Partners for Kids: Improving Care for Children in Ohio and Beyond – PediaCast CME 123
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Show Notes
Description
Leaders from Partners for Kids visit the studio as we explore how Ohio Medicaid coordinates, funds, and improves pediatric care. Learn about fee-for-service and managed-care payment models, the role of an accountable care organization, pharmacy collaboration, Ohio’s Unified Preferred Drug List, and initiatives designed to improve access to pediatric dental care. We hope you can join us!
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- Read this information page.
- Listen to the podcast.
- Complete the post-test at Nationwide Children’s CloudCME.
- CME credit expires 3 years from this episode’s release date.
- You can view your transcript and print a certificate of completion at Cloud CME.
- Need help creating a Cloud CME account? Click Here.
- Still have questions? Contact CMEOffice@nationwidechildrens.org
Learning Objectives
At the end of this activity, participants should be able to:
- Describe Partners for Kids and its role as an accountable care organization.
- Compare how Medicaid funds are dispersed through fee-for-service and managed-care models.
- Describe Ohio’s unified list of medications and explain how the list is updated.
- Identify initiatives underway to improve dental care for children in Ohio.
Presenters
Dr Mike Patrick
PediaCast and PediaCast CME
Nationwide Children’s Hospital
Dr Alex Rakowsky
Primary Care Pediatrics
Nationwide Children’s Hospital
Dr Gavin Baumgardner
Chief Medical Officer
Partners for Kids
Dr Timothy Crabtree
Clinical Pharmacist
Partners for Kids
Dr Beau Meyer
Pediatric Dentist
Associate Medical Director
Partners for Kids
Links
Anchoring Health Financing on Better Outcomes: System Drivers and Opportunities for Reform
Disclosure Statement
No one in a position to control content has any relationships with ACCME-defined ineligible companies.
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Nationwide Children’s has not received any commercial support for this activity.
CME/CE Accreditation Statement
In support of improving patient care, Nationwide Children’s Hospital is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the American Nurses Credentialing Center (ANCC), and the Accreditation Council for Pharmacy Education (ACPE), to provide continuing medical education for the healthcare team.
AMA Statement
The Nationwide Children’s Hospital designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AAPA Statement
Nationwide Children’s Hospital has been authorized by the American Academy of Physician Associates (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credits. PAs should only claim credit commensurate with the extent of their participation.
APA Statement
Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. Nationwide Children’s Hospital designates this activity for 1.0 continuing education credits.
ASWB Statement
As a Jointly Accredited Organization, Nationwide Children’s Hospital is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Social workers completing this course receive 1.0 general continuing education credits.
ADA CERP Statement
Nationwide Children’s Hospital is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to the Commission for Continuing Education Provider Recognition at CCEPR.ADA.org. Nationwide Children’s Hospital designates this activity for 1.0 continuing education credit.
Contact Us
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Episode Transcript
[Dr Mike Patrick]
This episode of PediaCast CME is brought to you by Partners for Kids and Nationwide Children’s Hospital.
[MUSIC]
[Dr Mike Patrick]
Hello, everyone, and welcome to another episode of PediaCast CME. We are a pediatric podcast for healthcare providers.
This is Dr. Mike coming to you from the campus of Nationwide Children’s Hospital. We’re in Columbus, Ohio. It’s episode 123.
We’re calling this one Partners for Kids, Improving Care for Children in Ohio. I want to welcome all of you to the program. We are so happy to have you with us.
You know, caring for children involves more than what happens in the exam room. Behind every visit, prescription, referral, and preventive service is a complex system that demonstrates how care is funded, is a complex system that determines how care is funded, coordinated, and improved. Today, we are exploring Partners for Kids and its role as an accountable care organization serving children covered by Medicaid in Ohio.
We’ll look at how Medicaid dollars flow, how Partners for Kids uses information and care management to improve outcomes, why Ohio’s unified medication list matters, and what is being done to expand access to pediatric dental care. Whether you work in primary care, pharmacy, dentistry, or another pediatric specialty, this conversation will help you better understand the systems supporting the children and families you serve. And if you are not in Ohio, I think you’ll still find this conversation to be pretty interesting.
And there may be an opportunity for you, if you’re in the position for Medicaid kids in your particular state, this may give you some ideas. And I know that the folks at Partners for Kids are open up to collaborating with other states as well. So, stay tuned.
We have lots more coming for you. And of course, in our usual PediaCast CME fashion, we have three terrific guests joining us in the studio to discuss Partners for Kids. First, Dr. Gavin Baumgardner. He is chief medical officer of the organization. Dr. Timothy Crabtree is a clinical pharmacist. And Dr. Beau Meyer is a pediatric dentist and associate medical director, again, with Partners for Kids. And we have a guest host this week who’s going to guide us through the conversation. Dr. Alex Rakowsky is back. He is a primary care pediatrician.
He also serves as medical director for the Healthy Children lines, for the Healthy Children service line with Partners for Kids. Don’t forget, after listening to this episode, be sure to claim your free Category 1 CME credit. Really easy to do.
Just head over to the show notes for this episode at PediaCastCME.org. Look for episode 123. You’ll find a link to the post-test in the show notes.
