Adolescence is marked by significant mental, physical, and emotional changes, as well as autonomy-seeking behavior as individuals approach adulthood. While it is physiologically one of the healthiest phases of life, adolescence (defined in this brief as ages 12-19) is also a developmental period in which youth may engage in risky behavior, such as experimentation with drugs and alcohol. ^1,2 These risk factors necessitate a tailored approach to health care that recognizes adolescents’ developmental needs. Health care services for adolescents are often siloed, which may require adolescents and their families to seek services from multiple providers who may not communicate with one another about patient care. There is also a shortage of adolescent health specialists who focus solely on the unique developmental needs of this population. Financial incentives, including value-based payment (VBP) models, can improve adolescent care delivery and wellness by encouraging primary care providers to provide more holistic care that treats not only physical health concerns, but also addresses drivers of individual health outcomes like mental health, substance use, and other health-related social needs (HRSN). ³

The Center for Health Care Strategies (CHCS), with support from the Conrad N. Hilton Foundation, conducted a literature review and interviewed child health experts, adolescent care providers, child health researchers, child health policymakers, and payment reform experts to identify opportunities and challenges related to better addressing adolescent health and wellness through provider financial incentive strategies. From these activities and a small group consultation, CHCS developed a set of recommendations for supporting provider financial incentives that can help improve adolescent wellness and care. This brief reviews the current landscape of adolescent care, including opportunities to improve access and delivery, and outlines five key strategies to support the development of incentives for providers to deliver comprehensive, developmentally appropriate care that addresses high-risk behaviors associated with adolescence.

An annual wellness visit is the only standardized and endorsed guidance regarding the frequency of adolescent care.⁴ Annual well-visits provide a valuable opportunity for providers to influence adolescents’ health and development.⁵ The American Academy of Pediatrics (AAP) recommends that adolescents be screened yearly for developmental, behavioral health, and substance use concerns.⁶

While the well-visit provides a single opportunity each year to identify concerns, these visits are often underutilized. ^7,8 A 2009 AAP study found that 38 percent of adolescents had a preventive care visit in the prior year, and that uninsured youth and those living with low incomes were at higher risk for not attending an annual visit.⁹ A 2010 study found that approximately 30 percent of adolescents did not attend a preventive visit at all from ages 13-17.¹⁰ This lack of routine well visits may inhibit providers from establishing rapport, asking appropriate screening questions, and connecting youth to services and supports that meet their individual needs. Additionally, without regular contact, providers may not be able to identify emerging needs related to adolescents’ mental health, substance use, and sexual health.

When adolescents do attend preventive visits, providers may not discuss risk-taking behavior or provide guidance that supports good decision-making to reduce or avoid risky behaviors. One reason for the lack of more regular screenings may be provider knowledge and support. Many providers, especially physicians, report that they do not feel adequately equipped and trained to screen and address adolescents’ risky behavior or may not be reimbursed for services.¹¹ Confidentiality may be another barrier to addressing sensitive issues. Adolescents may withhold personal information like sexual activity or substance use even when seeing providers alone, out of fear that such information will be shared with their parents or provider staff.¹² Lastly, when concerns are identified, providers may not refer adolescents for follow-up services because they are not aware of the services available to address those issues.

The next section outlines recommendations for implementing financial incentives to improve the quality of adolescent care by increasing attendance at adolescent health visits; improving rapport between providers and patients; increasing the use of screenings, including those to address behavioral health and social needs; and increasing overall provider capacity to engage with the adolescent population.

