The holy grail of health care reform is achieving the so-called “triple aim” of improved health care quality, gains in population health, and reductions in per capita health care costs.
Given the current status of state and federal budgets, many innovations not surprisingly focus on opportunities to lower health care costs and achieve “scorable” savings. As a consequence, proposed innovations in health care delivery tend to predominately address the needs of persons with complex and chronic health care needs.
This focus on complex and chronic needs is evident in child health care, with experts and leading organizations calling for initiatives that focus on the delivery of care to that 5% of children with complex, chronic conditions who account for 40% of children’s Medicaid expenditures. For example, a recently released report from the Children’s Hospital Association entitled, “The Landscape of Medical Care for Children with Medical Complexity,” describes the opportunity for health care redesign to address the needs of “children with medical complexity” (CMC).
While improving care for children with complex and chronic conditions (the 5%/40%) is undeniably of critical importance, should these CMC be the exclusive focus of our reform efforts? Research, expert opinion, and even economics suggest otherwise. The dissemination of research findings on early brain and child development yields critical implications for our reform efforts, including the imperative to focus on all children, especially those vulnerable children at risk for poor outcomes. These are the children for whom services are most accessible and most effective. Furthermore, Nobel Prize laureate economist James Heckman speaks of the greatest return on investment when made during early childhood.
System building in support of all children’s healthy development does not undermine the importance of improving service delivery for children with medical complexity. In fact, such children will be the beneficiaries of improvements in care coordination, building of capacity, and addressing of gaps in programs and services.
However, the greatest opportunities to shift children’s developmental trajectories forward lie in addressing the needs of those vulnerable and at risk as a consequence of adverse early experiences, unfavorable social determinants, and toxic stresses.
It’s true that the short-term, “scorable” cost savings of addressing the needs of vulnerable children at risk for poor outcomes may be relatively modest compared to those relating to children with medical complexity. Nonetheless, such an approach makes important and substantive contributions and yields the greatest long-term return. As Heckman emphasizes, these long-term savings are undeniable.
However, such savings accrue to different sectors than those making the original investments. For example, capacity building in the child health sector that enhances the early detection of vulnerable children and their linkage to community-based programs and services ultimately yields savings in the behavioral health, special education, and juvenile justice systems. Our bookkeeping does not allow “credit” for this return on investment. Furthermore, the time frame for such returns exceeds the term limits of most elected officials.
We must develop both the strategies and long-term vision to overcome such barriers. Children with medical complexity certainly demand the very best services and supports that we can provide. Yet an exclusive focus on the 5% of children who comprise this subgroup is shortsighted and will not allow us to achieve ultimate benefits both to children and to society.