all know is very important.
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It improves access to care as opposed to the fee-for-service model.
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It ensures that services are being used appropriately, and that is perhaps more
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important than it ever has been, given the national and state dialogue about
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waste, fraud, and abuse in social services programs to include Medicaid,
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and we'll talk about that later.
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In theory, there's improved client and provider satisfaction.
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There's a focus on medical homes and making sure that members have a primary
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care provider, be it a general pediatrician or a family physician.
27:02
There's a direct tie to health outcomes. In fact, we have metrics and targets
27:07
that we make the managed care companies hit.
27:09
Otherwise, they will lose some of the money where the higher performing plans
27:14
will take away some of that at-risk money or those at-risk dollars from the
27:18
lower-performing plants.
27:20
And promoting care in the least restrictive setting. And when I think of this, it's
27:25
individuals with disabilities that are able to be served in their home or in
27:28
the community rather than in a hospital or institution, and our managed care
27:32
companies are charged with making sure that that happens.
27:36
Obviously, there is a cost-effectiveness aspect of managed care that,
27:42
again, is very important.
27:44
And just to put some numbers on that, when you look at the time period between 2012 to 2022,
27:51
the average per capita, so per human cost of health care expenditures in the
27:56
U.S., has increased 52 percent.
27:59
But when you look at Texas Medicaid specifically, it's only increased by 14%.
28:05
And obviously, again, given that Medicaid has such a large impact on our budget,
28:10
this is very important for our appropriators with the managed care model.
28:16
So again, health care is complex. These are programs that you might have heard of before.
28:22
The first thing that I'll tackle, though, is why is everything called STAR?
28:27
I would like to think it's because we're the Lone Star State,
28:30
but this actually harkens back to the legislation that was passed in the mid-90s
28:35
that directed our agency to pursue a managed care model for Medicaid.
28:39
And so it stands for State of Texas Access Reform.
28:43
If you knew that, you get a bonus. That is not one of the CME questions,
28:47
so don't worry about remembering that.
28:49
Our largest program is STAR, which covers those low-income, healthy,
28:53
typically developing kids, pregnant postpartum women.
28:56
Our STAR Kids program, which we'll take a deeper dive on shortly,
29:00
covers kids and youth with disabilities.
29:03
We talked about the role of CHIP. STAR Health, we cover every single child,
29:09
adolescent, and young adult in our foster care system that are in foster care, child welfare.
29:15
And we have a single statewide managed care model that does that program because
29:21
we know that youth in foster care move frequently.
29:23
And so the idea is with one managed care company, they're able to better preserve
29:28
access to primary care and behavioral health care.
29:31
We also have a variety of foster care centers of excellence through Star Health throughout the state.
29:36
I'm very proud that in the School of Nursing at UT Health San Antonio.
29:41
They have a clinic called Wellness 360.
29:43
That is one of the foster care centers of excellence. And then lastly,
29:47
the STAR Plus program is for adults with disabilities.
29:51
We do cover dental services for children. We have three dental maintenance organizations
29:56
or DMOs, and there are some dental coverage for adults with disabilities,
30:02
but primarily the dental benefit is for kids.
30:06
This is a scary-looking map because we have divided the state into managed care service areas.
30:13
Kind of at the bottom left in the yellow, you can see the bare service delivery
30:17
area and which managed care companies are operating in which program in which area of the state.
30:24
You can see that some MCOs only participate in one of the programs.
30:29
Some of them participate in all of the programs.
30:31
They have the ability to select when they're applying essentially to participate
30:36
in Medicaid, which programs they want to be a part of.
30:40
So I'll talk a little bit about, again, what is one of our most important jobs
30:45
as the Health and Human Services Commission. We are ultimately the regulator
30:49
of the MCOs. We have to provide oversight of those very, very large contracts.
30:55
And I failed to say earlier that the contracts that the state has with the managed
30:58
care companies are some of the largest state contracts in the entire country.
31:04
So oversight is really, really important from a financial standpoint,
31:08
but also to make sure, again, that the people that we serve are getting what they need.
31:12
So I'll talk through some of the tools that we have to make sure that our managed
31:16
care companies are doing what they are being paid with taxpayer dollars to do.
31:20
So in terms of access to services, we have network adequacy requirements where.
31:25
A client has to have, for example, a primary care provider within so many minutes
31:31
of driving or so many miles.
