Update:  We posted this story on Tuesday evening and received a response from the Department of Health Care Services Wednesday that clarifies additional information. DHCS information Officer Katharine Weir said that subject to budget approval by the legislature and the governor:  The reimbursement rate will be $29.  Federally Qualified Health Centers will also be reimbursed for screening pediatric patients for trauma through Prop 56 funds and federal matching funds.  In response to a question about whether health care providers who use the Whole Child Assessment to screen pediatric patients  for trauma, or a third option that meets the Department's minimum requirements, Weir said "It is not being considered at this time."

The California chapter of the American Academy of Pediatrics urged the California Department of Health Care Services to broaden its proposed decision for ACEs screening of children in the state to allow for greater adoption by the state’s health care providers, according to comments made to the DHCS, which were obtained by ACEs Connection through a public records request. 

“Limiting providers to a single tool restricts providers who may find that a validated screening tool that they are already using meets the needs of their population,” said an unsigned letter from the state’s AAP chapter.

The California chapter of AAP’s letter was among more than 60 letters from dozens of California-based health care clinics and organizations,children’s advocacy and social service organizations that weighed in on the Department of Health Care Services proposed decisions around screening the state’s children for adverse childhood experiences.  (The public comments are attached below.)

Governor Newsom has set aside $45 million from Proposition 56 and a matching amount from federal funds for ACEs screening. DHCS proposed a $29 supplemental payment per screening and recommended that children be screened for ACEs annually. (Read this related story.)

This process began when a bill, AB340, calling for ACEs screening of children in the state’s Medi-Cal program, a was signed into law in 2017. How that was to play out was determined by the California Department of Health Care Services, which convened the AB 340 work group to make recommendations. That work group included pediatricians and other health care providers, and representatives from social service and children’s advocacy organizations who met quarterly in 2018. The work group recommended allowing Medi-Cal providers to select one of three options of how they’ll screen children for ACEs.

In March, however, the DHCS proposed that only one of three recommended options for screening children for ACEs be reimbursed — the PEARLS (Pediatric ACEs and Related Life-Event Screener) tool.

However, I did learn that reimbursement for screening, which had been scheduled to begin July 1, has been pushed back to January 1. DHCS Information Officer Katharine Weir said that DHCS’s proposed decision is still in flux. “The Proposition 56 trauma screenings proposal has not been finalized,” she said.

The AAP aligned itself with the AB 340 work group, which in addition to the PEARLS tool, had recommended the Whole Child Assessment and an alternative tool that anyone could propose, provided that it meet the state’s minimum requirements for screening for trauma.

Other organizations expressed concerns similar to AAPs. “We are concerned with the promotion of a single tool to screen for trauma. In our experience, different tools are appropriate for different communities,” wrote Tracy MacDonald Mendez of the California School Based Health Alliance.

That sentiment was not limited to direct-service health providers. The California Association of Health Plans expressed concern about form fatigue, citing the many forms that patients and providers are required to fill out. To help with that, it wrote “DHCS should consider allowing greater flexibility of which tool to use for these screenings so that providers can capitalize on improved efficiency where efforts are already in place.”

In fact, the WCA, one of the tools recommended by the AB340 work group, already combines questions about safety and health — such as whether there’s a gun in the house, or enough to eat — with ACEs questions. (See this related story about the WCA).

The San Francisco-based Center for Youth Wellness (CYW), which is one of the entities that developed the PEARLS tool along with UCSF Benioff Children’s Hospital in Oakland and the University of California, San Francisco, emphasized in comments it submitted the great need for training in trauma-informed practices for all of the staff involved in ACEs screening. That concern was echoed by The Children’s Clinic, based in Long Beach.

“Screening for trauma and hearing results can be traumatizing for staff especially if they have experienced their own trauma. We need to combat burnout and compassion fatigue,” wrote Elisa Nicholas, representing The Children’s Clinic.

According to the DHCS’s Weir, the department will provide training prior to Jan. 1, 2020, when it will begin reimbursing health care providers for ACEs screenings.   

Besides weighing in on flexibility around ACE screening tools, a number of community health center groups from around the state pushed for the DHCS to reconsider providing reimbursement to these centers, which are Federally Qualified Health Centers and serve, they say, one-third of all of the state’s Medi-Cal participants. “But unfortunately, in discussions with DHCS, the state is not allowing CHCs to participate in this specific program, arguing that these dollars come from Prop 56 monies that were intended to target non-FQHC providers,” wrote Bobbie Bliatout of the Greater Fresno Health Organization, which comprises two main clinics in Fresno County. Those sentiments were shared by similar organizations up and down the state, including the Central City Community Health Center, which operates 15 clinics in Los Angeles, Orange, Riverside and San Bernardino Counties, according to its website.

Several of those who reached out to DHCS were concerned that pediatric practices that are interested in screening their pediatric patients need to have a plan in place that ensures that patients who need mental health or other supportive services related to their experiences of ACEs get them. “There is no evidence that providing families with a phone number of these programs will make a significant impact,” according to the letter submitted by the California chapter of the AAP. “Routine screening for increased vulnerability is useful only if collaborative relationships exist with local services to address the identified concerns.”

DHCS’s Weir said she was unable to say when its proposed decision would be finalized, and that “further information is forthcoming.” By the time we were ready to publish this article, the Department of Health Care Services had not responded to specific questions related to the public comments it received. Those questions include:

• Whether FQHCs will be reimbursed for screening pediatric patients in the Medi-Cal program for ACEs?
• Since DCHS’s proposed decision is not finalized, does that mean it may allow reimbursement to providers who use the Whole Child Assessment tool, or the third option for screening pediatric patients?
• Is the DHCS considering changing the proposed reimbursement amount of $29 for trauma screening?

The two top questions were also sent to Assemblymember Joaquin Arambula, the lead author of AB340, who wrote in response why AB340 is necessary: “Trauma screenings are one of the first and most critical steps in ensuring children who have faced adverse childhood experiences (ACEs) are diagnosed and treated early,” said Arambula. “I will continue to provide legislative oversight and accountability to ensure that the trauma screening is moving in the direction we had envisioned….”

 If you have questions, please add them in the comments, and we will make sure that DHCS representatives receive them.