Babies Don’t Go to the Doctor By Themselves
Babies Don’t Go to the Doctor By Themselves: Innovating a Dyadic Behavioral Health Payment Model to Serve the Youngest Primary Care Patients and Their Families
The caregiving and family context is the most critical factor influencing development for young children ages birth to 3 years old. Pediatric well baby visits—of which there are seven during the first years of life and 12 by the time the child turns 3 years old—comprise the most frequent point of contact with the healthcare system for families with young children. Research shows this to be true even for caregivers, who are notorious for not seeking their own health care during the early years of their child’s life. As a result, much of the caregiver and family surveillance and family-based intervention to support child development (i.e. “dyadic health care services”) occurs within the context of routine well-child care in pediatrics. However, in the absence of a diagnosable mental disorder for the infant (as is the case with most children, even those at risk for future mental disorders as a result of family adversity), the majority of dyadic health care services delivered during pediatric well-child visits are not reimbursable in the current health care payment structure.
The UCSF/Zuckerberg San Francisco General Hospital and Trauma Center Children’s Health Center, in collaboration with The California Children’s Trust, proposes a one-year pilot to include dyadic health care services reimbursement codes under the Mild to Moderate Mental Health Benefit administered by California’s MediCal Managed Care Organizations. This proposal outlines four billing strategies for health plan leadership to consider. The proposal caps the financial exposure of participating plans and is restricted to the CHC. Concurrent with the pilot’s implementation is a direct advocacy strategy to insure that Department of Health Care Services amends its guidance to plans to provide direct assurance that pilot expenditures will be included in future rate-setting negotiations. The proposal also details the historic challenges that have prevented the provision and reimbursement of dyadic models, the evidence base and health outcomes data associated with these models, and the mechanics of the pilot and associated advocacy strategy.
This proposal to Anthem Blue Cross and San Francisco Health Plan is a one-year pilot in one of San Francisco’s highest volume safety net pediatric clinics. The goal is to demonstrate the clinical benefit and impact of aligning reimbursement for mild to moderate mental health services with dyadic models, specifically the evidence-based HealthySteps Model of integrated primary care.