31:33
One of the biggest functions of the medical director's office is to provide utilization review.
31:38
And so we have a team of roughly 250 individuals, many of which are nurses,
31:43
behavioral health clinicians, and therapists that will pull a statistically
31:47
valid sample from some of our programs and make sure that our members are getting what they need.
31:52
I mentioned earlier that we do have a variety of quality programs where the
31:57
MCOs, again, are what we say are at risk for dollars, where if they're not performing
32:01
well, they will actually lose out on some of those dollars.
32:05
We have value-based enrollment, which means that when someone does not elect
32:10
which plan they want to choose, they will actually be defaulted to the higher performing plan.
32:16
We have a large operations area that conducts what are called readiness reviews.
32:20
And so as an example, if one of the MCOs would want to
32:24
use a third party vendor to do prior authorization, they would have to prove
32:29
to us first that they understand our policy and they know how to do things.
32:34
And we ultimately have to sign off.
32:36
And then I mentioned before that we have financial tools.
32:40
Again, I'm going to very quickly get out over my skis. I don't know about you,
32:44
but I didn't have any coursework in medical school on financial oversight of
32:47
health insurance companies, but I know a lot more now.
32:50
We have financial statistical reports where the MCOs have to report how much
32:54
money they're spending on actual health care versus administration versus overhead.
32:59
And again, we have built in profit limits where if an MCO is making over 3%
33:05
of profit, they have to begin to share in a graduated manner back with the state some of their profits.
33:12
So that's kind of a built-in protection from a financial standpoint.
33:17
Now, because of the national discourse, I did want to spend a few minutes talking
33:22
about waste, fraud, and abuse.
33:24
Again, lots of conversation about waste, fraud, and abuse in Medicaid programs,
33:29
in child care programs, in applied behavior analysis for individuals with autism.
33:35
And we work very closely with our Office of Inspector General,
33:38
or OIG, which you're likely familiar with, to prevent, detect,
33:43
monitor, enforce fraud.
33:46
We work with the managed care companies. Each of them have what is called a
33:50
special investigative unit, which is kind of a mini version of the OIG,
33:55
where the MCOs are charged with also looking for waste, fraud, and abuse.
33:59
And then lastly, we do work with the Office of Attorney General's Medicaid Fraud
34:03
Control Unit when there is a case of fraud that's being prosecuted from a legal
34:08
standpoint rather than from an administrative standpoint.
34:11
And what you don't see pictured here is you.
34:14
You may know that as part of your Medicaid enrollment, you are obligated to
34:18
report concerns about waste, fraud, and abuse. And that's one of the most critical
34:22
ways by which our agency becomes aware of bad actors.
34:27
I think it's really unfortunate that there's a really, really small number or a smallish number,
34:32
of providers that are doing the wrong thing, where all of us are working very
34:37
hard to serve vulnerable Texans, but I think we all have a role in preventing
34:42
waste, fraud, and abuse in Medicaid.
34:45
Just really quickly, I wanted to outline that when we are developing a policy,
34:49
we're actually thinking about waste fraud and abuse prevention or program integrity,
34:53
as it's called, from the very inception.
34:56
And so we will think about things like quantity limitations or diagnostic restrictions.
35:01
Going back to the example of ABA, we require that to get ABA,
35:06
a child has to have a confirmed diagnosis of autism.
35:10
Whereas other programs make other ABA for other diagnoses, we know that the
35:15
evidence is strongest for kids with autism at younger ages, close to the time of diagnosis.
35:20
And so we build those things into our policy. And I have to say,
35:25
when I was in full-time clinical practice mode, I had lots of thoughts and feelings
35:30
and opinions about things like quantity limits and diagnosis restrictions.
35:35
But sitting in the chair that I do now, I have a much richer understanding for
35:39
why these things exist and why they need to exist.
35:43
We have prior authorization tools, which I know that certainly is a bad word.
35:47
I think the health system in general can do a better job at balancing that.
35:52
As an example, we require the health insurance companies we contract with to report to us every year
35:58
prior authorizations that they are taking offline or putting online,
36:03
and we'll work with them if they have a service where they're approving it 95%
36:07
of the time is that prior authorization really needed anymore.
36:12
All right. We'll pause for a second about Medicaid waivers. I think the number
36:17
two most common flavor of question that I get only second to eligibility is
36:22
Medicaid waiver. What is a waiver?