Follow that link to Cloud CME. Click on the materials tab, take and pass the post-test and the Category 1 credit is yours. We offer credit to many pediatric professionals, including doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists.
And since Nationwide Children’s is jointly accredited by all of those professional organizations, it’s likely we offer the credits you need to fulfill your state’s continuing medical education requirements. Of course, you want to be sure the content of this episode matches your scope of practice, which, you know, when we’re talking about Medicaid funding, I think it’s important for all of us to understand how those dollars flow and take care of kids. Complete details on the CME credit is available.
Again, it’s free at PediaCastCME.org. Also want to remind you, the information presented in our podcast is for general educational purposes only, and your use of this audio program is subject to the PediaCast CME Terms of Use Agreement, which you can find at PediaCastCME.org. So, let’s take a quick break.
We’ll get Alex, Gavin, Tim, and Beau settled into the studio, and then we will be back to talk about partners for kids and improving care for children in Ohio and beyond. That’s coming up right after this.
[MUSIC]
[Dr Mike Patrick]
We have assembled a terrific panel in the studio as we consider partners for kids and its role in caring for children and teenagers in Ohio.
We have several folks from the organization, including Dr. Gavin Baumgardner. He is their chief medical officer. Dr. Timothy Crabtree is a clinical pharmacist, and Dr. Beau Meyer is a pediatric dentist and associate medical director. Again, all of them with Partners for Kids. We also have a guest host this week, Dr. Alex Rakowsky. He is medical director of the Healthy Children’s Service Line for Partners for Kids and a primary care pediatrician at Nationwide Children’s Hospital.
So, Alex, I will hand the reins over to you. And like the rest of our audience, I am eager to hear about the great work Partners for Kids is doing here in the state of Ohio.
[Dr Alex Rakowsky]
So please take it away. Thank you, Dr. Mike. Gentlemen, good morning and thank you for joining us.
I know Partners for Kids is probably not as well-known as people should know about it because we do a lot behind the scenes. So hopefully this is one of several episodes that we kind of get to go behind the curtain of Partners for Kids. So, Gavin, I’m going to start off with some like really big hitting questions here.
So just to kind of like set the framework of what Partners for Kids does. So, an overview in general of who pays for pediatric care in this country. So basically, percent who are covered by private insurance, percent who are covered by Medicaid and then those who are uninsured.
[Dr Gavin Baumgardner]
Yeah, no, happy to start off with that. That’s a big one, of course. So, the short version is that the government pays for the majority of pediatric health care through the Medicaid program.
The longer version is that about half of the kids across the country are covered under the Medicaid program. This is funded primarily in Ohio through the about two thirds of the budget comes from the federal coffers and then about a third of it comes from a variety of funding sources here in Ohio. About 55 percent of children are also covered under commercial insurance.
The reason why that doesn’t add up to 100 percent is because we do have a number of children that are covered under both commercial insurance and Medicaid and about five percent are uninsured and those numbers vary a little bit from year to year. But when we look drill down to Ohio, about 1.2 million children across Ohio are covered under the Medicaid program. When we look then here more locally, about one in three children across Ohio are covered under partners for kids.
We’ll get into what that model looks like a little bit later. And then when we look very specifically at nationwide children, it’s about 55 percent of the children we see each year both in outpatient and inpatient settings and nationwide children are on Medicaid. So, the Medicaid program has a big impact on pediatric health care here in Ohio.
[Dr Alex Rakowsky]
So as far as the funding, so it sounds like a combination of federal for about two thirds, one third from state and other sources. Does it go to a central like funding place and then and then it gets divvied up or how does that work?
[Dr Gavin Baumgardner]
Yeah. So again, you mentioned two thirds comes from the federal budget and a third comes here from our Ohio funding sources that gets funneled then through the Ohio Department of Medicaid, which is a state agency that administers the Medicaid program here both for adults and children. And then that Ohio Department of Medicaid contracts with a number of different managed Medicaid organizations.
I’m going to list a couple just because it gives a little context for those who may not be as familiar. So, groups like CareSource and Molina are fairly well-known names for a lot of people. Those are two of the managed Medicaid organizations that are contracted with Ohio Department of Medicaid, and they help manage networks of providers.
They pay bills, they do utilization review and prior authorizations. And we’ll get into the Partners for Kids model a little bit. But part of what we do then is we through Partners for Kids contract with each one of these managed Medicaid organizations to take on some of the financial and quality risk and care for these patients.
So, we partner with them. So, when we look at the Affordable Care Act that came out over a decade ago, that expanded Medicaid funding. Primarily in the adult side of the equation, it had a lesser effect on children.
But when we look at that expansion population, that’s some of what’s being affected currently through some federal policies and some changes. But the bottom line is that the funds flow through Ohio Department of Medicaid to manage Medicaid organizations and on through to providers. We can talk a little bit about how Partners for Kids then helps facilitate some of that care.
[Dr Alex Rakowsky]
Yes. So, I think to better understand the role of Partners for Kids, there seems to be two models of payment. There’s a fee-for-service model and a value-based care model.
Just for like the general pediatrician, a brief overview and pros and cons of both until we start digging into more of what Partners for Kids does.
