The Pediatric Medical Home is directed by a pediatrician-led healthcare team that:
• Manages or facilitates all aspects of pediatric care
• Fosters a shared partnership with the child and family based on mutual respect and trust
• Supervises these vital services over the course of the child’s life
Such comprehensive care also includes pediatric medical and surgical sub specialists, who help to provide care for children with more complex medical or mental health needs. This comprehensive care will provide children in need with the ability to grow to their fullest potential in physical, oral, vision and mental behavioral/health. The Pediatric Medical Home can help lower financial costs to the individual and the community over the short and long term.
However, there are barriers to those goals, including:
• Financing and payment for care that is at least on par with Medicare payment for the same service
• Payment parity for telemedicine/telehealth services provided in the Pediatric Medical Home
• Infrastructure for care coordination
• Provider network scarcity in subspecialty coverage
• Compensation for all services as defined in Bright Futures and EPSDT benefits
• Support and compensation for care coordination delivered by the Pediatric Medical Home
• Payment for behavioral/mental health services to pediatric providers
Currently, New Jersey faces critical shortages in general pediatrics and pediatric subspecialties such as rheumatology, cardiology, orthopedics, child psychiatry and others. Lack of access to these services significantly impacts the quality of life for patients and requires many families to leave NJ to obtain the needed specialty care for their children.
Payment barriers and provider network scarcity continue to bar families from obtaining necessary and timely specialty care. These barriers can be effectively bridged by offering incentives to specialists that are most needed by our families. Appropriate insurance reform that does not penalize children covered by state-supported insurance is crucial. New Jersey continues to make progress in the financing of healthcare for children with the Children’s Health Insurance Program (CHIP) and NJ Family Care, but substantial gaps remain.
Pediatric health services provided by private, public insurance plans and managed care organizations should cover all services as defined by Bright Futures and the Early and Periodic Screening, Diagnostic and Treatment benefit (EPSDT). To ensure pediatric access to needed services, Medicaid and Medicaid HMOs must implement payment parity with Medicare to pediatric providers and limit bundle payments for preventative services.
A study conducted by the University of Pennsylvania and published in the New England Journal of Medicine, reported that New Jersey achieved one of the country’s largest increases in patient access to Medicaid services when payments were increased to parity with Medicare. Conversely, an NJAAP survey revealed that the failure to renew these Medicaid parity payments resulted in a reduction, and in some cases, the elimination of these increased services throughout New Jersey.
A Medicaid Card Alone Does Not Ensure Access To A Pediatric Medical Home
Explore NJAAP Medical Home Programs
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