36:24
So the word waiver actually has to do with waiving the section of the Social
36:30
Security Act where the Medicaid law lives to give states permission or flexibility to do something novel.
36:36
So there might be a specific provision that has to be waived to allow a state
36:41
to provide a different kind of service.
36:43
As an example, in one of our specialized waivers for youth with complex behavioral
36:48
health needs, they can actually access equine therapy, music therapy.
36:53
Those are not services that Medicaid traditionally offers, but through a waiver,
36:57
we're allowed to offer those services.
36:59
And you can see some of the other reasons for which states seek waivers.
37:04
The last one in terms of new service delivery and management models,
37:08
some of you may remember what is called DISRIP, the Delivery System Reform Incentive
37:13
Payment Program, which is what some others would refer to as our 1115 waiver.
37:17
That's an example of a state, Texas, trying to do things novel and innovative through Medicaid.
37:23
And this is a bit of a scary chart, but it lists out all of the different waivers that we operate.
37:30
We'll focus on the bottom shortly. Those are what we call our home and community-based
37:35
services waivers. Again, 1915C refers to a specific provision of the law.
37:41
And these waivers are all about keeping individuals with complex needs out of institutions.
37:48
And so I think that's a really good segue into our STAR Kids program and then
37:53
a little later, our medically dependent children program waiver.
37:57
So I mentioned earlier that it's really at the direction of our legislature
38:01
that we have moved to managed care, but we didn't start with everybody at once.
38:06
In the mid-90s when we were directed to create the first managed care program,
38:11
it was the STAR program. So it was those healthy, typically developing kids
38:15
and pregnant and pre-partum women.
38:20
STAR Kids is actually one of the more new programs, if I can use that word,
38:24
where the legislature directed the state in 2013 to develop this novel Medicaid
38:30
managed care program for children and young adults with disabilities.
38:34
And that was really the birth of Star Kids, which first became active in 2016.
38:40
And you can see that the mission of this program is really to help make sure
38:44
that kids with disabilities can maximize their potential and live the best life they can.
38:51
So who's eligible for STAR Kids? There's quite a few categories here.
38:56
I think the most common way is those kids that are receiving Supplemental Security
39:01
Income, or SSI, which is a program by which individuals with disabilities can
39:06
receive some additional dollars every month to help with other expenses.
39:11
I think another thing for providers to think about, especially when they're
39:15
seeing a patient with disabilities for the first time, is asking them,
39:19
are you receiving SSI? Because if they get SSI and they're a child,
39:23
they will be enrolled in STAR Kids.
39:26
SSI is actually determined by the federal government. That's its own complex
39:30
process, but SSI has a really important role here.
39:34
If you receive SSI in Medicare, you're eligible for STAR Kids.
39:38
If you're in the MDCP waiver or the yes waiver, you're eligible for STAR Kids,
39:44
as well as if you are receiving other waiver services or if you're actively
39:48
residing in a nursing facility.
39:51
So some of the unique features of STAR Kids is a focus on health homes,
39:56
our Texas Health Steps program, which is our well-child program,
40:00
which is actually available in all of our programs.
40:02
But it's important here because all kids need routine well-child care,
40:08
regardless of what their needs are. And again, that's our Texas Health Steps program.
40:13
Disease management, service coordination, we talked about transition planning.
40:19
I remember when I used to think that this was the cliff where a child would turn 21,
40:24
and age out of Medicaid or age out of another program and trying to find an
40:28
adult provider that is equipped to take care of a young adult with special needs
40:33
is still very challenging, regardless of what type of insurance you have.
40:37
But our Star Kids program requires
40:39
the MCOs to have dedicated transition planning staff to help with that.
40:44
I spoke earlier about those long-term services and supports.
40:47
We know that many children and star kids are receiving nursing services,
40:51
whether it's periodic skilled nursing service or private duty nursing.
40:56
There's a dedicated screening instrument. That's the one that's done once a
41:00
year to identify needs, and it goes by social factors, mental health factors,
41:06
organ system to identify needs.
41:08
This was a tool that was developed in collaboration many years ago with Texas
41:12
A&M University, and it is totally unique to Texas Star Kids program.
41:17
And every one of those children must have what's called an individual service
41:22
plan, which outlines the services that they need.
41:26
Now, in theory, if you are taking care of a STAR Kids patient,
41:31
you should be able to access the SKSAI through the Managed Care Organization portal.
