Aligning services with needs: characterizing the pyramid of complexity tiering for children with chronic and complex conditions
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Report (Lucile Packard Foundation for Children's Health)
- Author(s):
- Stille, Christopher J., author Antonelli, Richard C., author Spencer, Karen, author Forlenza, Eileen, author Marsh, Rebekah, author Mukherjee, Debjani, author Tomcho, Margaret, author Schiff, Jeff, author Wells, Nora, author Perrin, James M., author
- Contributor(s):
- Lucile Packard Foundation for Children's Health, issuing body.
- Publication:
- Palo Alto, CA : Lucile Packard Foundation for Children's Health, February 2018
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Child Health Services Chronic Disease Delivery of Health Care, Integrated Disabled Children Health Services Needs and Demand Mental Disorders Mental Health Services Adolescent Behavioral Medicine Child Family Insurance, Health, Reimbursement Risk Assessment Social Determinants of Health Humans United States
- Genre(s):
- Technical Report
- Abstract:
- As health care and financing systems become more sophisticated, anticipating and identifying which children are likely to be high utilizers of services is becoming more important. Anticipating the service needs of these children will allow the judicious provision of care coordination and other services where they will be most effective. Children and youth with special health care needs (CYSHCN), comprising about 19 percent of US children, require more resources than most other children. The 0.5 to 1 percent with the most complex conditions account for as much as one-third of child health care costs. This becomes more significant as payers and health systems introduce alternative and risk-based payment models that require accurate assessment of resource needs for individuals and populations. Payers must anticipate needs across the population of patients they cover for budgeting, rate setting, and contracting. Health systems must identify which children might need enhanced care coordination services, to plan for hiring care coordinators and negotiating with payers. "Risk tiering"--perhaps better called resource needs assessment--is a process that health care systems and payers in the United States increasingly use to group patients with similar degrees of health care resource needs. Families and care providers of children with special health care needs should understand the details of the process, as risk tiering may affect access to services these children need. We define tiering as the use of risk stratification methods to group children according to the intensity of their health care service utilization and care coordination needs. Risk assessment typically begins by using data on classification of conditions and health care utilization patterns. This work has included modeling by academicians and children's hospitals;1 diagnosis-based screener development by scientists associated with the Research Consortium on Chronic Conditions in Children; and the Agency for Health Care Research and Quality's childhood chronic condition grouper (among others). Research and literature on risk assessment is fairly well established, though consensus on a preferred methodology has not been achieved, and the choice of methods may reflect the intended use of the risk assessment. Next, children are stratified into three to four "tiers," with healthy children in the lowest tier, children with catastrophic conditions (usually <1% of the population) in the highest, and others in between. Depending on the methodology, the third tier is sometimes designated to encompass the nearly 5 percent of children who have complex, but not catastrophic, health conditions. Finally, these tiers can be used to establish policies around payment, so that capitated care for higher-risk children is reimbursed at a higher rate, or to determine eligibility for additional services such as enhanced care coordination. Decision-making based on tiering is beginning to be integrated into policies affecting adult health care, but child health care policy lags behind in this regard. All current stratification methods have their base in clinical variations; none yet incorporate social determinants of health (SDH) and their impact on medical conditions or care needs. Current tiering depends on data that exist in administrative (mainly billing) databases and medical records. Prediction of needs based on these data requires assumptions that may not be accurate when applied to children. Patterns of chronic conditions in children and the service needs associated with these conditions differ from those in adults; in addition, children's needs change more rapidly. As with adults, behavioral health issues and social factors (e.g., housing, family stability, and food security) interact extensively with medical needs to affect the resources needed to maintain or improve the health of CYSHCN. Current data sources may not include data on behavioral health or SDH, and health care systems are not well equipped to deal with the complexity those factors contribute to care. Similarly, but on the other side of the coin, current tiering methods do not typically incorporate data about family strengths and resources that might mitigate risk and inform resource allocation. Despite these limitations, resource allocation for CYSHCN requires planning, which begins by using available data and augmenting those data when possible. Recognizing the need for information about and improvements in the current state of risk tiering for CYSHCN, we undertook a nine-month project to understand current practices in tiering and make recommendations for policy and research. The project extended from December 2016 to August 2017, at the inception of which we assembled a panel of experts to identify key questions on the topic and begin the discussion of current status and future directions.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY license. (More information)
- Extent:
- 1 online resource (1 PDF file (14 pages)).
- NLM Unique ID:
- 101744810 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101744810