CMS Launches ASPIRE: A New Payment Model to Support High-Risk Children in Medicaid
The Centers for Medicare & Medicaid Services (CMS) has unveiled a new payment model, Accelerating State Pediatric Innovation Readiness Effectiveness (ASPIRE), designed to transform care for children with high and rising medical and behavioral health risks within the Medicaid program. The initiative aims to improve care coordination and outcomes for a vulnerable population often navigating a fragmented healthcare system.
Addressing Fragmentation in Pediatric Care
According to Abe Sutton, director of the Center for Medicare & Medicaid Innovation (CMMI) and deputy administrator for CMS, a key challenge for families of children with chronic conditions is the lack of coordination between various healthcare providers, and services. These can include school services, social workers, medical doctors, specialists, and therapists. Families often struggle to manage appointments, transportation, and communication between these different entities.
How ASPIRE Works
ASPIRE seeks to address this fragmentation by providing states with tools to empower pediatricians and support patients with complex needs. The model redefines priorities, payment, and accountability for pediatricians and subspecialists, challenging states to adopt a new standard of care. The core goal is to provide a coordinated approach for the 23% of Medicaid children identified as having high and rising risk, ensuring families receive guidance and support throughout their care journey. Learn more about the model.
Focus on Chronic Conditions and Rising Risk
The ASPIRE model focuses on both children with established chronic medical conditions and those at rising risk of developing them. This includes conditions like autism and asthma, recognizing the interplay between medical and behavioral health needs. By identifying and supporting children at an earlier stage, the model aims to delay disease progression and improve long-term outcomes.
Incentivizing Coordinated Care
ASPIRE draws on the accountable care organization (ACO) approach, incentivizing pediatric practices to take on accountability for the cost and quality of care for their high-risk patients. This includes providing financial rewards for care coordination, proactive engagement, and data sharing. Key components of the model include 24/7 access to clinical support and dedicated care coordinators to support families navigate the healthcare system. Read about the potential benefits and challenges.
A Phased Approach to Implementation
CMS plans to partner with states interested in participating in ASPIRE, offering a multi-year implementation period with a glide path to accountability. This allows practices to build infrastructure and capacity before taking on financial risk. The agency will provide data and tools to support practices in managing the population and improving outcomes.
Measuring Success
Success will be measured by improvements in the family experience, delays in disease progression, and the effective management of comorbidities. CMS will rigorously evaluate the model’s impact and share findings publicly. The ultimate goal is to transform the care journey for children with high and rising risk, ensuring they receive the support they need to thrive.
Looking Ahead
The ASPIRE model represents a significant step towards addressing the unique challenges faced by children with complex health needs in Medicaid. By incentivizing coordinated care and empowering pediatricians, CMS aims to improve outcomes and create a more supportive healthcare system for these vulnerable patients and their families.
Worth a look