CMS Announces ASPIRE Model for Complex Pediatric Care in Medicaid

This week, the Centers for Medicare and Medicaid Services (CMS) announced a new payment model that aims to bolster comprehensive health coverage for children with complex medical and behavioral health needs. The Accelerating State Pediatric Innovation Readiness and Effectiveness (ASPIRE) Model is a state-based model that will serve children up to age 21 enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) and meet certain criteria.

The model will run for ten years and up to five states will be eligible to participate. CMS intends to use the model to demonstrate potential pathways to comprehensive pediatric care for vulnerable youth while allowing them to thrive in the least restrictive setting. According to the CMS press release, the ASPIRE model will allow Medicaid providers to form networks that specifically serve qualifying patients.

CMS Administrator Mehmet Oz and Center for Medicare and Medicaid Innovation (CMMI) director Abe Sutton explained in an op-ed in STAT that the current Medicaid fee-for-service model fails children by failing to provide coordinated, whole-person care. Through a network of provider communication, children will be better positioned to have their complex and behavioral health needs treated and afforded a greater opportunity to develop social and communication skills as adults.

The ASPIRE Model is set to build off of the Integrated Care for Kids Model, and will specifically draw from the lessons and benefits of an integrated care management system for families. Inside Health Policy reports that the announcement follows a request for applications for its Make America Healthy Again payment model, which aims to test holistic care through nutrition and exercise. CMS will release a Notice of Funding Opportunity for the ASPIRE model later this year.

In tandem with the announcement, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) released a report on the unique needs of families with children with chronic conditions. The report found that the prevalence of pediatric chronic conditions in the U.S. has risen to over 30%, with conditions including asthma, diabetes, autism spectrum disorder and anxiety. Improvements in a child’s quality of life with chronic illness is directly correlated with access to care and the availability of family support for coordinated care and medication management.

Enabling better care for children is advantageous now and in the future with improved quality of life, health outcomes, health care utilization, caregiver and family health status, and potential youth long-term benefits such as productivity and health outcomes in adulthood. Cost and payment issues will also need to be addressed for viable implementation of strategies that hold promise in improving care for children and families.