41:37
Previously, they would fax you the 100-page long instrument,
41:41
which was not very user-friendly.
41:43
But again, all of us in theory have access to that SKSAI through the Managed
41:48
Care Organization portal so you can see what the assessment yielded.
41:53
So we'll talk for a second about one of those 1915C waivers or MDCP.
42:01
So this is a specialized waiver for children, adolescents, and young adults
42:06
that essentially require a nursing facility level of care.
42:12
And services can be delivered either through StarKids or StarHealth.
42:15
And so it's interesting. There's kind of two populations that make up our MDCP program.
42:21
And let me back up. STAR Kids, the enrollment is roughly 150,000 children and
42:26
youth. MDCP is roughly 6,500. So it is a subset.
42:31
One of the groups are those kids that are already in STAR Kids because of SSI
42:36
or already in STAR Health because they're having an interaction with the child welfare system.
42:41
And the other group of kids are actually kids that live in families that might
42:45
have commercial insurance.
42:47
They might have a parent that's a lawyer and the other is a teacher.
42:51
These are families that are more well-off than the average family enrolled in
42:55
Medicaid, but they can get Medicaid for their child with special needs through MDCP.
43:01
Now, they're going to have access to the specialized waiver services that I'll
43:05
tell you about shortly, but they really have access to full-fledged Medicaid.
43:11
And so an example of what we see is take a child with cystic fibrosis who is
43:15
now on a life-changing medication that costs thousands of dollars a month.
43:20
Their private insurance plan can say, we're not going to cover that.
43:24
But that is not an option in Medicaid.
43:25
Medicaid must cover all medically necessary services for children.
43:30
And so that child, even though they have commercial insurance, is able to get that drug.
43:35
Another example, a child on a ventilator in a G-tube, that commercial insurance
43:40
can say, we're not going to pay for nursing services.
43:42
But through this waiver, they're able to access all Medicaid services,
43:46
including private duty nursing, et cetera.
43:50
And so here you can see the eligibility, which we won't dive into.
43:53
We already talked about it.
43:55
These are some of the unique services that come with MDCP.
43:59
So this is what we really needed the waiver for, or at least partially.
44:02
So things like adaptive aids or communication devices.
44:06
There's actually built-in employment assistance for families.
44:09
Flexible family support, minor home modifications, whether that's a wheelchair
44:14
ramp, that's a bar in the shower, there's a budget for that,
44:17
respite services to help give the family an ability to take a breath and meet
44:22
their own needs while their child is safely cared for in another environment.
44:26
We have an entire supported employment program and, again, a specialized transition services program.
44:33
Now, one thing that I wanted to point out as something that is new,
44:36
and this is a bit in the weeds, but
44:39
I think providers especially, and in particular our complex care pediatricians,
44:44
of which we have some amazing complex care pediatricians here in faculty that
44:48
have actually helped provide input into this process, have a really important role.
44:53
And so there is a, let me first pause by go over the ways that you can get into the waiver.
44:58
So there is an interest list where there is a bit of a period,
45:02
an individual will have to wait to get a slot on the waiver.
45:06
There's money follows the person where someone is in a nursing facility for
45:11
30 days or more, and they can get the waiver.
45:13
And we currently and soon will not have what is called the limited stay option,
45:18
where if a child meets complexity criteria and stays overnight in a nursing
45:23
home, they're able to essentially jump to the front of the line.
45:26
And we are eliminating that program and creating these diversion slots.
45:32
And so this is a way for children who are the most complex of the most complex
45:38
to get to the top of the MDCP list and actually get a slot without having to
45:44
do that overnight stay in a nursing facility.
45:46
And so this is a group of kids that are so complex, it would not be safe for
45:51
them to have a 30-day stay in a nursing facility.
45:55
And the new process will go into effect on December 1st. So we are rapidly approaching that.
46:02
And the certification of whether or not the child meets certain medical criteria
46:07
are the forms that you would have a role in talking through and working through
46:12
and ultimately signing if you feel is it appropriate.
46:15
So here are the clinical criteria of which a child must meet two to qualify
46:20
for one of these slots. We've received lots of input from families,
46:24
from advocates for complex care pediatricians to help us create this list.
46:29
But at the end of the day, it is our office that will be making these determinations.
46:34
And of course, our medical directors have the right to still approve a case,
46:40
even if a child does not necessarily meet these criteria.
