Developmental Understanding and Legal Collaboration for Everyone DULCE
Developmental Understanding and Legal Collaboration for Everyone (DULCE) is transforming the way families experience healthcare
Potential Medi-Cal Cost Savings Through DULCE Summary of an analysis by Manatt Health for the Center for the Study of Social Policy February 2018
Purpose of the Analysis In 2017, CSSP contracted with Manatt Health to conduct an exercise to identify potential cost savings of DULCE based on enrollment in 5 clinic sites in California located in Alameda, Los Angeles, and Orange Counties. The aim of the analysis was to identify potential cost savings for the state Medicaid program (Medi-Cal in California), as well as for local managed care plans and the clinics implementing DULCE. The vast majority of DULCE participants are Medicaid/Medi-Cal beneficiaries. The findings are being used by local DULCE sites to cultivate health champions and build plans for sustainability and expansion. Overview of Assumptions & Approach DULCE has both short and long-run impacts on the health and wellbeing of children and their families –Most audiences likely interested in quantifiable, short-term impacts –Longer-term impacts are critical to explain, but harder to quantify and less compelling to certain audiences Family Specialists provide families with critical services, not all of which can be quantified for a business case Analysis focused on the short-run, quantifiable impact of DULCE, but also reviews the research basis for describing more qualitatively its longer-term value –For quantitative component, examined peer-reviewed literature on impact of interventions on health care utilization and costs –Gathered data from 5 DULCE sites on numbers served and types of interventions –Made a series of reasonable assumptions about impact –Displayed low to high impact estimates; data are pooled across sites given that some impacts may not be measurable for a small population
Key Findings: Potential Short Run Medi-Cal Savings from DULCE Based on data from the initial DULCE pilot at Boston Medical Center, and on the DULCE service population of 600 infants and their parents in five clinics in California counties, the following seven interventions could potentially generate between $311, 000 and $544, 000 in short run savings to Medi-Cal: 1. Improving flu vaccination rates 2. 3. 4. 5. 6. 7. • • Encouraging an early start to dental health care Reducing emergency department visits Screening and referral to supportive services for intimate partner violence Supporting breast feeding Screening and referral to care for postpartum maternal depression Encouraging use of family planning services for women at high risk of mistimed or unhealthy spacing of births This analysis draws on randomized controlled trial (RCT) results for the DULCE program and other evidence for supports facilitated by current DULCE sites The analysis accounts for potential savings to Medi-Cal state budget, and impact from Medi-Cal plans and DULCE site perspectives are noted as well
High End Estimated Short Run Medi-Cal Savings from DULCE Pilots, by Intervention $544, 000 Total = $5, 000 + $37, 000 + $75, 000 + $38, 000 + $58, 000 + $138, 000+ $193, 000 Low End Flu vaccination $311, 000 Total = $3, 000 + Dental ED visits Intimate partner violence $7, 000 + $56, 000 + $8, 000 Breastfeeding Maternal depression + $39, 000 + $69, 000 + $129, 000 Child interventions = Maternal interventions = $66, 000 - $117, 000 $245, 000 - $427, 000 Estimates for 5 California DULCE Sites Serving Approximately 600 Families Birth timing/ spacing
Potential Value of Interventions for Each Healthcare “Audience” Interventions Medi-Cal Managed Care Plan DULCE Clinic Site Flu Vaccination Save several thousand dollars annually Contribute towards immunization quality metric Increase patient panel by reducing sick visits; may increase provider incentive payments Dental Health Save up to $37, 000 Reduce medical costs associated with poor oral health Promote loyalty to medical home for sites with affiliated dental clinics Emergency Department Visits Save up to $72, 000 annually Create plan savings; improve ED quality metrics May increase provider incentive pay Intimate Partner Violence Save up to $38, 000 annually Create reinvestment or savings opportunities May increase provider incentive pay Breastfeeding Save up to $58, 000 annually Create reinvestment or savings opportunities May increase provider incentive pay Maternal Depression Screening Save up to $138, 000 annually Create reinvestment or savings opportunities May increase provider incentive pay Save up to $193, 000 Reduce medical costs associated with pre-term births and other adverse outcomes May increase provider incentive pay Birth Timing and Spacing
Detailed Analysis of DULCE’s Impact and Potential Cost Savings/Avoidance, By Intervention