[Dr Gavin Baumgardner]
Yeah, that’s a really good point because it is a very different model. So, I spent a large part of my career in adult healthcare, primarily in a fee-for-service model. And that is the model of paying for healthcare that the U.S. healthcare system has been built on. So that really equates to a volume-based model of care. So, if you do procedures, if you have office visits, if you do surgeries, you get paid for those on a fee schedule. And despite some efforts over the years, we’ve not really had a lot of success in shifting some of that fee-for-service to value-based care.
So, value-based care is really built on the principle of better quality at a lower cost for that care. And there’s a variety of different models, both in the U.S. and around the world, for how we can accomplish that better quality at lower cost. But in this model of care, you’re really paying for better outcomes and putting usually at risk some of the fees and payments based on quality outcomes.
So, the real advantages of value-based care that we see, and we see this play out in the Partners for Kids model, is that you’re incentivized to invest more upstream in preventative care, in wellness. That’s really the crux of what we do at Partners for Kids, is facilitating some of that model of care.
[Dr Alex Rakowsky]
Okay. And so, Partners for Kids is an accountable care organization. So how does that fit in with the seven managed care, Medicaid managed care organizations?
And what do we do? What do they do? Who pays for things, et cetera?
[Dr Gavin Baumgardner]
Yeah. So as an accountable care organization, Partners for Kids takes on responsibility for both the financial outcomes and the quality outcomes for about 400,000 children across 47 counties in Ohio. And we do that through contracts we have with the managed Medicaid organizations, as you mentioned.
So those funds flow through ODM to the managed Medicaid organizations. And then we take on the risk for the medical spend primarily for those children, 400,000 children across those 47 counties. The managed Medicaid organizations still pay the bills.
They do the prior auths and the utilization reviews. But PFK, at the end of the year, after those bills are paid, are able to reinvest a significant amount in a number of different initiatives. So many people know the population health programs through Nationwide Children’s and Partners for Kids by name like Healthy Neighborhoods, Healthy Families.
This is the program where Nationwide is able to reinvest in building homes and renovating homes because we know that’s a core function of wellness overall is stable housing and healthy housing. We’re also able to make significant investments in school-based health. And we can talk about some of those programs as well because I think those are some of the really high-impact programs that we have here at Nationwide.
And then, you know, Dr. Meyer here has oral health programs he’s going to talk about a little bit. We’re able to make investments in oral health programming. And in Tim’s case, we’re able to make significant investments in pharmacy services to be able to support our children as they navigate through and families as they navigate through a very complex healthcare organization.
So that’s really, I think, the crux of the Partners for Kids model.
[Dr Alex Rakowsky]
So just setting the table before you get into like some deeper dives with Beau and Tim, why do you think an ACL or value-based care model works best in pediatrics? Not just for us, but just nationally. I mean, it’s becoming more popular, but not 100%.
[Dr Gavin Baumgardner]
Yeah, it is a somewhat challenging model to develop. So, Partners for Kids has been around for almost 30 years. They were the first pediatric accountable care organization in this country, and they’ve grown into the largest as well.
The full risk model. So, Partners for Kids is a full financial risk model. So, we take responsibility for the financial outcomes for these children.
That’s a somewhat unusual model. It’s probably fewer than a dozen of these types of full risk accountable care models in the country. And that’s because of the, frankly, the financial risk and the degree of difficulty of doing that.
So, we’ve been able to contract with the managed Medicaid organizations to administer the program. But the real advantage, I think, is the investments that Partners for Kids enables nationwide children to make into population health programs. And that’s really the crux of the benefits that I see.
It is not an easy thing to do, but it is an extremely rewarding program when you’re able to really, I would describe Partners for Kids as a financial engine and a ton of support for a population health model. And that’s one of the real pillars of Nationwide Children’s Hospital is population health and what they’ve been able to do with reinvestments further upstream into wellness and prevention and, frankly, providing some basic support and care for children across these 47 counties.
[Dr Alex Rakowsky]
So, one last question, Gavin, and then we’ll switch over. So, you talked a lot about investing upstream, but you have to know what’s going on currently to start looking at the upstream sort of model. We do work with all seven Medicaid managed care plans in this state.
So, we get to look at the claims data for all seven. What’s the power of that? And why is that important to have one organization be able to see the whole picture compared to each MCO just seeing for their own members?
[Dr Gavin Baumgardner]
It’s a great question. I would consider data and analytics one of our superpowers of Partners for Kids. And I say that jokingly, but I do feel like data and analytics really enables us to fuel a lot of the population health programs that we have here at Partners for Kids.
We have sat on a large volume of claim data that we’re able to match up with clinical data in most cases to really fuel some of our programming. We have countless examples of how we put this into practice, but I think a couple that I would point out. One is in your area, Alex.
So, in the Healthy Children Service line, we have something called school roster matching. So, we’re able to take our claims data from Partners for Kids to identify children who are overdue for well-child visits. Some of these children are three plus years overdue for a well-child visit.
And then we can match that up with our school roster data to find out where those children are going to school. And then we work with our school health partners to get them plugged back into the school health clinic to get caught up on well-child visits and most importantly, plugged back into a medical home. And so, we’re able to navigate them back into a medical home in many cases and get them engaged back with the healthcare system.