There are few examples of successful provider financial incentives for adolescent care. While many provider and payer organizations increasingly pursue VBP arrangements, such models have seen less uptake when applied to the provision of adolescent care. VBP arrangements, some of which are referred to as alternative payment models (APM), are performance-based payments that link financial incentives to providers’ performance on a set of defined measures of quality and/or cost (see Exhibit 1).¹³

Exhibit 1. Health Care Payment Learning and Action Network Alternative Payment Model Framework

^{Adapted from Alternative Payment Model (APM) Framework: Refresh for 2017. The MITRE Corporation. 2017. Available at: http://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf.}

Note that total cost of care models mentioned in this brief are classified as Category 3 or 4 APMs. While such arrangements have the potential to align payer, provider, and patient interests, there is currently little research or experience with models that have a specific focus on the quality or cost of care for adolescents. This section outlines considerations for the implementation of financial incentives, including VBP arrangements, to improve care delivery for adolescents.

Financial incentives may promote better adolescent care by encouraging the performance of evidence-based practices or provision of beneficial services for adolescents. Five opportunities to employ provider financial incentives to improve adolescent care outlined below include: (1) linking provider financial incentives to wellness visits; (2) encouraging providers to build rapport with adolescents and their families; (3) promoting multidisciplinary and integrated care; (4) encouraging providers to address adolescents’ health-related social needs; and (5) pooling money from different sources.

1. Link provider financial incentives to adolescent wellness visits.

An annual adolescent wellness visit is the only point of contact many adolescents have with their primary care provider. Financial incentives could help ensure that adolescent providers encourage their patients to come in for this critical visit.

A quality metric could be used to reward providers for adolescent attendance at annual well-visits. Such a metric would measure the percentage of adolescent patients that had a well-visit over the past year, and tie performance on that metric to either a financial bonus or penalty through a pay-for-performance (P4P) incentive (LAN Category 2B) or a Category 3 or 4 APM. A direct tie to attendance via a P4P incentive offers a clear incentive for providers to improve on this metric, but the effectiveness of P4P incentives, however, is limited.^14_,15 Tying the metric to a shared savings or capitated arrangement would offer a less direct incentive (as a financial reward would also be tied to the adolescent’s total cost of care [TCOC]), but it could help to align incentives. For example, while delivery of a fixed fee for care under a risk-adjusted capitated arrangement could create a disincentive to conduct a well-visit since the provider would be paid the same amount whether the adolescent has a well-visit or not, providers may choose to encourage a well-visit to avoid providing future, more costly services and perform better on quality metrics associated with the payment.

2. Support and incentivize providers to build rapport with adolescents and their families.

A cornerstone of adolescent wellness is ensuring that the adolescent trusts that their provider’s advice is sound and that their questions and information will be handled confidentially. Adolescents may be hesitant to share their experiences in health care settings if they are not assured of confidentiality, particularly around risk-taking behaviors.¹⁶ Building and maintaining a rapport with adolescents is key to transparent conversations about their health and preventing or reducing risk-taking behaviors.

Patient experience metrics are one way to evaluate the rapport developed by providers and adolescents, which could be assessed through patient surveys. Questions could be specifically targeted to measure trust and perception of confidentiality, whether the patient perceives that the provider cares about their health and well-being, and whether the youth feel judged or supported around their behavior. Scores on these metrics could be tied to payment through a P4P bonus or using the metric as part of a shared savings, shared savings/risk, or capitated arrangement.

Another opportunity to build adolescent providers’ rapport with patients is through provider education on trauma-informed care and culturally congruent care. These educational opportunities are designed to give clinicians knowledge on how to better connect with patients by understanding their perspective based on past experiences or cultural context. While such trainings are common, they may be costly to providers. Creating a financial incentive for providers or provider organizations to complete courses may be an effective way to improve uptake. In addition to building rapport with patients, providers should have a meaningful understanding of adolescents’ needs in the context of their families. Educating and engaging parents to help foster healthy environments for their adolescent children is a critical point of care. Additionally, adolescents’ parents may have experienced unhealthy patterns in their own upbringing, which can lead to similar unhealthy patterns that result in adverse childhood experiences (ACEs) for their children. Parents may wish to break those generational cycles of trauma and adversity.¹⁷ Under the current system of care delivery, however, there may be little time, structure, and incentive for providers to proactively engage parents and families in in-depth conversations about issues that may impact their ability to provide a healthy environment. To ensure these conversations occur, payers should consider reimbursing providers for the time spent with families and their children, jointly and individually.