Flu Vaccinations Potential Impact Cost of Low Immunization Rates • Low-income children have higher rates of under-immunization, and more than a quarter of California children under age 5 were not vaccinated during the 2016 -2017 flu season • During the 2015 -2016 season, there were 2. 2 million flu cases among children under age 5 and these illnesses were associated with 1. 5 million medical visits and more than 200 deaths DULCE Can Improve Immunization Rates • DULCE infants are significantly more likely to receive their 6 -month immunizations on time and to have 5 or more preventive visits by age 1 • DULCE Family Specialists can provide early encouragement of flu shots that begin at 6 months, consistent with appointment reminders and follow-ups provided more broadly • Medi-Cal budget perspective: Potential savings from increasing flu vaccination rates and decreasing associated sick visits are several thousand dollars annually • Medi-Cal plan perspective: Immunization and other performance metric improvements are desirable for plans, particularly in light of auto assignment incentives • DULCE site perspective: Where applicable, sub-capitation revenue could increase if a reduction in sick visits allows for a larger patient panel, and incentive pay could increase for individual practitioners meeting performance metrics
Dental Health Potential Impact Cost of Limited Access to Dental Care for Children • Nationally, 11% of 2 -year-olds, 21% of 3 -year-olds, 34% of 4 -year-olds, and 44% of 5 -year-olds have had dental caries; those affected earliest have the most intense disease experience • Low-income children whose first dental visit occurs before age 4 have dental costs that are more than $400 lower over an 8 year follow-up period due to early treatment DULCE Can Support an Early Start to Dental Care • Based on data reported by DULCE sites, relatively few DULCE parents currently discuss dental health with a Family Specialist • Counseling on recommended care (including a first dental visit by age 1) is important given that few dentists routinely accept patients with Medicaid and/or treat very young children, and that dental utilization rates for Medi-Cal children are low • Medi-Cal budget perspective: Potential savings from early initiation of dental care for young children are up to $37, 000 • Medi-Cal plan perspective: Dental is covered outside of the benefit package required of plans, but increased utilization could reduce medical costs associated with poor oral health • DULCE site perspective: For sites with affiliated dental clinics, use of this care can strengthen family attachment to the site as a medical home
Emergency Department Visits Potential Impact Cost of Unnecessary Emergency Department (ED) Visits • Among U. S. Medicaid children under age 5, more than 30% had an emergency department visit over the past year; the rate for Medicaid infants can be in excess of 40% • For U. S. children under age 2 with Medicaid coverage and ED use, the average ED expense is more than $900; in comparison, Medi-Cal payment for an office visit may be less than $50 DULCE Can Lower Rates of Unnecessary Emergency Department (ED) Use • DULCE is associated with a 27% decrease in ED use, with 36. 5% of intervention infants having an ED visit by age 6 months versus 49. 7% for control infants (RCT) • Across 3 California sites providing estimates, between 30% and 70% of DULCE parents contacted a Family Specialist via phone/text about whether to bring a sick child in for a visit • Medi-Cal budget perspective: Potential savings from decreasing ED use among infants are up to $75, 000 annually • Medi-Cal plan perspective: Averting unnecessary ED visits frees up capitation dollars that may be reinvested or retained by plans, and improves ED performance metrics • DULCE site perspective: Where applicable, incentive pay could increase for individual practitioners when ED use is a performance metric
Intimate Partner Violence Potential Impact Negative Effects from Intimate Partner Violence • An estimated 12% of women with Medicaid coverage currently experience severe intimate partner violence (IPV) • These women have higher Medicaid expenditures than others; in addition, IPV is associated with an increased child risk of psychological, social, emotional, and behavioral problems DULCE Can Support Parents Experiencing Intimate Partner Violence • Based on data reported by DULCE sites, most DULCE families are evaluated for intimate partner violence and less than 5% screen positive • Medi-Cal budget perspective: Potential savings from increasing intimate partner violence counseling and related supports are approximately $38, 000 annually, via decreased health care costs for parents • Medi-Cal plan perspective: Averting unnecessary ED and other health care costs frees up capitation dollars that may be reinvested or retained by plans • DULCE site perspective: Where applicable, incentive pay could increase for individual practitioners when ED use is a performance metric
Breastfeeding Potential Impact Costs of Lack of Support for Breastfeeding • Among children who are not breastfed or are breastfed for shorter durations, childhood diseases such as otitis media (ear infections) are more common • Only 32% of mothers report exclusive breastfeeding at 3 months postpartum, and only 12% report exclusive breastfeeding at 6 months postpartum DULCE Can Support Breastfeeding Mothers • Based on data reported by DULCE sites, the share of DULCE mothers who discuss a need for breastfeeding assistance with a Family Specialist varies • Medi-Cal budget perspective: Potential savings from increasing duration of breastfeeding is up to $58, 000 annually, via decreased ear infections and associated sick visits that may be in an office-based or emergency department setting • Medi-Cal plan perspective: Averting unnecessary ED and other health care costs frees up capitation dollars that may be reinvested or retained by plans • DULCE site perspective: Where applicable, incentive pay could increase for individual practitioners when ED use is a performance metric
