Eugene L. Mahmoud, MD

Neonatologists, as well as all health-care providers, should keep abreast of the benefits of health insurance guidelines and the negative effects of inadequate health coverage. Children in poverty who otherwise would not have access to health care have greatly benefited from Medicaid and the Children’s Health Insurance Care Act. Recent data from the Centers for Medicare & Medicaid Services show the number of children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) nationwide fell by more than 840,000 in 2018. The AAP and its members have undertaken robust advocacy efforts to protect against ongoing threats to health insurance coverage, such as proposed cuts to Medicaid and policies to undermine the Affordable Care Act. On January 22, 2018, Congress passed a six-year funding extension for CHIP. Private insurance is more likely than public insurance to cover the provisions needed but does less well than public coverage in leaving families with reasonable health care expenses. In the last three decades, there has been a major transformation in the way in which private and public health insurance is offered. Once the most common form of coverage, indemnity plans accounted for 73% of employment-based health insurance as late as 1988. Over the next 20 years, only about 3% of workers with employer coverage were enrolled in indemnity plans in 2007, whereas 57% were enrolled in preferred provider organizations (PPOs), 21% in health maintenance organizations (HMOs), and 13% in point-of-service plans, which combine features of HMOs and PPOs. Consumer-directed health plans (CDHPs) have emerged. These plans, which trade lower premiums for higher deductibles, account for a small but growing segment of employer-based coverage. Health insurance entities that provide finance along with private insurance, employers, and government must continue to work together to ensure that all children have health insurance that meets their needs.

One service within the healthcare industry that has experienced notable growth is independent medical peer review, conducted by independent review organizations (IROs). A big contributor to this growth is the Affordable Care Act as it allows for the use of external IROs to serve as unbiased, third-party reviewers of denied medical claims to determine whether or not a healthcare service is appropriate and medically necessary. IROs play an important role in the goal of making healthcare safer and more affordable for every U.S. resident. They also offer advantages for health plans and their patients, including reduced costs, access to clinically trained resources, improved compliance, and objective decision-making. IROs have become a popular choice for medical reviews because they offer unbiased decisions and eliminate conflicts of interest. They ensure that each party is considered through a resolution that examines clinical documentation, applies evidence-based guidelines and plan language, and oftentimes includes peer-to-peer calls in which the treating physician and reviewing physician confer over a case. The peer-review calls allow for an explanation of the medical necessary benefits, which may not have been provided in the original request. When a requested service from the provider or patient is denied for insurance coverage, it may be subject to a series of review processes. With the internal appeals process, the insurance client is free to request internal guidelines, plan language, and/or medical literature being used to support the rationale and make a recommendation. And with the external appeals process, evidence-based, peer-reviewed medical literature should be consulted and used to support recommendation.

Private insurance carriers with expert medical involvement generate clear policies and procedures with criteria to their subscribers delineating which medical services are covered by insurance and which medical services are not covered by insurance. Medical providers are expected to make available all medical documentation to ensure that the request for medical care insurance coverage is consistent with what is the standard care of practice commonly provided.

This relates to Neonatal Care, children with disabilities, and developmental delays often have unmet needs for rehabilitation therapy services, especially if they have inadequate insurance. Some insurance plans have coverage for rehabilitation therapy services. And these may have high copay fees, high coinsurance rates, or cap the number of visits or services. As a result, many families may report unmet health needs on account of inadequate coverage. When this is the situation, the physician is needed to help coordinate services as much as possible and make the needed referrals to an advocacy organization that helps families find appropriate health providers. Working with Social Services to keep a list of agencies and organizations to which the families may access is recommended. Inpatient and outpatient therapy services are based on goals for developing new skills, regaining lost skills (due to illness or medical intervention), maintaining skills at risk of decreasing, making adaptations for functional loss, and providing accommodations. Determining the appropriate dose of therapy is elusive and subjective. Children with chronic health conditions disabilities often need therapy on an ongoing basis with variable intensities for their individual functional goals.