3. Promote multidisciplinary care.

Based on interviews, while it is not widely implemented or paid for, using a team-based model could bolster the quality of care for adolescents. Team-based care improves patient experience by having a robust care team of physicians, physician assistants, nurses, specialists, social workers, and other providers work together to tailor and coordinate services to meet the needs of the adolescent.¹⁸ Having a care team can promote streamlined care for adolescents and provides opportunities to build rapport and trust with staff. Including peer workers as part of a care team can help provide youth with a sense of safety in the provider environment. With an intentional focus on representation and cultural responsiveness, employing a care team offers the potential for increased cultural and linguistic competency in care staff, which can make adolescents feel more comfortable sharing personal information.¹⁹ Payers should consider reimbursing providers at a level that permits the staffing of a comprehensive team.

4. Incentivize providers to assess and address adolescents’ behavioral health and health-related social needs.

The conditions in which people live, grow up, work, and age, otherwise known as social determinants of health, can profoundly impact health and well-being.^20,21 Screening for and addressing health-related social needs (HRSN), such as housing instability or food insecurity, may help improve adolescents’ health outcomes by creating opportunities for critical dialogue between the patient and provider, as well as helping identify families’ unmet needs.²²

Behavioral health screenings, on the other hand, can lead to more conversation between primary care providers and young patients about their mental health and risk factors for mental illness.²³ Behavioral health screenings can also encourage discussion about adolescents’ risk of engaging in unsafe or unhealthy behavior. In addition to behavioral health screenings, ACEs screenings can help providers identify trauma or toxic stress affecting adolescents, as well as the potential causes of current risky behaviors.²⁴

If these screenings indicate the need for more than a brief intervention, providers should ensure linkage to appropriate services and supports. P4P quality metrics tied to social needs screenings are one way to link financial incentives to the use of HRSN screening assessments, but the financial incentive to address positive screens is limited if a provider is not incentivized to follow up with social service providers or community-based organizations to address HRSN. A TCOC arrangement, such as shared savings or capitation, could provide an incentive to address social needs for adolescent patients. While there is not a direct incentive for providers to address HRSN under such an approach, it provides flexibility for health care organizations to perform high-value services (such as HRSN screenings) that may not be reimbursed under a fee-for-service (FFS) model. Addressing HRSN also has the potential to impact costs associated with these needs, which could allow providers to achieve financial incentives under a shared savings or capitated arrangement.

5. Pool money from different health and social service funding streams.

Braided or blended funding mechanisms combine health care funding streams with those of social services, public health, or other areas.²⁵ Under a braided funding approach, each funding source must be used for its designated purpose, but a single organization or group of organizations can coordinate the funding across silos. In a blended funding arrangement, separate funding streams are combined into one funding stream. Such models offer increased flexibility for providers or other organizations to spend funding on what patients need most, whether it be medical care or helping to address social needs.

Blended and braiding funding at the payer level can help achieve better care for adolescents. States receiving federal funding for services may be limited by narrow federal requirements on covered services. Braided funding is one approach that promotes provision of additional services despite potential limitations.

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which provides comprehensive dental, physical, behavioral health, and specialty care for people under age 21 enrolled in Medicaid, is a robust benefit; however, federal requirements can inhibit flexibility and the ability to implement new models.²⁶ For example, federal regulations regarding waivers for children and adolescents can limit innovation. While the Centers for Medicare & Medicaid Services have the authority to waive Medicaid regulations, it cannot waive rules around data sharing and child welfare funding. Payers should consider how other funding streams (e.g., Every Student Succeeds Act education funding and child welfare funding authorized through the Family First Prevention Services Act) can be leveraged to avoid over-reliance on Medicaid, and unnecessarily limiting services and supports to those that are Medicaid-reimbursable.