Maternal Depression Screening Potential Impact Costs of Maternal Depression • Postpartum depression (PPD) affects up to 60% of low-income mothers, who have a higher risk of infant hospitalization and higher medical costs than those who are not depressed • Recognizing the impacts on both mothers and children, the American Academy of Pediatrics / Bright Futures in 2017 added PPD screenings during well child visits to its recommendations; Medi-Cal plans are contractually required to cover these recommended services DULCE Can Support Mothers with Postpartum Depression • Based on data reported by DULCE sites, most DULCE mothers are evaluated for maternal depression and up to 15% screen positive • DULCE provides access to concrete supports for newborns and their families, which previous research suggests may reduce parental stress and protect against child neglect and abuse • Medi-Cal budget perspective: Potential savings from averting infant hospital stays and lowering health care costs for mothers are up to $138, 000 annually • Medi-Cal plan perspective: Averting unnecessary hospital and other health care costs frees up capitation dollars that may be reinvested or retained by plans • DULCE site perspective: Where applicable, incentive pay could increase for individual practitioners when inpatient admissions or total cost of care is a performance metric
Birth Timing and Spacing Potential Impact Cost of Unintended or Closely Spaced Births • In California, 48% of pregnancies are unintended; many of these are mistimed, and pregnancies less than 18 months after a birth are associated with adverse health outcomes • Among unplanned births in California, 64% are publicly funded; including maternity care and 60 months of care for the child, the cost per publicly funded birth exceeds $19, 000 DULCE Can Support Improved Timing and Spacing of Births • Based on data reported by DULCE sites, relatively few DULCE mothers currently discuss family planning services with a Family Specialist • In California, 6% of women with a recent birth are not using contraception postpartum • Medi-Cal budget perspective: Potential savings from decreasing unintended pregnancies are up to $193, 000 • Medi-Cal plan perspective: Improved birth spacing could reduce medical costs associated with preterm birth, neonatal morbidity, low birthweight, and other adverse outcomes, which frees up capitation dollars that may be reinvested or retained by plans • DULCE site perspective: Where applicable, incentive pay could increase for individual practitioners when birth spacing influences health outcomes that drive performance metrics
Additional Potential Cost Impacts of DULCE
Medi-Cal Enrollment and Retention Potential Impact For Medi-Cal plans, a lapse in coverage has financial consequences • Loss of capitation payment from state, up to $165 per member per month ($1, 980 per year) for common child eligibility groups • Potential for a family that loses coverage to switch to another plan upon re-enrollment (in counties where choice is available) • DULCE can help improve plans’ bottom line by facilitating continuous enrollment For DULCE sites, lack of coverage can lead to uncompensated care costs and medical debt collection issues • Enrolling eligible individuals in Medi-Cal ensures coverage for all eligible services. This helps avoid unnecessary stress for families as well as easing the burden on the health care provider. • At some sites, up to 30% of DULCE families need help with medical bill problems. As DULCE can demonstrate its impact on helping families resolve problems with billing and securing or retaining eligibility, a strong business case can be made for DULCE contributing to cost savings for managed care plans and for clinics.
Appendices
Selected Literature Sources DULCE Sege, R. et al. “Medical-Legal Strategies to Improve Infant Health Care: A Randomized Trial. “ Pediatrics 133, no. 1 (2015). 97 -106. https: //www. ncbi. nlm. nih. gov/pubmed/26034248. Flu Vaccinations Centers for Disease Control and Prevention. Flu Vaccine Effectiveness: Questions and Answers for Health Professionals. https: //www. cdc. gov/flu/professionals/vaccination/effectivenessqa. htm. Centers for Disease Control and Prevention. 2016 -17 Influenza Season Vaccination Coverage Dashboard. https: //www. cdc. gov/fluvaxview/reportshtml/reporti 1617/reportii/index. html. Jayasundara, K. , et al. “Natural attack rate of influenza in unvaccinated children and adults: a meta-regression analysis. ” BMC Infectious Diseases (2014). https: //www. ncbi. nlm. nih. gov/pmc/articles/PMC 4272519/pdf/12879_2014_Article_670. pdf. Ortega-Sanchez, I. R. et al. “Indirect, out-of-pocket and medical costs from influenza-related illness in young children. ” Vaccine 30 (2012). 4175 -81. https: //www. ncbi. nlm. nih. gov/pubmed/22546332. Rolfes M. A. et al. Estimated Influenza Illnesses, Medical Visits, Hospitalizations, and Deaths Averted by Vaccination in the United States. Centers for Disease Control and Prevention (2016). https: //www. cdc. gov/flu/about/disease/2015 -16. htm.