Another great example is with our Chronic Conditions Service line and our asthma patients. So, we’re able to use our claims data to identify those children with persistent asthma who haven’t had a controller filled in a number of months or even in some case over a year. And then we’re able to work with some of our care coordination programs to get them plugged back into the system and in some cases even link back up with our school-based asthma therapy programs to get controllers prescribed and then filled, in some cases even delivered to the schools.
And the school-based asthma therapy program is a brilliant program where the school nurses actually administer the controllers Monday through Friday and get these kids much better controlled. Has tremendous impact on things like absenteeism and ED utilization. So, two good examples, I think, of how we use our data to really power some population health initiatives to improve the health of these children.
[Dr Alex Rakowsky]
Thank you. All right, Tim, let’s skip over to you. So, outside of medical claims, one of the biggest uses of Medicaid funding is for pharmaceuticals.
So how does that money flow there? Does it go through the managed care organizations, directly sent to pharma? How does that work?
[Dr Timothy Crabtree]
So, I think Gavin laid the groundwork really nicely as a lead into this question. So, we’ve got that money flowing into Ohio Department of Medicaid. And then from there, in a typical system, the money then flows to the managed care plans who would then contract with what we would call a pharmacy benefit manager or a PBM.
PBM is probably a term that some people are familiar with, but what PBMs do at their core is they are the ones who are communicating with the pharmacies to figure out what medications are covered, what medications aren’t covered. What’s the copay going to be? What are the prior auth criteria that need to be met if there are any?
Things like that. In a nutshell, that’s what the PBM is doing. So, you can think of them sort of like health insurers.
Gavin was stating they’re the ones paying for the pharmacy claims on behalf of the managed care plan that contracts with them. So that’s the usual flow of money within the health care system. Just one other note, pharmacy benefit managers can do some other things too.
Sometimes they’re the ones that set the formulary. Sometimes they’re the ones that set the prior auth requirements, but sometimes they are just taking direction from the health plan and passing that onto the pharmacy and they’re really running those claims on the background for the pharmacies.
[Dr Alex Rakowsky]
So, I think Mike, myself and Gavin are old enough to remember that each of the MCOs had their own formulary. So, I think this is a Nobel Prize winning endeavor where the MCOs all came up with an approved formulary, which is like a universal formulary. How did that happen?
And what role did Partners for Kids have in getting that set up?
[Dr Timothy Crabtree]
So, I think that’s a really, it’s a great question. And going into how we got to this one formulary, I answered in the previous question, in a normal system, we’re going through each one of the managed care plans. Here in Ohio, it’s actually Ohio Department of Medicaid who sets that one formulary.
And that changed shortly before Gainwell came into place. Gainwell is Ohio’s single pharmacy benefit manager. So, I said normally the managed care plan contracts with the pharmacy benefit manager, and then they administer benefits on behalf of the health plan.
Here, it’s Ohio Department of Medicaid direct to the pharmacy benefit manager. That’s where we get that single list from. Ohio Department of Medicaid is the one who sets that list.
So, it’s ODM who is determining what medications are covered, what medications are non-preferred, which means you need a prior authorization for them. And they’re also the ones that set the criteria if something is a non-preferred drug. So, they’re setting the formulary.
Here, we call that the unified preferred drug list or the UPDL. So, if you hear me say UPDL, what I mean is formulary. They work with Gainwell to enact that formulary.
So, it’s Gainwell who’s sort of communicating with the pharmacies. And then the pharmacies are able to tell you, yes, that drug is covered, or no, that drug needs a prior authorization. One thing I want to mention about that process and where Partners for Kids fits in, ODM.
So, they meet quarterly at what’s called pharmacy and therapeutics committee. They take experts both within ODM and external to ODM. So, folks who are medical practitioners but aren’t involved in ODM, they meet and they decide what drugs are covered and what drugs won’t be covered.
So new products come onto the market. Old products leave the market. Guidelines get updated.
ODM has to take in all of this information. And it’s the P&T committee, the pharmacy and therapeutics committee, that decides what are we going to cover, what’s not going to be covered. Partners for Kids sees that process developing.
We check ahead of time. And we’re able to meet with ODM. We’re able to talk with ODM about what will impact pediatrics.
And we can try to influence some of those decisions. So, one quick story that I will tell that was a really heavy impact in the state of Ohio, brand name Flovent is an inhaled corticosteroid. And Flovent brand name was going to be taken off of the market.
And when the formulary came out for the pharmacy and therapeutics committee, again, it’s publicly available. We can see it. When that came out, it said that Flovent would be removed.
And the products coming on board were not compatible with spacers. As pediatricians, we sort of recognize immediately that we need spacers to go with inhalers for those kiddos. So, we worked with our partners at ODM and made sure that generic Flovent was covered at a time when the vast majority of Medicaid plans across the country were not covering generic Flovent.
So, thanks to our intervention and preemption with ODM, we were able to make sure that kids still had that necessary inhaler.
[Dr Alex Rakowsky]
So, is it fair to say that if clinicians do see a problem to reach out to you and your team about potential discussions? Absolutely.
[Dr Timothy Crabtree]
If there are any problems, we are always happy to help.