46:44
But we feel that these are kind of some of the highest priority criteria,
46:48
again, for a child to bypass that interest list and get an emergency slot.
46:54
So let's talk for a second about value-based care.
46:59
So you may be familiar with this framework of alternative payment models.
47:04
And so on the far left is fee-for-service. I described this earlier.
47:08
A physician gets paid for the number of patients they see, the more lab tests
47:12
they order, the more prescriptions they write, the more surgeries they do.
47:17
There's really no connection to quality or value. And then as you move to the
47:21
right, there's a connection built on quality.
47:24
And then ultimately, there's dollars on the line that are tied back to those quality metrics.
47:30
And so in Category 2, for example, let's say you have your own private practice pediatric office.
47:35
You might get paid a bonus, as it were, to report your metrics to the health insurance company.
47:41
You might enter a shared savings agreement where if you take your population
47:45
of kids with asthma, and you can prove that you can decrease the emergency room
47:50
visit rate, that's going to represent a savings for the health insurance company,
47:54
and they will share some of that savings back.
47:56
And then on the far right is really risk-based or capitated models where the
48:02
practice takes on all of the financial risk.
48:07
We have been in a journey with value-based payment back since 2012 and are actually
48:13
one of the leading states when it comes to this.
48:16
We have a dedicated framework by which we incentivize the managed care companies
48:21
to prioritize the issues you see on the screen.
48:24
I would say almost all of which have a direct impact on the kids with medical
48:29
complexity that are served by our STAR Kids programs.
48:33
But I want to zoom in just briefly on comprehensive health homes.
48:38
So let's talk about the Chic Kids Pilot. I did not come up with that acronym,
48:43
but it is what we have. So this is the Comprehensive Health Homes for Integrated Care Kids Pilot.
48:49
We're Texas. We have to do our own thing.
48:51
You may remember that back in 2019, at the federal level, there was something
48:56
called the ACE Kids Act or Advancing Care for Exceptional Kids,
49:00
which was about specially designed health homes for children with medical complexity.
49:05
There were additional dollars for states to share with providers.
49:10
Texas did not elect to participate in that. Most states did not, as a matter of fact.
49:16
But in 2021, our state leadership wanted Texas to do our own version,
49:22
and so we developed the Sheik Kids pilot.
49:26
So I want to quickly talk to you about what that model is and what some of our outcomes were.
49:31
So what this really is, is a partnership between a managed care organization
49:36
that does StarKids and our complex care pediatric providers.
49:40
Very, very proud that our own complex care clinic was part of this,
49:44
thanks to the leadership of Dr. Medellin, Dr. Wu, and Dr. Lubrin.
49:49
And it was really about making sure that that service coordination was happening in a robust manner.
49:54
And so the goals were to improve care coordination, improve access, improve outcomes.
50:00
Improve satisfaction and stress levels for families, and also,
50:04
and perhaps most importantly to providers at times, is reduce administrative burden.
50:10
So the pilot ran for just about three years. There were 11 collaborations,
50:15
including eight of the MCOs and nine of the health homes.
50:19
Almost 1,300 unique STAR Kids members participated, of course,
50:23
with consent, and there were clinics in Austin, Corpus, Dallas,
50:26
Houston, and in San Antonio, as I said.
50:30
We did a quasi-experimental study to see if this actually worked.
50:36
So when it came to care coordination, there was a statistically significant
50:40
increase in the use of that child's core health team and the use of a family-centered
50:45
care plan. And we all know those are both very important.
50:49
There actually was a decrease in the time making appointments or coordinating,
50:53
which certainly was good for families and good for providers.
50:57
There was a statistically significant increase in the use of home-based care
51:01
services, largely driven by respite.
51:04
And what this told us was that perhaps this model was helping families identify
51:09
those ultra-specialized services that they might not be aware of,
51:13
but they can certainly take advantage of, and I think respite is one of those services.
51:17
There was an increase in outpatient encounters, which again,
51:21
I would like to think is a good thing, and that suggests that they're getting
51:23
those checkups, they're getting their follow-up care, which is certainly much
51:27
better than receiving that care in an emergency room.
51:31
There was no change, interestingly, to the number of inpatient hospitalizations
51:35
or the number of ER visits, but we did see a statistically significant decrease
51:40
in the cost per inpatient hospitalization.
