Showing papers in "The Future of Children in 1998"

The extent and consequences of child maltreatment.

Abstract: Specific, accurate understanding of the extent of maltreatment in American society, the nature of the maltreatment that occurs, and the consequences it has for children are crucial to inform policies regarding child protection and to guide the design of prevention and treatment programs. This article examines how child abuse and neglect are defined and discusses the controversies that surround that definition, which attracts attention because it justifies government intervention to stop actions by parents or caregivers that seriously harm children. The article also presents statistics indicating how widespread maltreatment is, reviews research on the characteristics of families that are more prone to abuse or neglect, and summarizes knowledge about the impact of maltreatment on children. Finally, it mentions the efforts of public child protective services agencies to responsibly ration calls on their limited resources by using risk-assessment approaches to target scarce services to the children who need them the most.

When children cannot remain home: foster family care and kinship care.

Abstract: Despite the best efforts of child welfare agencies, community agencies, and individuals, some children are not safe in their homes and must be placed in substitute care settings by child welfare authorities. Increasingly, as this article points out, child welfare agencies are placing children in the homes of their relatives rather than in traditional foster family homes (31% of all children in out-of-home care in the early 1990s were living with kin). This article discusses how such factors as the availability of foster homes, the demand for foster care, attitudes toward the extended families of troubled parents, and policies regarding payment for the costs of care have contributed to the rapid growth in kinship foster care. It discusses differences in the personal characteristics of kin and traditional foster parents and in the supports provided to the caregivers by child welfare agencies. Research findings suggest that kinship homes can promote the child welfare goals of protecting children and supporting families, but they are less likely to facilitate the prompt achievement of legal permanence for children. To forge a coherent policy toward kinship caregivers, officials must balance the natural strengths of informal, private exchanges among family members with the power of government agencies to provide both resources and oversight.

Rethinking the Paradigm for Child Protection.

Abstract: Mounting pressures on the nation’s system for helping children who are abused and neglected have prompted new efforts to reform the child protective services (CPS) system to better protect children’s safety. As this article explains, current reform efforts are focusing on the “front end” of the system, in which reports of abuse and neglect are screened and investigated, and caseworkers recommend whether and when to close a case, provide in-home services, or remove a child from a home. This article discusses the problems of the CPS system that are currently receiving attention, and it closely examines one proposal for reform—the community-based partnership for child protection. This approach emphasizes targeting investigations by CPS toward only high-risk families, building collaborative community networks that can serve lower-risk families, and providing a differentiated response to both high- and low-risk families that is tailored to each family’s situation. Early experiences implementing these ideas in Missouri, Florida, and Iowa illustrate the promise and challenges of reform.

Past, Present, and Future Roles of Child Protective Services.

Abstract: Contemporary social issues typically spring from historical roots, and, as this article points out, that is particularly true of the effort to find a balanced, fair, and helpful way of responding to child abuse and neglect. This article examines how today's child protective services system evolved from a past of almshouses, orphan trains, anticruelty societies, and legislation establishing the protection of children as a government function. The author finds that the history of child protection in the United States is marked by a continuing, unresolved tension between the aim of rescuing children from abusive homes and that of strengthening the care their families can provide. Against that backdrop, this article explains the structure of the typical child protective services (CPS) agency (the unit within a broader public child welfare department that focuses on abuse and neglect) and outlines the roles in child protection that are played by the police, the courts, private and public social service agencies, and the community at large. According to the author's analysis, the fundamental challenges facing CPS can be captured in two questions regarding appropriate boundaries for the agency: Which situations require the agency's intervention? And how can the broader resources of the community be mobilized in the effort to protect children?

Family-centered services: approaches and effectiveness.

Abstract: Much of the emphasis in the nation's system of child protection focuses on investigations to determine whether child abuse or neglect has occurred, and procedures for arranging out-of-home care for children who are not safe at home. Less attention often goes to the capacity of public and private agencies to provide services that help stressed families prevent child maltreatment before it begins, or that enable families with serious child-rearing problems to stabilize the home and provide more appropriate care for their children. This article examines the current understanding of the most promising and effective means of serving families. It highlights the family-centered service approach, which encompasses family support services for families coping with normal parenting stresses, and family preservation services designed to help families facing serious problems and possible out-of-home placement. The article explains the characteristics of family support and family preservation services, and discusses how these services are accessed and financed. It reviews available evaluation findings regarding the effectiveness of the two types of family-centered services, and considers the challenges faced when evaluating such services. Finally, the article discusses issues related to planning and service delivery, such as coordination and system reform, financing, targeting, relationships between workers and families, and efforts to strengthen entire communities.