While the options provided in this brief offer opportunities for financial incentives to improve adolescent care, there is also a need for innovation. A review of case studies and states’ VBP programs show that there is no single solution to effectively reimburse different types of providers for different types of activities.^27,28,29,30 Further, many activities that benefit adolescents are not reimbursable under an FFS model.³¹ As a result, additional financial incentives, including VBP approaches, offer payers the opportunity to reimburse for care, time spent, and adequate staff to help keep adolescents well.

Traditionally, payers do not incentivize cost savings for adolescents due to the assumption that adolescents typically have minimal health care needs and are rarely high cost.^32,33 However, studies have shown that Medicaid expenditures for children and youth receiving behavioral health services are significantly higher than those who do not have behavioral health needs, including adolescents.³⁴ Preventive services, effective screenings, and intervening before a crisis develops, however, can lead to better outcomes and lower costs later in life. Following are broad considerations for payers offering financial incentives to providers of adolescents.

Pay providers for outcomes rather than volume of services — but be flexible.

Increasingly, payers are focused on paying for quality and outcomes of services rather than volume to improve the patient experience and population health and reduce the per capita cost of care. Payment models like P4P, however, may feel like micromanagement to providers, increase administrative burden, not offer enough of an incentive to change behavior, and may not result in improved health outcomes. As a result, some payers and providers still prefer FFS to P4P. More comprehensive strategies, such as capitated payment models that link payment to measurable outcomes, could allow providers more flexibility and deliver greater improvements on cost and quality, and potentially reduce administrative burden.

Develop more holistic approaches to payment that address health-related social needs.

In addition to regular medical care, adolescents can benefit from more comprehensive approaches that address their HRSN. Braided and blended funding can allow for additional funding, coordination, and flexibility across silos to care for adolescents. More holistic approaches, however, can also be hard to organize, as many silos have unique regulatory requirements. Federal waivers can be used to remove barriers to cross-sector collaboration, but these also require a formal review and approval process and negotiation with the Centers for Medicare & Medicaid Services.

Align requirements across payers to ease provider burden.

Aligning payment models and approaches across payers is critical for reducing burden on providers. While VBP approaches hold promise to improve patient care and control costs, they are typically more administratively complex than FFS. To help ease the burden, payers can strive to align where possible on quality metrics, infrastructure and reporting requirements, and other factors. Complete alignment, however, should not be the goal either, as some variance is needed for different populations, care settings, or focusing on areas of improvement. Alignment of payment models and incentives for adolescents should be based on provider goals in caring for this age group relative to others.

Many providers, child health quality experts, policymakers, and state-level officials agree that fundamental changes in funding (for primary care practices, provider organizations, etc.), care coordination, and consistency in cross-silo standards for care need to be implemented for adolescents. The strategic use of financial incentives — including those that pay for both quality and outcomes rather than quantity — can support more holistic opportunities to address adolescent-related health issues. These value-based payment strategies also aim to improve cross-sector partnerships to transform how adolescent needs are met in the primary care setting and beyond. Although financial incentives alone may not be sufficient to influence improvements in adolescent care access and delivery, they support the provider’s role in educating and engaging adolescents in their own health care and represent an area of pediatric care primed for intervening before risky health related behaviors set the course for avoidable long-term poor health outcomes and their associated expense.