51:43
I think this slide is really important, and it's something that certainly at
51:47
a health policy perspective, we don't think about nearly enough.
51:51
And that is, what is the experience for the family?
51:55
Very proud that the results showed that this did help family care for their child's needs at home.
52:02
Families reported that they felt like they were living a better life.
52:05
It helped their child's mental health.
52:07
And again, it increased access to outpatient encounters.
52:11
And almost all of the survey respondents, which again were largely parents and
52:14
guardians, were satisfied with the way that their care team was working together.
52:19
Now, I wouldn't be a good academician by heart without talking about limitations.
52:24
So the design was quasi-experimental. We didn't have a control group.
52:30
For example, the sample size was relatively small. It's 1,300 kids,
52:34
but 1,300 out of a universe of 150,000 kids in StarKids.
52:39
We really did not power this for any more detailed analysis than what I showed.
52:44
There were care coordination services that were existing before,
52:48
and so to what degree did the pilot really impact that?
52:51
Again, we didn't have any pre-pilot data, and the implementation dates of the
52:55
pilots kind of varied throughout those three years.
52:58
But very promising work. We thank the complex care clinics, the MCOs,
53:02
and advocates. And so I think we're wondering about things like,
53:06
how can we use these models now
53:08
to expand care to specialists and other long-term services and supports?
53:13
How can a model like this support rural practices where perhaps it's one family
53:18
doc that's still on paper records where he might only have one patient that
53:23
has complex needs? How can a model like this support that provider?
53:28
What happens when a youth ages out of pediatric care, that cliff that I talked
53:32
about? What are the lessons learned from this model and how can we move forward?
53:37
So I want to share a few parting thoughts and a few helpful resources and then
53:41
happy to take whatever questions you might have.
53:45
So this is a non-exhaustive list of what I'm calling challenges,
53:49
but this is really a list of kind of things that keep me up at night.
53:53
Program integrity is waste, fraud, and abuse. I think we've spoken about that today.
53:58
Lots of excitement about the Rural Health Transformation Program,
54:02
which you're likely familiar with. Texas received one of the largest,
54:05
if not the largest, amount of dollars from our federal partners to help improve rural health care.
54:11
I talked a little bit about high-cost therapeutics.
54:15
I don't know about you, but never in my life did I think we would have medications
54:20
that could essentially cure conditions like Duchenne muscular dystrophy,
54:25
spinal muscular atrophy, sickle cell disease.
54:28
These therapies cost millions of dollars per patient. And certainly if it were
54:33
my child, I would want them to receive everything and anything they needed to
54:37
live their life to their fullest.
54:39
But we've talked about fiscal responsibility and the role of Medicaid in state budgets.
54:44
And so certainly these high cost therapeutics are something that we're thinking
54:48
through and trying to learn from other states and making sure that at the end
54:52
of the day, kids that need these therapies are able to get them in a timely manner.
54:57
Genetic testing, or biomarkers as they're called, is an ever-expanding group
55:02
of tests that we have been directed to cover by our legislature,
55:06
some of which cost thousands of dollars per test.
55:09
Lots of discussions about artificial intelligence, which I think will have implications
55:16
on the next legislative session.
55:18
I mentioned the behavioral health continuum of care.
55:20
We've done some work that actually unlocks, if you will, partial hospitalization
55:25
and intensive outpatient as in lieu of services, which we could have a whole
55:30
other conversation about.
55:32
I continue to be very concerned about individuals that have co-occurring intellectual
55:37
developmental disability and behavioral health needs.
55:40
It's just very, very difficult to find a provider that's equipped to care for
55:45
them. And so what can we do as a system?
55:47
And then the ASPIRE model, which you can see what that stands for.
55:51
CMS, again, our federal partners have released a variety of innovation models to improve care.
55:58
This model is all about kids with medical and behavioral health complexity.
56:03
And so we're eagerly awaiting additional information that I think will be released
56:06
in 2027 to see if this model would be a good fit for the state of Texas.
56:13
You may know that we do have a very robust Texas Health Steps online provider
56:17
education platform that has
56:19
countless hours of free continuing education on topics ranging from sickle cell
56:24
disease to sexually transmitted infection screening to routine well child care.
56:30
The single best source of information, I think, about Texas Medicaid is this
56:35
pink book, which if you happen to have a hard copy, which is coveted,
56:39
the cover is pink, but you can get this online and it has a really well done executive summary.