Selected Literature Sources (continued) Dental Edelstein, B. L. and Chinn , C. H. “Update on Disparities in Oral Health and Access to Dental Care for America's Children. ” Acad Pediatr. 9, no. 6 (2009). 415 -9. https: //www. ncbi. nlm. nih. gov/pubmed/19945076. Nowak, A. , et al. “Do Early Dental Visits Reduce Treatment and Treatment Costs for Children? ” Pediatric Dentistry 36, no. 7 (Nov. Dec. 2014). http: //www. aapd. org/assets/1/7/2016_Legislative_Fact_Sheet_4 -PD_Article_Early_Visits. pdf. Office of Inspector General, U. S. Department of Health and Human Services, Most Children with Medicaid in Four States Are Not Receving Required Dental Services. OEI-02 -14 -00390 (2016). https: //oig. hhs. gov/oei/reports/oei-02 -14 -00490. pdf. Emergency Department Visits Agency for Healthcare Research and Quality. Emergency room services - Median and Mean Expenses per Person With Expense and Distribution of Expenses by Source of Payment: United States, 2014. https: //meps. ahrq. gov/mepsweb/data_stats/quick_tables_results. jsp? component=1&subcomponent=0&year=2014&table. Series=1&search. Text=&search. Method=1&Action=Search. Machlin, S. and Adams, S. Expenses for Office-Based Physician Visits by Specialty, 2013. Nov. 2015. https: //meps. ahrq. gov/data_files/publications/st 484/stat 484. pdf. Medi-Cal Rates As of 1/15/2018 (Codes 94799 Thru 99600). https: //files. medical. ca. gov/pubsdoco/rates_information. asp? num=22&first=94799&last=99600.
Selected Literature Sources (continued) Maternal depression Adamo, Sharon, Isadora Hare, Mindy B. Legere, Janet L. Max, Samantha Meltzer-Brody, Pat Paluzzi, and Michael W. O'Hara. Identifying and Treating Maternal Depression: Strategies & Considerations for Health Plans. Issue brief. Washington, DC: NIHCM Foundation, 2010. Chung, E. , et al. Maternal Depressive Symptoms and Infant Health Practices Among Low-Income Women. June 2004. http: //pediatrics. aappublications. org/content/pediatrics/113/6/e 523. full. pdf. CMCS. Informational Bulletin: Maternal Depression Screening and Treatment: A Critical Role for Medicaid in the Care of Mothers and Children. May 2016. https: //www. medicaid. gov/federal-policy-guidance/downloads/cib 051116. pdf. Dagher Rada, K. , Mc. Govern Patricia, Dowd Bryan, and Gjerdingen Dwenda. “Postpartum Depression and Health Services Expenditures Among Employed Women. ” JOEM 54, no. 2 (February 2012). Downloaded July 25, 2016. http: //citeseerx. ist. psu. edu/viewdoc/download; jsessionid=75760 A 0 EF 38495 C 560 F 61 A 83 CB 026 F 87? doi=10. 1. 1. 224. 5402&rep=rep 1&type=pdf. Diaz, J & Chase, R. 2010. The Cost of Untreated Maternal Depression. Research Brief. St. Paul, Minnesota: Wilder Research. http: //www. wilder. org/Wilder. Research/Publications/Studies/Cost%20 of%20 Untreated%20 Maternal%20 Depression/The%20 Cost%20 of%20 Untreated%20 Maternal%20 Depression, %20 Brief. pdf. Mc. Daniel, M. and Lowenstein, C. Depression in Low-Income Mothers of Young Children: Are They Getting the Treatment They Need? April 2013. http: //www. urban. org/sites/default/files/publication/23546/412804 -Depression-in-Low-Income-Mothers-of-Young-Children-Are-They-Getting-the-Treatment-They-Need-. PDF. Olin, Su-Chin Serene, Bonnie Kerker, Ruth E. K. Stein, Dara Weiss, Emma D. Whitmyre, Kimberly Hoagwood, and Sarah M. Horwitz. "Can Postpartum Depression Be Managed in Pediatric Primary Care? " Journal of Women's Health 25. 4 (2016). 381 -90. Web. 26 May 2016. Sontag-Padilla, L. , Maternal Depression: Implications for Systems Serving Mother and Child. The RAND Corporation. 