Communication and Swallowing Disorders in Children: Budget and Policy Implications for State Medicaid Agencies

Abstract

Increasing enrollment in state Medicaid programs combined with a significant increase in the prevalence of pediatric communication and swallowing disorders over the past decade will challenge state Medicaid budgets. This research identifies payment and policy trends related to the provision of pediatric speech therapy services across state Medicaid programs and proposes alternative payment models for the provision of services.

Fee-for-service payment rates for 2017 were evaluated to determine overall patterns of Medicaid reimbursement in the United States (U.S.). Descriptive statics were calculated to determine the mean and median national Medicaid published rates. These rates were compared to the 2017 Medicare fee schedule and publicly available private market fee data to assess their adequacy. The accompanying therapy policies were also analyzed to identify trends across state Medicaid agencies related to qualified provider provisions, prior authorization requirements, benefit limits, and telepractice. Additionally, pediatric speech-language pathologists were surveyed to identify their perceptions of clinical and administrative quality. The cost data identified was combined with provider perceptions of quality to propose alternative payment models that could be used instead of the fixed, fee-for-service payment model.

An analysis of published payment rates with the comparison programs revealed that Medicaid payments for individual treatment services were 30% less, on average, than comparable Medicare or commercial rates. Texas Medicaid payment rates were significantly higher than those paid by other state Medicaid agencies, strongly suggesting that policymakers should consider cost containment action. An analysis of the related therapy policies showed that most states have established parameters related to qualified providers requirements, have developed language regarding benefits limits, and require referrals and prior authorization before the initiation of services. Further, pediatric speech-language pathologists placed greater emphasis on measures of clinical quality than on measures of administrative quality, providing a framework for the development of alternative payment models.

The use of episodic payments and top performing provider designations for claims payments is a promising option to potentially reduce the incentive Texas Medicaid providers currently have to prescribe more health care services than are necessary and can also reduce variations in payments to providers resulting in a cost savings for state Medicaid agencies.