56:45
And if you care to read it, we
56:47
do have a 1600 plus page policy manual that outlines all of our policies.
56:53
And that's also available on the web.
56:55
I think in terms of what you can do to engage with this system,
56:59
I'd like to think that the hour you've spent with me this morning has helped
57:02
you become a little bit more informed, being familiar with those community resources
57:07
that are increasingly partnering with our managed care organizations,
57:10
such as the San Antonio Food Bank, the San Antonio Housing Authority,
57:15
actively seeking to collaborate with the service coordinator of the MCO or the
57:20
child welfare caseworker to make sure that you're part of those conversations.
57:24
I think I learn something new every day in this job, and it's something new
57:28
that I can educate patients about when I'm in clinic.
57:31
And we also have over 30 different advisory committees and councils,
57:34
which periodically have openings for providers and physicians specifically.
57:39
And some of those advisory committees are dedicated to infants,
57:44
neonates, NICU care, specialized needs. And there's quite a few faculty on this
57:48
call right now that have active roles in those committees.
57:52
A few other things, and then I really will be done. The picture on the bottom
57:57
is hilarious to me because I think this was taken in 2014 in my first year out of residency.
58:02
I was lighter. I had no gray hair. And while the receding hairline had started, it's much worse now.
58:08
But again, very formative years at the Southeast Clinic off of Ada and South Cross.
58:13
And then the top picture is a retirement ceremony for someone that had dedicated
58:17
30 years of her life to state service.
58:20
For me, leadership has been a journey. I learned from all different types of individuals.
58:26
Perhaps I thought when I took this job that I'm the physician in the room and
58:30
I should be the one making the decisions, and that has turned out not to be the case.
58:36
I think one of the most challenging things for a leader is to communicate,
58:40
but I think pediatricians are really good at doing that in general.
58:44
I think about this a lot, and this is one of the reasons why I felt so strongly
58:48
about continuing to see patients is that to be able to bring the provider voice
58:53
to the health policy discussion, you have to be an excellent clinician first.
58:57
I think that's particularly important for the trainees on the call.
59:01
It's a really small world.
59:03
One of the managed care organization medical directors was by attending when I was a resident.
59:09
And it's just fun to have those connections. And then just a reminder to take care of yourself.
59:13
I think it's a really interesting time to be a pediatrician,
59:17
be in health policy, be in Medicaid. And I see, I can't say that enough.
59:21
And with that, I'll take down the slides.
59:25
And then Dr. Sutter, thank you again. Thanks to everybody. And I'm happy to take questions.
59:30
Thank you so much, Ryan. That was a great talk, and it was so informative,
59:35
and I think there's so much interest in this topic. I'm getting texts from people
59:39
about, you know, this is a great Grand Rounds while it's still going on,
59:43
so that tells you something.
59:45
So I'm going to read the questions from the chat. And if people have other questions
59:50
and they want to jump on, raise their hand, add to the chat, all those are options.
59:56
And then a reminder that the CME link is in the chat as well.
59:59
So for those who want to change CME, it's there.
1:00:02
So the first question I see on here is from Dr. Janet Williams.
1:00:06
If a parent responds that they do not have SSI for the child,
1:00:10
where should they be sent to enroll in that? Who is the contact?
1:00:14
And does that refer them to getting STAR program access as well?
1:00:19
Thank you, Dr. Williams. I would say two things.
1:00:22
So there is a website. If you Google SSI, it'll have the information.
1:00:27
The application is quite complex, but my best recommendation is having that
1:00:31
family reach out to their service coordinator, assuming they're in Medicaid,
1:00:36
and they are well-equipped with helping them navigate that process.
1:00:40
We are aware, though, that those determinations can take many, many months.
1:00:44
There's often requests for additional information, but I would refer them to
1:00:47
their service coordinator.
1:00:49
If the family doesn't have one, I usually advise them to call their Medicaid
1:00:52
number, and I'll sometimes have them do that from the office to make sure that they get connected.
1:00:58
Okay, great. And then Dr. Arondas asked, with the CHIP program,
1:01:03
do you think that the reduced cost for inpatient encounters had something to
1:01:07
do with improved unified treatment goals and more focused treatment plans during those admissions?
1:01:13
And was there a reduction in length of stays?
1:01:16
Yeah, thanks, Dr. Arandas. I don't believe there was a reduction in length of stay.