With increasing numbers, children with unresolved medical problems or special health care needs (such as hospice and palliative care) have been discharged requiring some form of supportive technology. For newborn and premature infants, as well as those with complex medical conditions, gavage feeding may be used safely in the home. In addition, home intravenous nutritional support may be needed when enteral feeding is not possible with home health care support. Care of each high-risk neonate after discharge must be carefully coordinated to provide ongoing multidisciplinary support for the family, including the neonatologist, nurse practitioner, pediatric medical subspecialists, nursing staff, respiratory, physical, occupational, and speech therapists, social services, and discharge planner This is especially required when oxygen therapy or pulse oximetry is involved with newborns having respiratory conditions requiring continued use. Management of continued use is under the direction of a physician. For those infants needing mechanical ventilator support by endotracheal or tracheostomy tube, home health nursing is indispensable for at least part of the day.

For those families who need to provide the medical childcare in the home, this may produce somewhat of a crisis by not being able to work outside of the home in order to care for the child, which complicates how much health insurance may be available for the child’s medical health care. Parents in lowerincome families raising children with special health care needs are especially overburdened by debt that may be incurred. Cost-sharing burdens among the privately insured have grown over time. Medical bills are a leading cause of financial harm associated with poor health outcomes and reduced quality of life.

As a nation, we spend 17.9% of our gross domestic product on health care or ~$10,348 per person per year. The largest share of this spending comes from the federal government. Because the increased focus has been turned to curbing health care costs, a possible approach to reducing federal health care spending would be to tighten eligibility requirements for public insurance, including Medicaid and the Children’s Health Insurance Program (CHIP). Indeed, President Trump’s proposed 2018 budget included a plan to reduce eligibility for CHIP, which was projected to result in a net saving of $5.8 billion over 10 years. Although Congress recently reauthorized the CHIP at stable funding levels, the administration’s 2019 budget proposal continues to propose >$1 trillion in Medicaid cuts over a decade, with the reallocation of some funds coming in the form of block grants to states.

Medicaid and the Children’s Health Insurance Program (CHIP) provide health care to over 30 million children. Income eligibility limits for Medicaid have historically directed Medicaid-funded health care to children in poverty. In 1997, the introduction of CHIP (hereafter, Medicaid and CHIP will be referred to simply as “public insurance”) expanded health care access for children, including many in low-income working families.

Reducing public insurance eligibility may potentially result in a large number of children who are currently publicly insured having to either purchase commercial insurance or become uninsured. With these findings, we can also predict substantial shifts in costs to lower-income families, commercial insurance (if obtainable by families), and/or the health care institutions that serve them. Increases in child health care access resulted in more consistent primary care use, decreases in avoidable hospitalizations, and decreases in child mortality. Rollbacks in public insurance eligibility criteria may potentially result in large increases in both non-insurance and underinsurance owing to the cost of obtaining commercial insurance coverage for low income working families. Reducing public insurance income eligibility criteria may place health care institutions at greater financial risk, especially safety-net hospitals, which already operate at narrower financial margins and other hospitals serving large numbers of newborns and low-income families. Any reductions in state-level funding for pediatric public insurance programs may result in lowering of eligibility thresholds. Reducing public insurance eligibility limits would have resulted in numerous pediatric hospitalizations not covered by public insurance, shifting costs to families, other insurers, or hospitals. Without adequately subsidized commercial insurance, this reflects a potentially substantial economic hardship for families and hospitals serving them.

References:

1. Consumer Health Insurance Shopping Behavior and Challenges: Lessons From Two State-Based Marketplaces, Anna D. Sinaiko, Jon Kingsdale, Alison A. Galbraith Medical Care Research and Review July 5, 2017 Vol 76, Issue 4, 2019
2. Refining Our Understanding of Value-Based Insurance Design and High Cost Sharing on Children Randall P. Ellis, Sara S. Bachman, Hui Ren Tan Pediatrics, May 2017, 139 (Supplement 2) S136-S144
3. Pediatrics May 2017, VOLUME 139 / ISSUE Supplement 2 Innovative Health Care Financing Strategies for Children and Youth With Special Health Care Needs James M. Perrin
4. Pediatrics September 2017, VOLUME 140 / ISSUE 3 From the American Academy of Pediatrics Policy Statement Principles of Child Health Care Financing Mark L. Hudak, Mark E. Helm, Patience H. White, COMMITTEE ON CHILD HEALTH FINANCING
5. Children’s Health Insurance Program (CHIP): Accomplishments, Challenges, and Policy Recommendations COMMITTEE ON CHILD HEALTH FINANCING Pediatrics, Mar 2014, 133 (3) e784-e793