WILMINGTON – Delaware and Nemours are paving the way as the first in the nation to create a pediatric global revenue budget model, one that could benefit the state’s 120,000 children who are currently enrolled in Medicaid.
The new joint payor agreement seeks to flip the typical payment narrative upside-down in hopes of decreasing the amount of unnecessary medical expenses before they occur by incentivizing Nemours and its providers when they address both medical and non-medical drivers of health.
“We know that what happens in a child’s home, school, and community is critical in setting them up for lifelong health, yet America’s healthcare institutions are primarily paid for providing medical care. Today’s agreement creates the financial incentives for Nemours and the state of Delaware to align on what we all want: healthier kids who grow up to become healthier adults,” Nemours Children’s Health President and CEO Dr. R. Lawrence Moss said in a press release.
Nemours Executive Vice President and Chief Population Health Officer Kara Walker told the Delaware Business Times that aligning the health outcomes is really what it’s all about for the two entities.
“When we are on a fee for service basis, our families pay for more things like visits, tests and x-rays. This is really allowing us to lean into [questions like] how do we prevent and track those things together,” she told DBT.
While the average parent and/or patient may not notice any changes at first, she said the changes will hopefully become noticeable over time by caregivers and providers.
“Only 20% of what matters to create health happens inside the walls of a hospitals or physician office. So much of it is outside our walls – where you live, where you play, where you worship… We know those other things matter; they are the social determinants of health,” Walker explained.
“You know that there’s so many other needs, but we’re often not oriented in that way. We’re not taught to think about that, not given the tools necessarily. This is a moment for Nemours to be bold, to be aggressive… We know that nutrition matters. We know that asking about mental health care matters. We know that avoiding that visit because the child has asthma and didn’t have the right medication matters. And now we’re going to be financially rewarded for making sure that kiddos that need those steps get them,” she added.
The change in its payor model will encourage providers to ask more questions about safe housing or food insecurity, allowing them the chance to offer resources to help in other areas beyond medical care.
“This is allowing us to create that alignment. It truly is kind of the first in the nation in terms of aligning all of the Medicaid revenue in pediatrics. Others have done it in the adult space. But for us, we believe in the long trajectory of life where every child has the opportunity to thrive. It requires partnerships which requires leaning in to the whole person health aspects,” Walker told DBT.
President of the Delaware Valley Region Mark Marcantano called the opportunity to expand health options for Delaware children transformational, detailing some of the topics mentioned by Walker, as well as literacy concerns, food insecurity and other topics that support a child’s whole wellbeing.
“This is what we live for. This is why we’re in this space. Every opportunity we have to bring our worldclass talent and abilities, to earn their right to be their first choice, that’s where we pinch ourselves, right? This is a transformational payor model. It’s easier and more comprehensive. It doesn’t get much better than that. It’s so good for the state,” Marcantano told DBT.
The initial payor agreement is set for three years, during which updates will be provided between the two parties through the Centers for Medicare and Medicaid Services (CMS) and the Delaware Division of Medicaid and Medical Assistance (DMMA) to track various metrics. Marcantano said he is hopeful that the new changes truly are as transformational as he believes they can be, lending itself to the possibility of extension and expansion.
“If we can make this experiment work for the longer term and have the cooperation we anticipate from the state and other key stakeholders, and gain ground on affordable healthcare, that’s going to be attractive to the business community, as well,” he told DBT. “We can help sustain businesses while helping provide healthcare for employees. As we get to sit in places like the Delaware Business Roundtable, chambers of commerce and other areas, these are obviously big areas of concern, and I think this is one way we can help provide solutions.”