The Costs of Child Protection in the Context of Welfare Reform

Abstract: The financing structure of any large public service system both reveals the priorities held by policymakers and drives the delivery of services. Of the $11.2 billion in public funds for child welfare services, somewhat less than half is federal. As this article explains, federal funds for child welfare overwhelmingly go to support out-of-home care (foster care and adoption services), and these costs have risen sharply in recent years. In contrast, federal funding for child protection investigations, prevention programs, and treatment services is more limited, and expenditures have not risen apace with reports of maltreatment. The article compares the high cost of foster care with the lower per capita cost of cash assistance to poor families and the per-case costs of child protection investigations and service provision. Pointing out that the great majority of families served by the child welfare system are poor, the author argues that child welfare and cash assistance should be seen and analyzed as interrelated programs serving poor families. The article examines the varied ways in which the changes in cash assistance programs introduced by the 1996 federal welfare reform law may increase the need for child welfare services and drive up the costs of child protection.

Managed care for children: effect on access to care and utilization of health services.

Abstract: The rapid trend toward enrolling children in managed care has occurred largely without conclusive evidence about the effects of these arrangements on two important aspects of care: access and utilization. Although the effect of managed care on these measures has been studied more widely in the adult population, the results may not be applicable to children, who have unique health care needs centering around prevention and early treatment of acute illnesses to avoid long-term health problems. Moreover, several methodological challenges make it difficult to evaluate the impact of managed care on health care access and utilization in general. This article reviews what is known about the effect of managed care on access to health services, as well as utilization of hospital care, emergency department (ED) visits, primary care services, and specialty services for the pediatric population. In each area, findings from privately insured children and Medicaid enrollees are considered separately. There is little conclusive evidence on the effect of managed care on access to and utilization of pediatric health services. A recurring theme is that the effect of managed care is dependent on several factors, including whether providers assume financial risk through capitated reimbursements or retain fee-for-service payments; the comprehensiveness of benefits offered by health plans; and the level of cost sharing required of families. Among privately insured children, for example, managed care usually has been associated with higher primary care visit rates, though the benefit of managed care is reduced when fee-for-service plans cover preventive care and require minimal or no cost sharing for these services. Among Medicaid recipients, studies suggest that managed care is more likely to be associated with a decrease in preventive visits when provider payments are capitated. Attempts to decipher effects by health plan type are made more difficult by the rapid evolution of both managed care and fee-for-service plans, which often blurs the distinction between these two entities. Nonetheless, in some areas, managed care does appear to have an identifiable effect on pediatric health services. For Medicaid recipients, managed care has been associated with decreased emergency department use and decreased access to specialty care for chronically ill children. As enrollment of children in managed care plans increases, the need continues for methodologically sound studies evaluating the effect of these arrangements on the delivery of pediatric health services and on health outcomes.

The impact of managed care on mental health services for children and their families.

Abstract: For more than a decade, the philosophy of community-based systems of care has guided the delivery of mental health services for children and adolescents served by publicly funded agencies. This philosophy supports system attributes that include a broad array of services; interagency collaboration; treatment in the least-restrictive setting; individualized services; family involvement; and services responsive to the needs of diverse ethnic and racial populations. The notion of systems of care emerged in an era when managed health care also was gaining popularity. However, the effect of managed care on the delivery of mental health and substance-abuse services--also known as behavioral health services--has not been widely studied. Preliminary results from the nationwide Health Care Reform Tracking Project (HCRTP) inform discussions about the impact of managed behavioral health care on services for children and adolescents enrolled in state Medicaid programs. Most states have used some type of "carve-out design" to finance the delivery of behavioral health services, and there is a trend toward contracting with private-sector, for-profit companies to administer these benefits. In general, managed care has resulted in greater access to basic behavioral health and community-based services for children and adolescents, though access to inpatient hospital care has been reduced. Under managed care, it also has been more difficult for youths with serious emotional disorders, as well as the uninsured, to obtain needed services. With managed care has come a trend toward briefer, more problem-oriented treatment approaches for behavioral health disorders. A number of problems related to the implementation of managed behavioral health care for children and adolescents were illuminated by the HCRTP. First, there is concern that ongoing efforts to develop systems of care for youths with serious emotional disorders are not being linked with managed care initiatives. The lack of investment in service-capacity development, the lack of coordination with other agencies serving children with behavioral health problems, and cumbersome preauthorization requirements that may restrict access to appropriate service delivery were other concerns raised by respondents about managed care. As the adoption of managed behavioral health care arrangements for Medicaid beneficiaries expands rapidly, the HCRTP will continue to analyze how this trend has affected children and adolescents with behavioral health problems and their families.