[Dr Alex Rakowsky]
Other ways that the pharmacy team, health providers, I use the prescribing guidelines on the PFK website all the time. The residents are drilled to use this literally all the time. And I think the part that we all go to right off the bat are the drug lists.
What role, how are these things developed? I mean, I know your team plays a big role, but who else is involved with making these prescribing guidelines or medical guidelines a reality?
[Dr Timothy Crabtree]
So, this is one of my favorite aspects of being at Partners for Kids. We’re able to take evidence-based guidelines and we’re able to boil them down, as you said, into something digestible, something that can be used by residents or people who are making treatment decisions on the fly. You mentioned the Unified Preferred Drug List, so the drug list that we create.
That is a pediatric-focused version of the Unified Preferred Drug List with easy-to-use links. So, you click on the drug class that you’re looking for, and it pops up immediately with the drugs that are covered in the dosages that you can give to your patients. So, it’s a little bit easier to use than the full Unified Preferred Drug List.
Although sometimes we still have to point people to that full 100-page gigantic list if they’re looking for drugs that don’t fall on our nice, clean, truncated list. Getting back to the evidence-informed prescribing guidelines, we like to take guidelines that are used frequently by pediatricians, largely primary care, but we do have some specialty ones. We take big guidelines that are often text-based, and we convert them into cleanly laid out algorithms that are meant to help providers walk from diagnosis through treatment and then through monitoring.
I believe in the show notes there will be a link to Partners for Kids’ website. We have a lot of wonderful resources underneath the resources page. If you see anything that says prescribing guidelines or pathways or toolkits, the pharmacy team collaborates with providers and experts at Nationwide Children’s.
We collaborate with experts here within Partners for Kids. Make sure that all those guidelines are really high quality.
[Dr Alex Rakowsky]
One last question, and I’ll have maybe a humdinger if we have time for you later on. So, QI projects, we talked about upstream and looking at things to kind of improve care in the future. What kind of QI projects is your team involved with at Partners for Kids?
[Dr Timothy Crabtree]
Okay. So, I may have to apologize lightly. I said before the prescribing resources were one of my favorite things.
I think the QI work may actually be my favorite thing. I get to work with experts in quality improvement, medical directors. I’m working with nurses and social workers.
And we get to bring all of our expertise to the table and then make care decisions that impact patients. I’ll give you an example of where pharmacy expertise came in since I am a pharmacist. We work with children with sickle cell disease on one of our medical complexity service lines.
So, Gavin sort of laid the groundwork. We have a number of different service lines where we focus on different conditions. But for this medical complexity service line, we’re looking at sickle cell disease.
And one of those outcomes is antibiotic prophylaxis adherence for little kids with sickle cell disease. They have what we would call functional asplenia, which means they are at a really high risk of opportunistic infections from the age of zero to five years old. So, from the age of zero to five, they aren’t yet vaccinated for all of these opportunistic bugs.
And we have to make sure that they’re getting amoxicillin or penicillin around the clock to prevent these, what can become really devastating and life threatening and life impacting infections. We were hovering at only around 10 percent of patients being adherent to their antibiotics. So, seeing that we were hovering slightly below what studies show the national averages, the studies were showing usually between 14 and 20 percent.
So nationally, not going much better, but here around 10 percent. So, we felt that that was a really good opportunity to leverage our teams to improve some adherence. Given that I’m a pharmacist, one of the immediate things that I recognized is penicillin and amoxicillin liquids, they’re going to expire in 14 days.
For a family with child with sickle cell disease, often other siblings, often going into the clinic frequently. Now you’re stacking on a trip to the pharmacy every 14 days. It’s a lot.
And it’s especially a lot whenever you’re talking about getting meds. The other meds are coming every 30 days. So, we worked with some of the pharmacy team at Nationwide Children’s.
We even worked with some of our pharmacy partners in the community. So, give Kroger Pharmacy some credit. We worked with Kroger Pharmacy.
They were wonderful partners. What we did, we came up with a methodology for training patients to mix their own antibiotics at home. So, they get a premixed bottle, 14 days, and then they get a dry powder bottle and the exact quantity of water to mix up that dry powder at home.
And then they’re able to get that full 28-day supply. And the whole process is controlled. We worked with everybody that we needed to work with to make that work out.
And what we saw working with all of our partners was an increase in adherence from 10% of patients are adherent all the way up to about 35%. So, a really dramatic improvement in the adherence to antibiotics. And something that I really love to talk about, as you can probably tell since I’m talking about it now.
[Dr Alex Rakowsky]
No, thank you. That’s a great example. I think this goes back to Gavin’s point about us seeing data for everybody, where if you’re just at one clinic, you’re seeing your slice.
If you’re at one hospital, you’re seeing your slice. But you’re able to see the slice of 450,000 kids and then the ones with sickle cell. And how many of them actually were adherent because you have ways to connect it all.
So again, data is our secret sauce and our superpower to use that one. Well, speaking of superpowers, dental care. Thank you, Tim.
Dental care, we all know is vitally important. And there are studies after studies, mostly in adults, but more and more in pediatric age patients that poor dental care leads to poor health outcomes down the road. In other words, it’s not just correlative, it seems causative.
