“All politics is local. You can make them aware but you cannot make them care,” says a veteran youth court judge on a hot summer August day in Mississippi. He grew up in a town with daily youth curfews to avoid racial violence ripping through the south. A strong children’s advocate, he spent decades on the bench with the objective of centering children’s well-being in his court adjudication cases. He travels in and out of state with the goal of empowering jurists to balance compassion while enforcing the law. He is also the first person on my first day as a fellow at the Children’s Foundation of Mississippi to tie together equity, the law, politics, and the inadequacy of Medicaid coverage for children.
Medicaid is a health insurance program available to low-income adults, children, pregnant women, elderly adults, and people with disabilities who are US citizens. Medicaid is administered by the states and is jointly funded by the federal and state governments. The federal government approves each state to set parameters on supplements to the medical insurance of residents who are low-income. States have the latitude to limit access to individuals on additional services they provide and states can set tight eligibility rules. In Mississippi, the state limits medical access to some medical services, including behavioral health. Legislators are not persuaded by the medical access progress of other states unless the progress is by their southern neighbors (Alabama, Tennessee, or Louisiana). The rugged individualism of residents leads people to state, “Pick yourself up by your bootstraps.” As one child advocate said to me, “How can you pick yourself up when you don’t have any straps nor boots?”
The Children’s Foundation of Mississippi (CFM) is focused on advocacy in numerous health and social issues as they pertain to Mississippi children. The current focus is on advocacy to expand behavioral health services for children in foster care. CFM and the Mississippi Division of Medicaid (MSDOM) need a national landscape analysis of Value Based Purchasing (VBP) through managed care organizations (MCOs) that inform how Medicaid is reimbursed for children’s behavioral health. VBP is an alternative payment model different from Fee For Service (FFS). VBP is a “broad set of performance-based payment strategies that link financial incentives to provider’s performance on a set of defined quality and/or cost or resource use.”¹ The providers are not paid based on frequency of visits in a VBP model, but on a capitation model with incentives to increase quality of care. The MSDOM and CFM are dedicated to completing a redesign of services for children in foster care (CFC) under the Behavioral Health component of Medicaid. The different approach will identify mental health providers, increase the behavioral health reimbursement rates, and identify the specific VBP strategies and performance metrics that would lead to better outcomes for children in foster care. A VBP strategy ensures children with complex behavioral needs get tailored services that are opportune and uninterrupted to improve behavioral health for children in foster care.
The political perspectives of Mississippi residents and legislators are not to be dismissed. Story-telling is a strategy for trust building and acceptance of systems change. If Mississippi advocates can build bipartisan support for VBP they need to know what to highlight. The appalling stories of children being placed in hotels with a case worker due to complexity of behavioral cases is one story that can harness attention. There is currently an opportunity with the unprecedented crisis of Roe vs Wade being overturned, for advocates to demand increased medical care for vulnerable populations including post-partum care and other medical and behavioral services now denied to Medicaid residents. The mental health care for foster children is a complicated landmine to traverse to solve social inequities. The VBP model can provide rewards for health outcomes to address inequities, support investment in data to identify disparities and align equity to existing high priority activities related to payment reform. ² There are promising elements from other state models to emulate. Nevada developed a strengths-based tool (NV-CANS) that has aggregate outcomes evaluation indicators. ³ New York created subcommittees to oversee a VBP roadmap. ⁴ Massachusetts instituted global budgets specific to the needs of patients with complex needs. ⁵ Rhode Island’s Medicaid program supports screening focused on health disparities. ⁶
The state managed care organizations must depart from FFS models. The VBP models will decrease health costs, increase patient satisfaction, and focus on quality improvement in health care with better health outcomes. Mississippi can weave together a model that is sustainable and has buy-in from multiple implementing partners (patients, providers, advocates, legislators). Health access is a vital component of addressing inequities to ensure medical access and quality care are available to children.
We have an opportunity to support legislation to create a VBP focused for children in foster care. The unintended consequences of not addressing the behavioral needs of children in foster care are that residents will pay the price at the court systems, at the schools and emergency rooms as children become adults and require more intensive behavioral interventions. The price of instituting VBP within MCOs will save the Mississippi state millions by adopting a preventative (not a reactive) approach now.
Rosanna M. Batista, MPH, is a second year DrPH student committed to addressing domestic and global health disparities and through systems change shaping how health and family support are provided to communities impacted by structural inequities.