Protecting children from abuse and neglect: analysis and recommendations.

Abstract: An analysis of the challenges, pressures, and uncertainties facing the public child protection system, with recommendations for strengthening child protective services agencies, and expanding prevention and treatment resources. (Abstract Adapted from Source: The Future of Children, 1998. Copyright © 1998 by The David and Lucile Packard Foundation) Child Protection Child Abuse Victim Child Abuse Intervention Child Abuse Prevention Child Physical Abuse Victim Child Physical Abuse Intervention Child Physical Abuse Prevention Child Neglect Intervention Child Neglect Prevention Child Neglect Victim Child Victim Domestic Violence Intervention Domestic Violence Prevention Domestic Violence Victim Prevention Recommendations Intervention Recommendations 01-02

Four Commentaries: How We Can Better Protect Children from Abuse and Neglect.

Abstract: Editor’s note: Douglas J. Besharov, J.D., LL.M., is a resident scholar at the American Enterprise Institute for Public Policy Research and a professor at the University of Maryland’s School of Public Affairs. He was the first director of the U.S. National Center on Child Abuse and Neglect, and now serves on New York City’s Child Fatality Review Panel, consults to public and private child welfare agencies nationwide, and writes on issues relating to child abuse.

Managed Care and Children: An Overview

Abstract: This article lays the foundation for the other articles in this journal issue, which examine the effect of managed health care arrangements on a particular population: children. Although managed care has been used to finance and deliver health care services for decades, the meaning of this term often has been unclear to health care consumers and practitioners because new forms of managed care have evolved rapidly. The one consistent and unifying concept across all managed care arrangements is that enrollees obtain care from a network of participating health care providers who contract with the managed care organization and abide by the organization’s rules. The uncertainty of what managed care is has made it difficult to measure the effect of these arrangements on health service delivery and health outcomes, especially in the pediatric population, where the development of outcome and quality measures lags behind that for adults. The incentives posed by managed care suggest both potential advantages and disadvantages to these arrangements for children. On the positive side, managed care enrollment may offer a “medical home” for primary care services to children who otherwise would obtain only episodic care; improve the coordination of health care services; and encourage more preventive health services. On the negative side, under capitated reimbursement, health plans have an incentive to enroll only healthy children with the lowest expected health care expenditures, and providers have an incentive to offer fewer services than may be appropriate. Managed care also may limit enrollees’ choice of providers, particularly for specialty care. Despite the paucity of information about the effect of managed care on the delivery of pediatric health services and on child health outcomes, children are disproportionately being enrolled in managed care plans.

Medicaid Managed Care and Children: An Overview.

Abstract: In recent years, states have increasingly turned to managed care arrangements for financing and delivering health services to Medicaid beneficiaries. In 1996, approximately 40% of all Medicaid recipients were enrolled in some form of managed care. The rapid escalation of managed care in this population has been fueled by states' desire to slow the growth of Medicaid expenditures and by the trend toward managed care enrollment in the private health insurance industry. The effect of managed care on cost containment in the Medicaid program may be limited, however, because 85% to 90% of Medicaid managed care enrollees are women of childbearing age and children, who together account for 69% of Medicaid recipients, but only 26% of program costs. Nonetheless, the increase in managed care enrollment in this population may have a profound impact on health service delivery and health outcomes for U.S. children, approximately 20% of whom received health benefits through the Medicaid program in 1995. In the future, the proportion of Medicaid-eligible children enrolled in managed care will likely increase as a result of recent legislation that relaxed the requirement that states seek federal approval prior to mandating managed care enrollment for Medicaid beneficiaries. More states are relying on fully capitated arrangements as the preferred type of managed care for Medicaid recipients, despite the relative lack of experience many of these plans have in serving this low-income population. Moreover, managed care organizations have few incentives to enroll chronically or disabled children with higher-than-average expected costs. Without mechanisms in place that adequately adjust capitated rates to account for these higher-cost enrollees, managed care organizations may lose money, and children with the greatest health care needs may be underserved. As mandatory managed care enrollment for Medicaid recipients increases nationwide, states should carefully monitor changes in program costs and quality as well as implications for the delivery of pediatric health services and health outcomes.