Yet dental care, even though it’s part of Medicaid rules and some called EPSDT for the geeks out there who kind of know their rules for Medicaid, it’s not commonly provided or given to kids who are on Medicaid. And we’re not particularly good in Ohio, let alone anywhere in the country. Some general thoughts about why this is the case and what it’s going to get into what your team is doing to kind of work on this.
[Dr Beau Meyer]
Yeah, this is a complicated answer that probably would take the whole hour-long podcast. But some general descriptions or explanations for why Medicaid or access to dental care is difficult for Medicaid enrollees. It’s a complicated system.
And Gavin laid out sort of all of the complexities just from getting that dollar from the federal and state government down to the provider. For dentists, there’s another layer to participate in the Medicaid program in that all of the MCOs or managed care organizations vendor out their dental operation or the dental benefits. So, in addition to enrolling with the managed care entities, dentists have to enroll with the dental vendors as well to participate in the program.
So, it’s another layer of the onion to describe that participation for dentists. And I think that is very confusing for the general public to follow. And it’s very confusing for dental students and new graduates and dentists in the communities to kind of understand the nuances between what is participation look with plan A versus what is participation look like for plan B.
Because there are probably some differences because of the differences in vendors. So, there’s I think that’s a major complexity to the program that I think explains things here in Ohio. But I think the same would be true in other states as well.
I’m not calling out Ohio in any particular way on that. I think that’s just the general nature of how Medicaid dental programs tend to operate.
[Dr Alex Rakowsky]
So, I’m going to ask you another Ohio question then get into what the work that your team is doing. So ODM actually tried to work on this and did work on this by increasing dental reimbursement rates for children on Medicaid a couple years ago. And you and one of your dental fellows did a study that showed the impact or surprisingly little impact of this.
So even though efforts were made to improve reimbursement rates, do you think that confusion about how to navigate the Medicaid system was kind of came to fruition in a bad way by not increasing?
[Dr Beau Meyer]
Yeah, this is a loaded question, but a good one. I think the fee increase that was implemented by Ohio Medicaid in January of 2024 did lead to an increased number of dentists filing claims each month. And that was pretty substantial.
And that kind of surprised me a little bit. But you’re correct in saying that the increase in the number of children receiving care each month did go up, but not by substantial numbers. So, it begs the question of kind of what else is going on?
Is reimbursement alone enough to kind of engage in the system? And I would say that with all the complexities I mentioned to your previous answer, there probably needs to be some better like management or active intervention on the part of the plans or the program or groups like us to engage dentists in the system in ways that will increase utilization and access to care for the kids who really need it. What’s also not shown in that is that I think those increasing number of dentists are likely or it’s very plausible to me anyways that they’re seeing more adult Medicaid beneficiaries as well.
And that is something that I think is playing out in the fee increase that it’s just my hypothesis at this point.
[Dr Alex Rakowsky]
So, setting the table with those comments and your responses. So, what is your team doing? I know you’ve done some work with the primary care network as ways to kind of get people more engaged with the dental system in ways that I think are more easily adaptable in the region.
[Dr Beau Meyer]
Yeah. So, within Partners for Kids, the network of providers that we have and the dentists and the pediatricians that we have access to, we worked with groups that we have, I don’t work with just by the nature of the system. So, one of the ways that we’ve tried to address utilization, especially for young children who historically don’t get to the dentist until between the ages of three and five, is really focused on getting them a dental touchpoint earlier in life.
So, we’ve embedded a dental hygienist within primary care clinics at two primary care network sites and are planning a third. And they’re there five days a week and they focus on integrating themselves into that well-child visit for children ages one to three. And what we’ve seen with this program, and it’s been one of the proudest accomplishments of my career, is we’ve increased the follow-up with a dentist from around 10 percent prior to the project to closer to 40, 45 percent a year, year and a half into the project.
That’s a huge increase and nothing I ever really dreamed possible on such a short timeline. But I think that’s something that we’re able to do because of the nature of Partners for Kids and its focus on sort of these prevention efforts. A tangential benefit of that is the hygienist being present in the primary care team, I think has opened the eyes of the team to the value of oral health within the overall health picture.
So, they’ll often pull the hygienist to come look at a child who’s outside of our one- to three-year-old age range to say, hey, this looks kind of strange. Can you take a look? And one of the cool parts about our program is that hygienist is able to schedule them into the dental clinic for their next visit or follow-up.
And if they have urgent or time-sensitive needs, they’re able to get them into the dental clinic and we’re able to take care of their needs, get them the treatment that they need a little bit sooner. So, it’s really beneficial. The program has been really beneficial for children ages one to three, but really for the scope of the practice or the clinics that they’re in, it’s been a huge benefit for everyone.
[Dr Alex Rakowsky]
So, kind of building on that, you recently got, congratulations, a large grant that’s being managed by the Government Resource Center, the GRC at Ohio State, where you’re going to do education about dental health integration in almost all of our rural counties in Ohio. So just a real brief touch over the next five years, what are you going to be doing? And do you envision a similar impact like you’ve had at PCN?
[Dr Beau Meyer]
Yeah. So, thank you for the congratulations there. We received a grant from the Ohio Department of Health to do preventive oral health trainings in primary care clinics in all 73 of Ohio’s rural counties.
