Paying for caregiver screening and services in pediatrics: Overcoming barriers to provider reimbursement

By Brian Jenssen, | November 7, 2017

Stoneleigh Emerging Leader Fellow Leigh Wilson and Brian Jenssen explain how pediatricians can advocate for addressing caregivers’ health as a way to improve children’s health via PolicyLab. 

Pediatric clinical teams are uniquely positioned to support and protect child health by educating, motivating, and, when needed, directly addressing the health-related social needs of parents or primary caregivers. In our clinical experience, caregivers are distinctively motivated to change their behavior to help their children.

Pediatricians often represent a primary source of in-person health care advice. While healthy parents may have little contact with their own physicians, parents see their child’s doctor on average four times each year, and are receptive to their pediatrician offering interventions to them directly. These can include services for their tobacco use or mental health needs.

growing evidence-base shows increasing recognition that caregiver screening and service delivery can improve the health outcomes of children – so how can health care systems pay for it? Reimbursement, sometimes through the child’s insurance, is necessary to ensure physicians are widely using screening.

Building Billing Infrastructure for Caregiver-directed Services Under A Child’s Insurance Plan
States and health care systems have begun exploring the possibility of billing the child’s health insurance plan for reimbursement of parent-focused screenings or services that can directly improve the health of the child. Two existing examples of this are: 1) smoking and tobacco use cessation screening and counseling and 2) maternal depression screenings and brief treatment:

  1. Smoking Cessation: The Centers for Medicare & Medicaid Services (CMS) announced coverage benefits for tobacco cessation counseling from a qualified physician or other CMS recognized practitioner in April 2010. Most private payers follow CMS guidance regarding health plan benefits.
  2. Maternal Depression: At least 13 states, including Pennsylvania, follow recent CMS guidance that allows pediatric health systems to bill the child’s Medicaid plan for maternal depression screenings and, in some cases, brief maternal treatment.

These examples present an infrastructure for thinking more holistically about how we can best support children and their families in pediatrics.

Challenges to Billing for Parent-focused Services in Pediatrics
Yet, pediatric providers face several barriers when billing for parent-caregiver services. First, reimbursement for parental-screening and services in pediatrics is not standardized across or within states. For example, among the states that allow the child’s Medicaid plan to reimburse for maternal depression screenings, there is variation in which visits the screening can be performed (e.g., routine newborn or four month visits), how often, and whether the reimbursement extends to brief treatment. Additionally, while making reimbursement possible under pediatric Medicaid plans is a great step, it can present logistical challenges for health care systems that have a large proportion of patients with private health care plans.

Second, although pediatricians can be reimbursed for providing certain services to parents, current billing and coding structures often separate this option from preventive health visits. Smoking cessation services for parents, for example, are often only reimbursed during acute visits, in which a child must be experiencing adverse effects from a parents’ tobacco use. Preventive health visits offer an often missed opportunity to discuss parental needs and health care before it negatively affects the child.

Third, it is commonly unclear to pediatric providers which code to use for caregiver-directed services. The AAP provides guidance on what codes to use for caregiver smoking treatment and for maternal depression screenings, but more education is needed to ensure pediatric practices are aware that these codes are available and that families will not be billed.

Finally, reimbursement for these services is often provided in the context of fee-for-service payment models. As health systems move increasingly toward managed care arrangements, or contracts with health care providers and health systems to provide care for members at reduced costs, we will need to think innovatively about how to incorporate parent-caregiver services into value-based payment models.

Finding New Solutions and The Role of Innovation
Reimbursement for parent-caregiver services, embedded within pediatric preventive visits and covered under the child’s health insurance, offer new opportunities for value-based care. For example, under the Affordable Care Act (ACA) and Patient Centered Medical Home programs, opportunities exist to include parent-caregiver services in “bundles” of care related to social risk factors of child health.

Regardless of reimbursement infrastructure, pediatric and adult health care systems will need to better coordinate care for children and their families to address child health outcomes that are rooted in caregiver health behaviors. Health care systems are in constant evolution, with dramatic shifts in information technology, new ways to connect patients and providers, innovative therapeutic options, and changes in patient and family wants and needs. As how we practice medicine changes, so to must payment and reimbursement structures.

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