How we can better protect children from abuse and neglect.

Abstract: Editor’s note: Douglas J. Besharov, J.D., LL.M., is a resident scholar at the American Enterprise Institute for Public Policy Research and a professor at the University of Maryland’s School of Public Affairs. He was the first director of the U.S. National Center on Child Abuse and Neglect, and now serves on New York City’s Child Fatality Review Panel, consults to public and private child welfare agencies nationwide, and writes on issues relating to child abuse.

Managed care and the quality of children's health services.

Abstract: Managed care has changed the practice of medicine. The choice of health care providers has been narrowed, physicians are being held financially accountable for the number of services they use, and a new emphasis is being placed on the cost and quality of the care provided. The transition to managed care has occurred with little attention to its impact on access to health care services or the quality of services provided. There is an absence of information about how children fare in these new systems. What little is known indicates that children in managed care arrangements are less likely to be able to be seen by pediatric specialists, and that families and providers are less satisfied under managed care. The impact of these changes on children’s health status, however, is yet to be determined. For children with special needs, the problems of coordination of care, coverage of needed services, and the choice of the appropriate pediatric subspecialists, many of which existed in traditional fee-for-service systems, persist under managed care. In spite of all of the negative anecdotes about managed health care, managed care’s focus on its population of enrollees and its heightened sense of a need for health care accountability bring exciting new opportunities to measure and improve the health care children receive. A new emphasis is being placed on practicing evidence-based medicine; the focus is on closing the gap between what is known (effective, evidencebased care) and what is done (current practice). Improved health outcomes and reduced health care costs have been documented in demonstration projects in neonatal intensive care units and in pediatric offices. Applying the principles of these learning collaboratives and employing the tools of continuous quality improvement in health care are urgent challenges that deserve to be met. Health plans, physicians, health care purchasers, regulators, families, and their children must work together to assure that children receive the highest-quality care possible—care that is technically excellent and medically appropriate, and that improves the health of our children.

Children and managed health care: analysis and recommendations.

Abstract: Arevolution in health care has taken place during the past decade in the United States. The revolution was ignited by skyrocketing health care costs1 and fueled by the widespread public sentiment that the high cost of health care was the most important problem in the health care industry.2 The health insurance industry and providers responded to the public’s outcry by creating lower-cost health care insurance alternatives—managed health care plans. Managed health care is a vast array of financing and health care delivery systems that are designed to limit costs and ration health care. Employers and individuals seized the opportunity to lower their health care costs and began to buy these managed health care plans. Today, managed care plans are pervasive; 85% of all employed families and a growing number of those covered by Medicaid are in managed health care plans.3,4 By choosing managed health care, U.S. employers and consumers have changed the nation’s health care system.

Improving state Medicaid contracts and plan practices for children with special needs.

Abstract: The rapid transition of state Medicaid beneficiaries into fully capitated managed care plans requires a special focus on children with chronic or disabling conditions, who often depend on numerous pediatric physicians and other specialty services for health care and related services. Because managed care arrangements for this population are growing in popularity nationwide, it is important that states craft managed care contracts to address the unique needs of children with complex physical, developmental, and mental health problems. Based on the research reported in this article, in-depth interviews with state Medicaid agency staff, interviews with medical directors and administrators of managed care plans serving Medicaid recipients, and input from experts in pediatrics and managed care, a set of recommendations is made for tailoring managed care contracts to meet the needs of this vulnerable group of children. Six contracting elements that should be adopted by state Medicaid agencies include (1) clarifying the specificity of pediatric benefits, (2) defining appropriate pediatric provider capacity requirements, (3) developing a medical necessity standard specific to children, (4) identifying pediatric quality-of-care measures, (5) setting appropriate pediatric capitation rates, and (6) creating incentives for high-quality pediatric care. Nine approaches that should be adopted by managed care practices interested in providing high-quality care for children with special needs also are identified. These include (1) ensuring that assigned primary care providers have appropriate training and experience, (2) offering support systems for primary care practices, (3) providing specialty consultation for primary care providers, (4) establishing arrangements for the comanagement of primary and specialty pediatric services, (5) arranging for comprehensive care coordination, (6) establishing flexible service authorization policies, (7) implementing provider profiling systems that adjust for pediatric case mix, (8) creating financial incentives for serving children with special needs, and (9) encouraging family involvement in plan operations. Implementing these changes to managed care contracting could have a major impact on the quality and comprehensiveness of health care received by children with special needs. Successful implementation, however, requires strong support from both state Medicaid agencies and the managed care plans dedicated to serving this population.

