Health Affairs Looks at Vermont’s Pioneering, Statewide Approach to Pediatric Care Delivery Improvement

An article published in the October issue of Health Affairs looks at a statewide program that has improved outcomes in the state of Vermont, and whose successes have been applied to programs in a number of other states. The program, the Vermont Child Health Improvement Program (VCHIP), run through the University of Vermont in Burlington, has proved to be a success in improving the care delivered to children across Vermont. As Rebecca Gale writes in her article, “A Statewide Approach to Improving Child Health And Health Care,” “It has achieved this progress not by instituting new regulations or inventing new payment models but, rather, by serving as a central and honest broker to help pediatric providers, payers, and policy makers navigate the complex and constantly evolving push toward quality improvement in health care. VCHIP’s work has yielded positive results for children in Vermont, achieving high marks on nearly all metrics it has tracked: improved communication among family and pediatric providers, more well-child visits, better immunization rates, and better compliance with national guidelines for chronic conditions such as asthma.”

Gale interviews Judy Shaw of VCHIP, who traveled to the Children’s of Alabama in Birmingham, to share VCHIP’s successes with colleagues in Alabama. She notes that Shaw was pensive about how VCHIP’s success might possibly be replicated in Birmingham. “[E]ven if VCHIP’s approach has worked in Vermont, a small, homogeneous northeastern state represented by Bernie Sanders in the US Senate, one question kept coming up during Shaw’s visits to other states: Could it work elsewhere, in different regions with different populations and different health care markets? Alabama’s officials weren’t convinced, and Shaw had her own reservations. Still, she was used to traveling around the country—having visited nearly thirty states to speak on the topic—and was willing to share her experiences.”

The good news? “Since its launch two decades ago, VCHIP has never paid for, provided, or reimbursed directly for health care. Rather, it solves problems and identifies gaps in current health care delivery models and helps pediatricians meet the quality improvement metrics created by payers. In doing so, VCHIP has become the go-to problem solver for hospitals, insurance networks, providers, and advocacy groups in the state. And when its leaders go to places similar to Children’s of Alabama and share their successes, VCHIP finds willing allies who want to learn and gain from its expertise.”

As a result, Gale notes, “NIPN, the national network with a mission to help states set up improvement partnerships, was created by VCHIP’s leaders, who were eager to share lessons learned from their success.6 Beginning in 2003 with New Mexico and Utah, NIPN has provided consultation to more than twenty states, including Alabama, looking to start their own improvement partnerships.”

Of course, the program started out with some distinct advantages. As Gale notes, about 98 percent of Vermont’s children are covered by insurance, and nearly all pediatricians in the state accept Medicaid reimbursement, especially given that Vermont’s expanded Medicaid eligibility level covers up to 300 percent of the federal poverty level for children. What’s more, Vermont was able to reduce its overall uninsurance rate by nearly 40 percent between 2013 and 2017. It is also a very small state, both in terms of area and population.

What’s more, the American Academy of Pediatrics in 1999 published a periodicity scheduled called Bright Futures that specified recommendations for the frequency of screenings and assessments for well-child visits from infancy through adolescence, including for such elements as blood lead levels in infants and depression screening in adolescents.

It was in that context that Barbara Frankowski, a professor of pediatrics at the University of Vermont who has worked with VCHIP since the early 2000s, set about sharing the successes at VCHIP with leaders at patient care organizations nationwide, encouraging pediatric practices to focus on a specific adolescent area such as sexuality (sexual health, sexual orientation, contraception, and sexually transmitted infections), mental health and depression, substance use, nutrition, and healthy weight. Each of these areas was connected to a metric: screening for chlamydia, screening for depression, screening for substance abuse, and measuring and discussing the body mass index. Many small innovations contributed to the overall success of VCHIP.

In addition, on its road to success, VCHIP was also able to leverage Medicaid funding to compensate providers for attending statewide health meetings in person, such as a colloquium on children’s mental health. “Under a fee-for-service model, physicians have limited financial incentive to take time out of their schedules to attend in-person events,” Gale notes. “By using the Medicaid administrative match, which allows participating states to spend state Medicaid dollars to assist with the administration of the Medicaid program, VCHIP can reimburse physicians for their time at selected collaborative or statewide planning meetings. All states have some flexibility in using the match for Medicaid administrative activities, which are reimbursed at a slightly lower match rate (50 percent) for ‘proper and efficient’ costs associated with the state’s administration of its Medicaid program, which can include in-person events.”

Multiple challenges in adapting the program to different contexts remain: When Shaw goes to other states, as she did during her visit to Alabama, she stresses her belief that there are four specific and active participants necessary for any improvement program to succeed: an academic medical center, a Medicaid program, the state health department, and professional member organizations. In Vermont this multifaceted approach allows any provider, payer, academic, or advocacy organization to approach VCHIP about finding ways to improve child health outcomes within their state or to work with VCHIP to use metrics to demonstrate success in their quality improvement initiatives.

And, Gale notes, “Even with all of the pieces in place, however, it can still be an uphill battle. Pediatrics remains a very small percentage of overall health spending for payers. As a consequence, even as VCHIP has shown savings and improvements, payers and policy makers have been less interested in focusing on children’s health than adult health, and particularly chronic illness and care.”

But, she notes in her conclusion, “Frankowski and colleagues are optimistic that the same underlying flexibility and collaborative spirit that have allowed VCHIP to thrive during the past two decades will also give them the resilience to pursue their work in a post-COVID-19 universe. Whether those characteristics will surface in similar programs in other states facing the same (and often more acute) challenges remains an outstanding question. NIPN’s leaders believe that the programs they’ve supported are, at the very least, well prepared to confront with patience and creativity any tests that come their way.”