2014. Downloaded May 26, 2016 http: //www. rand. org/content/dam/rand/pubs/research_reports/RR 400/RR 404/RAND_RR 404. pdf. Sririram, DR. “Postpartum depression: Why pediatricians should screen new moms. ” Contemporary Pediatrics (June 2012). http: //contemporarypediatrics. modernmedicine. com/contemporary-pediatrics/news/modernmedicine/modern-medicine-feature-articles/postpartum-depression? page=full. Agency for Healthcare Research and Quality. Hospital inpatient services - Median and Mean Expenses per Person With Expense and Distribution of Expenses by Source of Payment: United States, 2014. https: //meps. ahrq. gov/mepsweb/data_stats/quick_tables_results. jsp? component=1&subcomponent=0&year=2014&table. Series=1&search. Text=&search. Method=1&Action=Search. Yu, H. , Wier, L. , and Elixhauser, A. Hospital Stays for Children, 2009. August 2011. https: //www. hcup-us. ahrq. gov/reports/statbriefs/sb 118. pdf.
Selected Literature Sources (continued) Birth spacing Karoly, L. A. et al. , Investing in Our Children: What We Know and Don’t Know About the Costs and Benefits of Early Childhood Interventions. RAND. 1998. https: //www. rand. org/content/dam/rand/pubs/monograph_reports/1998/MR 898. pdf. Kost, K. Unintended Pregnancy Rates at the State Level: Estimates for 2010 and Trends Since 2002. New York: Guttmacher Institute. January 2015. https: //www. guttmacher. org/sites/default/files/report_pdf/stateup 10. pdf. Mosher, W. , J. Jones, and J. Abma. “Nonuse of contraception among women at risk of unintended pregnancy in the United States. ” Contraception 92 (2015). 170 -176. Sonfield, A. and Kost, K. Public Costs from Unintended Pregnancies and the Role of Public Insurance Programs in Paying for Pregnancy-Related Care: National and State Estimates for 2010. New York: Guttmacher Institute. February 2015. https: //www. guttmacher. org/sites/default/files/report_pdf/public-costs-of-up-2010. pdf. Trussell, J. et al. , “Burden of unintended pregnancy in the United States: Potential savings with increased use of long-acting reversible contraception. ” Contraception 87 (2013). 154 -161. Breastfeeding Bartick, M. and Reinhold, A. “The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis” Pediatrics (April 2010). http: //www. breastfeedingor. org/wp-content/uploads/2012/10/burden-of-suboptimal-breastfeeding-in-the-us. -a-cost -analysis. pdf. Intimate Partner Violence Coker, A. L. , et al. “Physical Partner Violence and Medicaid Utilization and Expenditures, ” Public Health Reports (Nov. -Dec. 2004). https: //www. ncbi. nlm. nih. gov/pmc/articles/PMC 1497667/pdf/15504447. pdf.
Selected Literature Sources (continued) Cost-Benefit Analysis of Early Childhood Interventions Karoly, L. A. Toward Standardization of Benefit-Cost Analyses of Early Childhood Interventions. RAND. 2011. https: //www. rand. org/pubs/working_papers/WR 823. html. Nutrition & Food Insecurity Kids. Health. Nemours. Failure to Thrive. https: //kidshealth. org/en/parents/failure-thrive. html. Dulce Small Multiples, The Children’s Clinic Report. Run on 1/17/18. Adverse Childhood Experiences Felitti, V. J. et al. “Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. ” American Journal of Preventive Medicine 14, no. 4 (1998). 245 -258. http: //www. ajpmonline. org/article/S 0749 -3797(98)00017 -8/fulltext. Weintraub, K. “How Childhood Trauma Can Affect Your Long-Term Health. ” New York Times. February 1, 2018. https: //www. nytimes. com/2018/02/01/well/mind/how-childhood-trauma-can-affect-your-long-term-health. html. Housing Sandel, M. et al. Unstable Housing and Caregiver and Child Health in Renter Families. Pediatrics 141, no. 2 (2018). http: //childrenshealthwatch. org/wp-content/uploads/Unstable-Housing-and-Caregiver-and-Child-Health-in-Renter-Families. pdf.
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