Single (Aim)-Minded Strategies for Demonstrating Value to Payers for Youth With Medical Complexity

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Abstract

In the current financial climate, health care institutions and providers experience substantial challenges in achieving the Triple Aim in health care reform (i.e., reducing costs, improving health, improving care). The present study describes the successes and challenges of garnering payment for a population health program, Novel Interventions in Children’s Health care (NICH), for youth with both medical and social vulnerability. Using 4 real patient scenarios, this study provides examples of how to use economic data to demonstrate program value to key stakeholders (i.e., insurance providers, hospital administrators) and obtain authorization and payment for services. Health care utilization and cost data were retrieved through retrospective review of patient medical records and hospital financial records. NICH utilized distinct strategies to overcome systemic barriers, demonstrate value, and show need for intervention to key stakeholders. Strategies included highlighting patients’: (a) history of utilization, (b) accumulated medical expenditures, (c) projected costs for anticipated procedures, and (d) social risk linked to poor health and high utilization. We describe each effort using real patient scenarios that feature varied medical conditions including Type 1 diabetes, chronic pain, and failure-to-thrive. Economic data can be a useful tool in garnering support for behavioral health interventions. And while these data offer programs like NICH the opportunity to make the case for investing in an alternative intervention, the strategies utilized by NICH to advocate for services can be applied by pediatric psychologists working with youth with medical complexity and social vulnerability.

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