1. L. Achterbergh, A. Pitman, M. Birken, E. Pearce, H. Sno, S. Johnson. “The Experience of Loneliness Among Young People with Depression: A Qualitative Meta-Synthesis of the Literature.” BMC Psychiatry 20, no.415 (2020).
2. C. Hammond, L. Mayes, M. Potenza. “Neurobiology of Adolescent Substance Use and Addictive Behaviors: Treatment Implications.” Adolescent Medicine: State of the Art Reviews 25, no.1 (2014): 15-32.
3. For more information on the Accountable Health Communities Health-Related Social Needs Screening Tool, see: Centers for Medicare and Medicaid Services. Available at: https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf.
4. Bright Futures. “Performing Preventive Services.” Available at https://brightfutures.aap.org/Pages/default.aspx.
5. National Committee for Quality Assurance. “Child and Adolescent Well-Care Visits (W15, W34, AWC).” Available at: https://www.ncqa.org/hedis/measures/child-and-adolescent-well-care-visits/.
6. Bright Futures/American Academy of Pediatrics. “Recommendations for Preventive Pediatric Health Care.”
   Available at: https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf.
7. J.D. Nordin, L.I. Solberg, E.D. Parker. “Adolescent Primary Care Visit Patterns.” The Annals of Family Medicine, 8, no.6 (2010): 511-516.
8. C.E. Irwin, S.H. Adams, M.J. Park, P.W. Newacheck. “Preventive Care for Adolescents: Few Get Visits and Fewer Get Services.” Pediatrics, 123, no.4 (2009): e565-e572.
9. S.J. Levy, J.F. Williams, Committee on Substance Use and Prevention. “Substance Use Screening, Brief Intervention, and Referral to Treatment.” Pediatrics, 138, no.1 (2016).
10. J.D. Nordin, et.al., op. cit.
11. M. Clifton and A.M. Gonzaga. “Adolescent Medicine Training for Medical Students.” Ethics Journal of the American Medical Association, 7, no.3 (2005).
12. P. Ham and C.W. Allen. “Adolescent health screening and counseling.” American family physician 86, no. 12 (2012): 1109-1116.
13. Health Care Payment Learning and Action Network (HCP-LAN). “Alternative Payment Model (APM) Framework: Refresh for 2017.” Available at: https://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf.
14. A. Mendelson, K. Kondo, C. Damberg, A. Low, M. Motúapuakaet, M. Freeman, et al. “The Effects of Pay-for-Performance Programs on Health, Health Care Use, and Processes of Care: A Systematic Review.” Annals of Internal Medicine, 166, no.5 (2017): 341-353.
15. S.F. Delbanco, M. Lehan, R. Murray. The Evidence on Pay-For-Performance: Not Strong Enough on Its Own. The Health Affairs Blog, October 2018. Available at: https://www.healthaffairs.org/do/10.1377/hblog20181018.40069/full/. [1] P. Pathak and A. Chou. “Confidential Care for Adolescents in the U.S. Health Care System.” Journal of Patient-Centered Research and Reviews 6, no.1 (2019): 46-50
16. P. Pathak and A. Chou. “Confidential Care for Adolescents in the U.S. Health Care System.” Journal of Patient-Centered Research and Reviews 6, no.1 (2019): 46-50.
17. F. Meulewaeter, S.S.W. De Pauw, W. Vanderplasschen. “Mothering, Substance Use Disorders and Intergenerational Trauma Transmission: An Attachment-Based Perspective.” Frontiers in Psychiatry, 10, no.728 (2019).
18. S. Heath. How to Use Team-Based Care to Improve the Patient Experience. PatientEngagementHIT, July 2019. Available at:https://patientengagementhit.com/news/how-to-use-team-based-care-to-improve-the-patient-experience.
19. L. Schottenfeld, D. Petersen, D. Peikes, R. Ricciardi, H. Burak, R. McNellis, J. Genevro. Creating Patient-Centered Team-Based Primary Care. Agency for Healthcare Research and Quality, March 2016. Available at: https://pcmh.ahrq.gov/page/creating-patient-centered-team-based-primary-care.
20. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. “Social Determinants of Health.” Available at: https://health.gov/healthypeople/objectives-and-data/social-determinants-health.
21. R.M. Viner, E.M. Ozer, S. Denny, M. Marmot, M. Resnick, A. Fatusi, et al. “Adolescence and the Social Determinants of Health.” Lancet, 379, no.9826 (2012):1641-1652.
22. H. Gears, A. Casau, L. Buck, and R. Yard. Accelerating Child Health Care Transformation: Key Opportunities for Improving PediatricCare. Center for Health Care Strategies, August 2021. Available at: https://www.chcs.org/media/Report-Accelerating-Child-Health-Care-Transformation-Key-Opportunities-for-Improving-Pediatric-Care_8.24.21.pdf.
23. Substance Abuse and Mental Health Services Administration (SAMHSA). “Identifying Mental Health and Substance Use Problems of Children and Adolescents: A Guide for Child-Serving Organizations.” April 2012. Available at: https://store.samhsa.gov/product/Identifying-Mental-Health-and-Substance-Use-Problems-of-Children-and-Adolescents-A-Guide-for-Child-Serving-Organizations/SMA12-4700.
24. A. J. Barnes, B. J. Anthony, C. Karatekin, K.A. Lingras, R. Mercado, L.A. Thompson. “Identifying Adverse Childhood Experiences in Pediatrics to Prevent Chronic Health Conditions.” Pediatric Research, 87, no.2 (2020): 362-370.
25. A. Clary and T. Riley. Braiding & Blending Funding Streams to Meet the Health-Related Social Needs of Low-Income Persons: Considerations for State Health Policymakers. National Academy for State Health Policy, February 2016. Available at: https://www.nashp.org/wp-content/uploads/2016/02/Jean1.pdf.
26. Medicaid.gov. “Early and Periodic Screening, Diagnostic, and Treatment.” Available at: https://www.medicaid.gov/medicaid/benefits/early-and-periodic-screening-diagnostic-and-treatment/index.html.
27. M. Schulman, J. O’Brien, M. Pierre-Wright, C. Thomas-Henkel. Exploring Value-Based Payment to Encourage Substance Use Disorder Treatment in Primary Care. Technical Assistance Collaboration and the Center of Health Care Strategies, June 2018. Available at: https://www.chcs.org/media/VBP-for-SUD_Final_June-2018.pdf.
28. Bailit Health. “Value-Based Payment Models for Medicaid Child Health Services.” July 2016. Available at: http://www.bailit-health.com/articles/2016-0713-Bailit-vbf-final.pdf.
29. J. Perrin, E. Zimmerman, A. Hertz, T. Johnson, T. Merrill, D. Smith. “Pediatric Accountable Care Organizations: Insight from Early Adopters”. Pediatrics, 139, no.2 (2017). Available at: https://pediatrics.aappublications.org/content/early/2017/01/29/peds.2016-1840.
30. S. Brundage, C. Shearer. Reforming Payment for Children’s Long-Term Health: Lessons from New York’s Children’s Value-Based Payment Effort. The Commonwealth Fund, August 2019. Available at: https://uhfnyc.org/media/filer_public/01/14/01140be3-41eb-4931-acbd-aca871dc5563/uhf-cmwf-childrens-vbp-20190822.pdf.
31. C.A. Wong, J.M. Perrin, M. McClellan. “Making the Case for Value-Based Payment Reform in Children’s Health Care.” JAMA Pediatrics, 172, no.6 (2018): 513-514. Available at: https://doi.org/10.1001/jamapediatrics.2018.0129.
32. Ibid.
33. P. Flanagan, P.M. Tigue, and J. Perrin. “The Value Proposition for Pediatric Care.” JAMA Pediatrics, 173, no.12 (2019):1125–1126. Available at: https://doi.org/10.1001/jamapediatrics.2019.3486.
34. S. Pires, K. Grimes, T. Gilmer, K. Allen, R. Mahadevan, T. Hendricks. Examining Children’s Behavioral Health Service Utilization and Expenditures. Center for Health Care Strategies, December 2013. Available at: https://www.chcs.org/resource/examining-childrens-behavioral-health-service-utilization-and-expenditures-3/.