And these trainings will be primarily focused on fluoride varnish and silver diamine fluoride as two primary and secondary preventive measures that primary care physicians can provide. But they’ll also include trying to establish tighter dental referral networks with those practices, as well as some training for those dental practices to feel more comfortable treating kids. The grant includes a stipend to the primary care practice for participating in the project.
And it seems like we’re going to be able to scale some version of our integration, whether or not that’s a fully embedded hygienist or just hygiene support and training to a number of places in Ohio to really drive up and improve and really set Ohio apart from others through a topical fluoride and preventive oral health, a priority for young children.
[Dr Alex Rakowsky]
This is great. So, we got about five minutes before we do closing up. So, I got two tougher questions.
And Tim and Gavin, you’re the lucky recipients of these. So, Tim, there are, I mean, I’m jealous of my residents because 30 years ago, we had purely drug-based therapies. Now we’re looking at gene therapy, monoclonal antibodies, exon skipping agents, et cetera.
I mean, the medical field in 10, 15 years will be very different than when, let’s say, Mike, who’s a little younger and myself trained, but these are expensive drugs. So how does ODM have discussions about these very helpful and hopeful meds in a way where finances are tight?
[Dr Timothy Crabtree]
Yeah, it can be tough. And when I say can be, I mean, I think it’s difficult every time. We’re talking usually in the millions of dollars, low millions, but still one, two, three million dollars for these treatments.
But I think one of the ones that is worth highlighting is the sort of the stereotypical gene therapy. And I think what we’re hoping to see in the future is something like Zolgensma, which is a gene therapy for SMA, spinal muscular atrophy. So, with this medication, it’s, yes, it’s very expensive.
But when we, when we administer it, we’re administering a life-changing therapy, a life-lengthening therapy, something that is allowing a child to live a normal childhood and grow up and likely live a normal life. So, the price tag is really daunting. But the math that we have to do, or the math that rather ODM has to do in this case, which is difficult, is what are we saving in the long term?
Now that child’s going to grow up, they’re not going to need medical intervention going forward, ideally, outside of the normal medical intervention that a kiddo needs. And not only that, they’ll be able to enter society, they’ll have, you know, they’ll be able to work, and they’ll be able to live and do all of the things that we hope to be able to do as humans. So, all of these therapies are life-changing and they’re really awesome to see.
But that high price tag is, it’s definitely hard math to do.
[Dr Alex Rakowsky]
The human aspect, of course, is the most important. But again, going back to Gavin’s point of us sitting on all the data, you can show that this will save for admissions, ICU stays, therapies, et cetera, which may not cover those millions, but at least a chunk of it. And that’s something you can take to ODM and say, here is at least a financial model that this isn’t as daunting as it looks like by just looking at the initial price tag.
[Dr Timothy Crabtree]
Absolutely. And that is exactly what we do. And that is exactly what we’re well positioned to do.
So, thanks for calling that out.
[Dr Alex Rakowsky]
All right, Gavin, I’m going to end with a teaser for hopefully another whole episode. One big, beautiful bill. And this really will take up probably a whole episode.
But just quickly, we all have heard about it and the cuts in Medicaid are probably going to be coming and we’re well positioned in a state that is very supportive of pediatric care. But what impact do you see this having on PFK in the next few years, if any?
[Dr Gavin Baumgardner]
Yeah, you’re right. That’s a big one and could certainly take up an entire episode. I’d say the short version is that we’re definitely seeing as a state some effects from one big, beautiful bill on Medicaid enrollment.
It is disproportionately hitting the adult side because of the Medicaid expansion that happened during the time here of the ACA. Most of that Medicaid expansion has been on the adult side, and that’s where the initial rollbacks have been. But we are starting to see some effects on the pediatric side, primarily through, partly through one big, beautiful bill, but also some rollback of some programs that were initiated during COVID, which put some different programs on pause for patients to re-enroll in Medicaid.
So, some of those are being reenacted now, which has made it a little bit more challenging now for patients and families to get their kiddos re-enrolled in Medicaid. So, across the country, we’re seeing drop in enrollment, both for adults and children in the Medicaid programs, and we’re certainly seeing that here in Ohio. So, there’s been some effects of that.
But what I would say about one big, beautiful bill right now has been most of the effect bill has been primarily on the adult side, with some impacts on pediatrics. But it’s been some other policies that I mentioned that were enacted during COVID, some pausing of different programs that have been now reinstated that has had some of the biggest impact on our children. So, we’re doing a lot of work.
We didn’t really talk much about care coordination. That’s a great conversation for a podcast as well. I would consider care coordination another one of our superpowers at Partners for Kids.
And we have over 250 care coordinators caring for tens of thousands of our kids in PFK. And one of the things that they can do as they’re interacting with children is help families get their children re-enrolled in Medicaid. And we have other programs at Nationwide and Partners for Kids that we’re ramping back up, can help families and, frankly, providers as they’re seeing these children and families in their clinics, help them get routed back and get them some help in getting re-enrolled in Medicaid.
It is definitely a more challenging environment now.
[Dr Alex Rakowsky]
Yeah. Well, gentlemen, thank you so much for answering, I think, tough questions and a nice overview of PFK. And Dr. Mike, I’m going to put in the plug for future ones because, again, this is an entity. I’ve been here 22 years, but two years at Partners for Kids. And I thought I knew PFK until I came here. And I’m still learning about all the things that we do.