Child Indicators: Dental Health.

Abstract: Maintaining good dental health among children in the United States today should be easy: regular tooth brushing, flossing, exposure to fluoride, and attention to good nutrition, together with visits to a dentist twice a year, should be enough to assure that a child rarely suffers the pain of an abscessed tooth, or loses a tooth to severe decay. However, many young children, especially those living in poor families, continue to suffer with mouths full of deep cavities, swollen jaws and cheeks, and episodes of around-the-clock pain. Some children regard tooth decay as inevitable and the pain associated with dental therapy as so unpleasant that they would rather have their teeth pulled than fixed. 1 Maintaining good dental health in children is important not only because it prevents childhood pain and suffering and the school absenteeism that results from dental disease, but also because tooth loss in childhood can adversely affect how the jaws and teeth function as the child matures. 2 Furthermore, unhealthy teeth are considered unattractive, and negative responses to the appearance of a child’s teeth can impair the child’s social confidence. Dental health can influence a child’s overall chances for success just as do other, more frequently recognized aspects of physical health. 3 This Child Indicators article reviews several measures of dental health in children and the evidence on children’s dental health. While children’s dental health has improved substantially over the past two decades, with large declines in the average number of cavities per child, a number of children experience a disproportionate share of dental disease. 4 Poor children in particular, because they are less likely than their wealthier peers to receive dental services, are at the highest risk of suffering the pain and consequences of untreated dental disease. Although federal law requires states to provide dental services to poor children through the early and periodic screening, diagnosis, and treatment (EPSDT) component of the Medicaid

The State Children's Health Insurance Program (CHIP).

Abstract: Between 7 million and 10 million children in the United States lack health insurance. Many of these uninsured children experience difficulty obtaining needed health care.1 To expand health insurance coverage for children, in August 1997, Congress enacted the State Children’s Health Insurance Program (CHIP) as part of the Balanced Budget Act of 1997.2 CHIP, also known as Title XXI of the Social Security Act, offers states new federal funding in the form of block grants to provide “child health assistance to uninsured children in low-income families in an effective and efficient manner that is coordinated with other sources of health benefits coverage for children.” The program is authorized for 10 years and is expected to provide insurance coverage for millions of currently uninsured children. Federal expenditures on child health assistance under the law are estimated to total $40 billion to $50 billion over the life of the legislation.

State Regulation of Managed Care: The Impact on Children.

Abstract: As more and more children enroll in managed care, states have responded to concerns expressed by their constituents by passing legislation and developing credentialing requirements to assist families with children in receiving appropriate care from managed care plans. Although most of the legislation and credentialing requirements apply to the population generally, a few provisions apply specifically to children. The legislation and credentialing requirements attempt to improve both access to medical care and the quality of care by enacting access-to-care and quality-of-care provisions, reducing the financial incentives for providers to offer inappropriate care, and providing families with more information about their choices and opportunities to redress their grievances. Although there is no empirical evidence, analysis of similar types of legislation suggests that certain approaches will be more successful than others; one obvious indicator of success is the ability of the regulatory agency to develop clear, unambiguous, enforceable rules. Existing legislation varies widely across states in terms of the issues addressed and the specificity of the laws. For the most part, this legislation has been piecemeal, addressing specific issues as they arise. In the long run, state legislatures may not have the time or the expertise to regulate the managed care industry, and other regulatory bodies may be better equipped to address concerns about managed care. If utilized, however, existing regulatory bodies, which historically monitored feefor-service medicine, will need to be redesigned to monitor managed care.

The State Children's Health Insurance Program (CHIP). Revisiting the Issues.

Abstract: Between 7 million and 10 million children in the United States lack health insurance. Many of these uninsured children experience difficulty obtaining needed health care.1 To expand health insurance coverage for children, in August 1997, Congress enacted the State Children’s Health Insurance Program (CHIP) as part of the Balanced Budget Act of 1997.2 CHIP, also known as Title XXI of the Social Security Act, offers states new federal funding in the form of block grants to provide “child health assistance to uninsured children in low-income families in an effective and efficient manner that is coordinated with other sources of health benefits coverage for children.” The program is authorized for 10 years and is expected to provide insurance coverage for millions of currently uninsured children. Federal expenditures on child health assistance under the law are estimated to total $40 billion to $50 billion over the life of the legislation.