This article first appeared in the St. Louis Beacon, Jan. 31, 2011 - More than 30 states, including Illinois, have adopted the American Academy of Pediatrics' philosophy that every child needs a medical home. Missouri is studying the idea and could decide later this year whether to embrace it.
Although the medical home model isn't new, it only began to take off in this decade when North Carolina shifted Medicaid children from fee-for-service programs to the medical home model.
Contrary to what it sounds like, the model isn't a place where kids live, but a care network in which they get comprehensive and preventive health services that help them stay well. Health care providers are encouraged to treat little problems before they become big medical issues. Children get checkups, screenings and shots; and parents and guardians are given advice on caring for children.
The model is said to help patients avoid costly hospital stays and emergency room visits that drive up the cost of health care. In fact, controlling health care cost is the first point North Carolina makes in explaining why it moved to a medical home system. State officials say it saved $231 million during the 2005 and 2006 fiscal years alone.
"I can tell you that it does continue to offer a great return for the state," says Tom Vitaglione, senior fellow with Action for Children North Carolina. "The way it works is that doctors are given an incentive to participate because they are not only guaranteed their usual billing rate for services provided, but they also get an extra $2 to $3 per month" as a coordination fee for each Medicaid patient served.
At the same time, he says children with high medical risks, such as asthma and diabetes, get ongoing care they otherwise might not receive.
"It saves the state money because children are in preventive care longer. They are no longer in and out of the hospital, so that reduces medical cost. It's an attractive program. Physicians across the state are joining it."
Aleasha Mays, assistant director of communications for the Missouri Department of Social Services, says Missouri has been studying medical home models but hasn't reached the stage of drafting a plan. She said officials were reviewing programs that might benefit certain children with chronic conditions. She says the state expects to complete its review by July. Doctors and other health care providers, as well as parents and advocates for children, would have the opportunity to comment on any proposal the state develops.
One provider who embraces the medical home model for children is Dr. Blaine Sayre, former president of the St. Louis Pediatric Society. He says Missouri already has a system in place to make medical homes feasible. The framework is in place because 80 percent of children receiving Medicaid already are enrolled with a specific provider.
"That's the first step for a medical home. A given provider is held accountable for a panel of patients. But the (Missouri) Medicaid managed care program turned out to be a way of managing costs as opposed to managing care."
To make the point, he mentions a patient, a 17-year-old girl who is "very intelligent, real college material with high aspiration." But he fears she will get lost because her weight has "ballooned in the last year up to 217 pounds. She's five feet tall and is not able to physically keep up with her peers. Because of that, her self image is terrible."
In addition, she's now pre-diabetic, he says, and lives in what she has told him is a "very depressing home setting." He says he can spend about a half hour with her, and can offer medicine to help her with depression. But he says, "I'm a poor substitute for that comprehensive care with allied health professionals that she really needs."
He says he gets $5 or $6 a month to provide certain services, while the insurer turns down approval for other health-related needs, such as family counseling and enrollment for her in a weight-loss program.
"This is what we're dealing with," he says of pediatricians. "Potentially, if we were to get money to provide better services, the child I described would receive much, much more effective care."
Such care, he says, "would mean the young lady's life would be turned around and she'd be more likely to reach her potential. Not only in terms of her health, but in achieving her intellectual potential and becoming a constructive professional in the community."
Local and state pediatric groups are supporting the creation of a medical home program for children receiving Medicaid in Missouri.
