Principles

1. Children have unique health needs, which is the framework in which to review all coverage and access issues.
2. TRICARE should adopt medical necessity and hierarchal review process specific to pediatrics (see AAP policy statement July 29, 2013).
3. TRICARE coverage and reimbursement should follow the care needs of the child, versus dictating the care that the child receives (provide flexibility to meet children’s needs).
4. Time is of the essence for access, identification, intervention, and treatment because children grow and develop rapidly so TRICARE must remove barriers to care such as archaic and difficult to navigate processes.
5. While all children have unique needs as compared to adults, military children face unique experiences due to the very nature of their parents’ service in our nation’s military.  The practical difficulties that accompany deployments and frequent relocations must be taken into consideration in fashioning the medical, educational, and social policy necessary to support these military children and their families.
6. These considerations take on an even higher significance when a child has a complex or chronic medical condition or disability. Specialty care and the effective coordination of that care becomes critical.

Premise

Children are not just little adults. Children’s health care needs and standards of care are different and distinct from those of adults. Not only do children utilize care at different rates, but in different settings, and for different conditions than do adults.

Because they continually grow and develop, robust specialty care and services for children with special health care needs and chronic health conditions is especially critical. Furthermore, the requirement for this specialized health care and developmental support is an ongoing and serious matter of day-to-day life for families with children with special, chronic and/or complex health needs.

Benefits and coverage should meet the unique needs of children of military families, with health care practices and policies that:

• Are designed to meet their pediatric-specific needs;
• Are developed and determined proactively and comprehensively; and
• Protect and maintain their access to pediatric-specific treatments, providers, and facilities.

Too often TRICARE has been reactive and prescriptive, which results in a piecemeal, inconsistent benefit and experience, and fails to be as effective, efficient or produce the outcomes it could and should.

Overall

TRICARE should adopt a pediatric specific definition of medical necessity and hierarchal review process of evidence based standards to apply to pediatrics consistent with American Academy of Pediatrics guidance (see July 29, 2013 policy statement). Then each element of the TRICARE program that is reviewed pursuant to TRICARE for Kids should be evaluated in the context of whether or not it is consistent with those pediatric principles and definitions.

Pediatrics Official Journal of the American Academy of Pediatrics. Committee of Child Health Financing Pediatrics 2013;132;398; originally published online July 29, 2013DOI: 10.1542/peds.2013-1637 http://pediatrics.aappublications.org/content/132/2/398.full.html

Access to Pediatric Care

Families’ challenges in accessing care

Families should not have to navigate outdated or inappropriate referral, authorization and approval processes, or arbitrary limitations on distance in order to access pediatric care.

Providers’ challenges in participating in TRICARE

Barriers to care also include archaic processes, procedures or idiosyncrasies that make TRICARE different and difficult for pediatric and family practice providers to navigate.

Applied Behavioral Analysis (ABA) Therapy

ABA therapy should be provided as a medical benefit to all TRICARE beneficiaries in a manner consistent with best practices.

Mental and Behavioral Health

A comprehensive, effective mental health care system for children in military families should be strength based and family centered, with a spectrum of services beginning with prevention and progressing through levels of acuity from least to most restrictive. The approach must meet the family “where they are” and attempt to sustain the child at home and in the community when clinically appropriate.

• Community based wrap around services
• Intensive outpatient programs
• Substance abuse policies tailored to adolescents versus adults

Access to Specialty Care

Timely access to pediatric specialists is always a concern due to national shortages, and the concentration of specialists regionally. Regional concentration occurs because pediatric volumes are less than for adults, thus pediatric specialists cannot maintain practices in every community, and need to work within the infrastructure of children’s hospitals in order to provide the necessary multifaceted care. TRICARE must recognize and adapt its policies and practices accordingly, to protect against exacerbating those difficulties with inflexible policies that create barriers such as referrals and authorizations that may be difficult to obtain or process, limitations such as requirements to be seen on base first without exception, or distance limits that do not make sense for pediatrics.

Reimbursement

Reimbursement should follow appropriate care, designed for and tailored to children, not form the basis for care decisions.

• Medicare based reimbursement not appropriate for pediatric care
• Emerging technologies and treatment options must be fostered
• Payment methodologies should reflect value and services of pediatric care

Extended Care Health Option (ECHO)

ECHO benefits are entirely within the purview of DoD and critical to fulfilling the readiness mission. The principal concerns with ECHO are that it is not available to all beneficiaries, does not integrate well with other programs in TRICARE/DoD or state (Medicaid), and has not kept the pace with its original intent to provide an alternative to Medicaid waiver services for military families.

Care Management

TRICARE does not, and cannot on its own, adequately provide care management for the sickest, most vulnerable children of military families. Children with medically complex conditions require the highest level of services and support from children’s hospitals due to the intensity of care and breadth of pediatric specialists required to care for their conditions. Children’s hospitals offer their expertise in partnership with TRICARE to improve children’s health and advance a care model that will improve care, improve coordination and transition among providers, better support families, and reduce cost.

Coordination of Supports and Services among DoD Programs and Resources

Coordination of DoD programs is essential; TRICARE and ECHO must work in tandem with Military Family Readiness Council, the Office of Special Needs, and the Exceptional Family Member Program to ensure consistent, complementary support.

Linking Families with Community Resources and Providers

• Medically complex care coordination through children’s hospital networks
• Inconsistent knowledge base among PCMs and other POCs for families seeking care

Mitigating the Impact of Frequent Relocations

• Medicaid portability
• Medically complex care coordination
• Hand-offs –appointments made for next location before move occurs