1:01:22
I'd have to check that, but I agree with where you're going.
1:01:25
I would like to think that that decreased cost per hospitalization was reflective
1:01:29
of more coordinated care, really inpatient and also before the hospitalization and after.
1:01:35
But I don't think the study was powered to really get at that,
1:01:38
but that's certainly what we would like to think.
1:01:40
And before I take the next question, I just want to acknowledge that I have
1:01:43
a variety of team members from the Health and Human Services Commission that
1:01:46
are on the call and just wanted to thank them for all that they do.
1:01:49
And I love being a part of their team. Back to you, Dr. Sutter. Oh, that's great.
1:01:54
So Dr. Piero is asking what percent of the cost of pediatric care is behavioral health?
1:02:01
Hey, Dr. Phelan. I don't have that number, but I do know that Medicaid is one
1:02:06
of the largest, if not the largest,
1:02:08
payer of behavioral health services in Texas and at a national level.
1:02:14
But I can look that up and I know
1:02:15
how to get a hold of you because I'm now interested in that percentage.
1:02:18
Okay, just to clarify, it wasn't Dr. Phelan, it was Dr. Fierro. Oh, sorry, Dr. Fierro.
1:02:23
Yeah, just so you get back to the right person.
1:02:27
Dr. Alice Gong is asking about can complicated NICU patients now transition
1:02:33
into waiver to get to home care without the requirement for nursing home?
1:02:41
Hey, Dr. Gong. So, yes, a child who is in the NICU, so long as they meet those
1:02:47
criteria, would be able to be assessed for MDCP and get one of those crisis slots.
1:02:53
We don't necessarily restrict it by their current care setting.
1:02:57
It's whether or not they have those complex needs. Okay, great.
1:03:02
And then Dr. Perlman is asking, what happens when the,
1:03:08
What's going to happen when, or I'm sorry, trying to clarify this question.
1:03:13
What happens when the biggest impact on health is not the 100,000 med,
1:03:18
but stable housing? Does Medicaid have any programs to address that for complex kids?
1:03:25
Thank you, Dr. Perlman. I can answer this more broadly.
1:03:30
We, for the past eight years, have been working with the managed care companies
1:03:34
on a non-medical driver of health initiative.
1:03:38
A few years ago, we put out our first ever Texas Medicaid non-medical driver
1:03:41
of health action plan, where we identified the top three needs that we wanted
1:03:46
our MCOs to be addressing with all members, not just kids with medical complexity.
1:03:50
And it will surprise nobody that those needs were housing, transportation, and food security.
1:03:56
And so most of the MCOs, if not all of them, do have dedicated programs where
1:04:01
they're working with members in partnership with the housing authority.
1:04:05
And again, I think the easiest way to access that would be going through the
1:04:10
child service coordinator, but they're doing a lot of really good work in that space.
1:04:15
Okay, great. Dr. Escaname is asking, any recommendations for transitioning to
1:04:19
adulthood for patients who are on expensive and specialty medications that aren't on STAR?
1:04:27
Yeah, thanks, Dr. Escaname. I think this is a really, really challenging space.
1:04:32
What I would say is that if the child is in regular STAR, and you have a patient
1:04:39
that is on specialty medication and does have complex needs,
1:04:42
I think the question is, why are they not in STAR Kids, there might be a good reason for that.
1:04:46
But again, helping them with their service coordinator figure that out because
1:04:50
if they are in STAR Kids, it's a bit easier to transition into the STAR Plus
1:04:55
program, which is the STAR Kids equivalent for adults.
1:04:58
But obviously, there's other eligibility criteria. And if they were to lose
1:05:02
Medicaid, I think the next best recommendation, especially here in San Antonio,
1:05:06
would be to a program like CareLink.
1:05:08
But that certainly doesn't have the same coverage that Medicaid would.
1:05:11
I know that wasn't a great answer. Also in the chat is a lot of kudos to you
1:05:15
from Dr. Wu, Dr. Williams, Dr. Gong, other people.
1:05:20
Well, thank you, Dr. Van Ramhorst. This was a great talk. We really appreciate
1:05:24
this. And we'll definitely be asking you to come back probably next year because
1:05:28
the updates are super helpful for our faculty and all of our joining pediatricians.
1:05:34
So thank you so much. We really appreciate you. Take care, y'all. Thank you so much. Bye.