Repairing the Safety Net: Maintaining Access to Primary and Preventive Care for Kids
Earlier this week, the Center for Medicare and Medicaid Services (CMS) released preliminary data showing that efforts to reduce the spread of COVID-19 in March, April, and May of 2020 led to an unprecedented drop in access to important, time-sensitive primary and preventive care services for children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).
CMS reports that during this time frame, Medicaid claims data show:
22 percent fewer vaccinations for children up to age 2;
44 percent fewer screening services to assess physical and cognitive development, and serve as early detection opportunities for conditions like autism and developmental delays;
69 percent fewer dental services;
44 percent fewer outpatient mental health services.
A decline in access and delivery of care during the spring of 2020 was expected; a direct result of a nationwide effort to curb virus transmission through quarantine. What was unknown until yesterday was the degree of that decline. If Medicaid is our nation’s safety net for our most vulnerable children, COVID-19 ripped at its seams.
What does this mean?
The decline in pediatric care requires attention for Medicaid and commercially-insured populations. CMS’ data can reasonably, directionally point to a similarly disturbing reduction in care for all children, regardless of payer, socio-economic status, race, or geography.
These data are despite a 2,500% increase in telehealth and teletherapies between February and April of 2020. It is unclear from CMS’ data report what specific impact virtual care modalities had in mitigating the reduction in primary and preventive service delivery during this time period.
More information about recovery rates is forthcoming. Due to the lag for processing medical claims, we do not yet know the degree of recovery as clinics began to reopen or increase volumes served over the summer months. Though it is likely the rates of services provided will improve, it is unrealistic to expect rates to fully recover to pre-pandemic levels for some time.
All of the services highlighted in the CMS report are time- or age-sensitive. Vaccination schedules are calibrated to ensure optimum protection for a child, based on age, and optimum efficacy of the vaccine, based on dosing schedules. Delays in physical and cognitive development or dental decay are critical to identify as early as possible.
Disruption in child therapeutic care may continue. With schools closed or limiting in-person instruction, children who receive therapies in schools may not have a clear, consistent, or realistic back-up option for this important care. Similarly, children who would be evaluated for Birth-to-Three services, receive therapies in their homes, or be triaged to school-based care as they approach preschool age may struggle to access the care they need.
The onset of COVID-19 compounded pre-existing challenges for families enrolled in Medicaid. Lack of reliable transportation; living in neighborhoods with few health providers; health needs that extend well beyond medicine, like food insecurity, housing, or unemployment; system racism and cultural insensitivity – these are all known barriers to Medicaid members, particularly those families of color, to access care. These factors remain and likely have become more acute in the midst of the pandemic.
What comes next?
COVID response planning often conjures up a scene in Apollo 13, in which NASA engineers need to figure out how to fit a literal square filter into a round canister, using only materials on hand, to build a rudimentary system to scrub carbon dioxide from the air in the space shuttle and save Tom Hanks.
The recent data from CMS heightens the urgency to plan to protect access to pediatric primary and preventive services during an extraordinary upcoming viral season. While these plans must be anchored by local transmission rates, population risks, resources, etc., we believe that common factors will be shared among communities best prepared. Some examples follow.
Children’s primary and preventive care must be considered an essential service.
A cross-sector team of clinicians, public health leaders, early-childhood educators, social service providers, and government agencies can and should develop scenarios based on minimum and target levels of access regardless of transmission rates within a community.
Medicaid and commercial payers should further expand authorization and reimbursement for telehealth and teletherapy services, particularly for mental and behavioral health care. For example, payers can cover the costs of at least ten telehealth services for each individual, eliminating the initial need for patients to pay upfront.
Children enrolled in Medicaid, who are under the age of two, and children with special health needs should be prioritized to maintain AAP periodicity for well-child checks and vaccinations.
Clinics and health systems have already responded in the spirit of NASA engineers by critically evaluating and redesigning care delivery. More is needed. Examples include:
Turning parking garages and lots into drive-through testing sites and vaccination clinics, for appropriate age groups and vaccines.
Establishing “clean” clinic locations, days of the week, or hours in the morning to exclusively schedule well-child visits
Re-imagining provider and caretaker communication strategies and redefining respective roles and responsibilities in order to best benefit kids.