And it’s just amazing work that most people don’t know about. So, I’ll stop there.
[Dr Mike Patrick]
This has been a really interesting conversation. And I know a lot of primary care docs, you know, the finance part of it sort of exists in a black box. And there was a time when primary care docs ran their own offices, were very involved in the finances and reimbursements and all that.
But now, as more and more of us practice within organizations, there’s a lot of advantage that comes with that. But then we also sort of lose touch of how things get paid for, which is very important, especially as we want to advocate for kids and make sure that the resources are available and they have access to care and dental health and the right drugs and all of those things. And so, you guys are doing great work at a lot of states do not have something similar.
And so, their kids suffer a little bit because of it. Gavin, are you open to folks from other states who might want to, you know, look at Partners for Kids as a model, you know, and ask questions and, you know, be there as a resource for other states?
[Dr Gavin Baumgardner]
Absolutely. In fact, just coincidentally, we had some folks from Colorado reach out a few weeks ago. And I just had a conversation yesterday afternoon with a team from Colorado University who’s been tasked from their Department of Medicaid to come up with a better system to unique environment because they actually don’t have managed Medicaid.
So, you’re going directly from Department of Medicaid to Colorado University and shuts and asking them to look at a different model. So just as a quick example of we have folks all the time reaching out to us and asking about the PFK model.
[Dr Mike Patrick]
Yeah, yeah. Hopefully you won’t get, you know, a ton of folks from this all at once descending upon you. But at the same time, that’s a good problem to have as we, you know, think about really caring for kids around the entire country and doing so in a way that provides equitable care and really quality care too.
And you guys are welcome back anytime. I would love to hear more in the future regarding Partners for Kids. We are going to have some links in the show notes.
Most notably, we’ll have a link to Partners for Kids. You can check out the formulary there. I would imagine that there’s a way for folks to contact you through the website as well at Partners for Kids.
And again, we’ll put that in the show notes. Also, a link to an interesting article, Anchoring Health Financing on Better Outcomes, System Drivers and Opportunities for Reform. That’s from the National Academy of Medicine.
So, if you want to read up a little deeper, we’ll have that link for you in the show notes. Just head over to PediaCastCME.org and look for the show notes for this episode and you’ll find them there. Once again, thanks so much to Dr. Gavin Baumgardner, Chief Medical Officer with Partners for Kids, Dr. Timothy Crabtree, Clinical Pharmacist with that organization, and Dr. Beau Meyer, Pediatric Dentist at Nationwide Children’s Hospital and Associate Medical Director of Partners for Kids. And a special thanks to Alex Rakowsky with Primary Care Pediatrics and also with the Healthy Children Service Line, Medical Director of that over at Partners for Kids. But you did a great job, Alex, hosting. You’re welcome back anytime.
[Dr Alex Rakowsky]
Thanks, Mike. And I’m looking forward to our next conversation.
[MUSIC]
[Dr Mike Patrick]
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast CME a part of it. We really do appreciate your support. Also, thanks again to our guests this week from Partners for Kids, Dr. Gavin Baumgardner, Chief Medical Officer, Dr. Timothy Crabtree, Clinical Pharmacist, and Dr. Beau Meyer, Pediatric Dentist. And of course, thanks again to Dr. Alex Rakowsky with Primary Care Pediatrics at Nationwide Children’s Hospital. Don’t forget you can find us wherever podcasts are found. We are in the Apple Podcast app, Spotify, iHeartRadio, Amazon Music, Audible, YouTube, and most other podcast apps for iOS and Android.
Our landing site is PediaCastCME.org. You’ll find our entire archive of past programs there, along with show notes for each of the episodes, our CME information, that terms of use agreement, and a handy contact page if you would like to suggest a future topic for the program. Reviews are also helpful wherever you get your podcasts.
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So, you have listened to the podcast. Now be sure to claim your free Category 1 continuing medical education credit. Really easy to do.
Just head over to the show notes for this episode, episode 123, at pediacastcme.org. You’ll find a link to the post test in the show notes. Follow that link to Cloud CME.
Click on the materials tab, take and pass the post test, and the Category 1 credit is yours. No charge. It’s free.
And we do offer credit to many pediatric professionals, including doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And it’s because Nationwide Children’s is jointly accredited by those professional organizations that we can offer you the credits you need to fulfill your state’s continuing medical education requirements. Complete details are available at pediacastcme.org.
Also, if you are a faculty member of an academic institution, we have a faculty development podcast for you. It’s from the Center for Faculty Advancement, Mentoring, and Engagement at the Ohio State University College of Medicine. We cover lots of great topics for faculty.
You know, things like work-life balance, promotion and tenure, mentoring, coaching, sponsorship, using artificial intelligence as we do the many aspects of our role in academic medicine, from teaching to research to clinical care. So, lots of stuff there for you. Again, it’s a faculty development podcast called FAMEcast, and you can find it wherever podcasts are found.
Just search for FAMEcast. Thanks again for stopping by. And until next time, this is Dr. Mike saying, stay informed, keep it evidence-based, and take care of those kids. So long, everybody.
[MUSIC]
