US healthcare is advancing toward value on many fronts – sometimes by focusing on specific diseases like cancer or kidney care, at other times by focusing on particular populations of patients. One of the most important and promising areas of advancement today is in pediatric care. This white paper will delve into the critical issues confronting pediatric providers working in value-based programs and describe the progress made by some of its leading practitioners.
Although value-based pediatric care is getting more attention today, pediatric care is actually a forerunner of modern value-based programs. In fact, many of the concepts and approaches embedded in value-based care evolved out of the pediatric space.
Pediatric value-based care is rooted in the original “medical home” which the American Academy of Pediatrics (AAP) introduced in 1967. The medical home was a profound reimagining of primary care based on an understanding that continuous, coordinated, preventive, and holistic care is critical for driving better health outcomes. Behind that reasoning lay an implicit belief that children can be the “gateway” for providing better health to others in the family and the community and that better health outcomes can only be achieved by also applying supportive social care.
In 1992, the AAP took this understanding to another level in a policy statement and framed the medical home as a critical model for providing high-quality care for children at lower overall costs. When the Affordable Care Act was enacted in 2010, the AAP’s concepts were embodied in the idea of Accountable Care Organizations (ACOs) and patient-centered medical homes (PCMHs).
A number of CMS-focused experiments, models, and regulations followed, and pediatric-focused ACOs and PCMHs were launched around the country. Very quickly, these organizations showed a positive impact by bringing coordinated, preventive care to children. Early intervention, prevention, coordination, and social services improved health outcomes and reduced costs.
Yet, the adoption of value-based care in pediatrics still lags other areas of US healthcare. One important reason is the lack of standardized quality measures – critical for establishing a value-based program – to assess outcomes and health status for pediatric patients. Another reason might be that children are generally healthier than other populations. This makes it harder to demonstrate cost savings on the one hand, and yet puts providers at great risk for outlier patients with serious illnesses or conditions who can require enormous care resources. At the same time, however, pediatric value-based care also has enormous benefits because early prevention and appropriate intervention can significantly improve long-term health status, help children thrive socially and educationally, and dramatically impact overall downstream costs.
In other words, the health of children is an investment that pays significant but difficult-to-define dividends. This explains progress on multiple fronts.
Some states have implemented Medicaid programs for children with value-based components. Leading practitioners are developing more standardized quality measures on their own. Data analytics are being used to more accurately identify and assess the health risks of children in the population in order to intervene more effectively and show the impact of services. And there is growing recognition that providers must coordinate or enable access to social services and behavioral healthcare to really impact health and total costs.
To that end, this paper looks at some significant new areas of progress, including how providers are tapping community-based organizations for social care; focusing on behavioral health differently; working to reduce emergency department (ED) utilization; and using technology and data to shape workflows and develop productive value-based contracts.
Enabling closed-loop referral systems for pediatric value-based care
Children’s Mercy Hospital and Clinics in Kansas City is the only pediatric trauma center between St. Louis and Denver. In its clinically integrated network, Mercy also operates a pediatric ACO-type entity that serves Medicaid and commercial enrollees in risk-capitated or value-based payment models. Mercy also works with 40 independently owned pediatric primary care clinics in the community, making it ultimately responsible for covering the cost of care for 250,000 children in the Kansas City metro area, or about 50% of the population of children.
Mercy is building out its model for the medical management of pediatric patients as a single integrated service that crosses between hospitals and community practices with complex care, care management, coordination, and patient case management. Mercy is also adding pharmacy and community education to its model.
Mercy first began to screen for social determinants of health in 2020 but quickly encountered a problem – What could it do for patients who screened positive for a particular need?
Community-based clinical practices lacked resources and relationships with social care specialists making follow-up difficult to impossible. But screening families felt unethical if Mercy could not then meet those needs with appropriate services or care.
So, Mercy began to work with a partner organization to build out a social care referral platform, branded under Mercy. The platform provides an up-to-date list of non-profit agencies or community-based organizations available to families. And it allows Mercy to submit referrals on behalf of patients and families directly to those organizations. Now, when families are screened for a specific need, their care provider can use the platform to quickly connect them to community-based organizations (CBOs).
Those CBOs then reach out to the family and close the loop on that referral by informing Mercy whether they were able to help the family or not, and if not, why not. That data can then be tracked and tied to health outcomes and an updated patient record that includes recommended care, immunizations, screenings, and clinical and social care needs, recent ED or urgent care visits, inpatient admissions, specialty visits, a section on social determinants of health, and every referral and the status of those referrals.
This streamlines information flow and eliminates the need to utilize different tools or portals. The electronic medical record also includes claims data which can help providers meet contractual requirements.
While the technology platform is critical, Mercy realized it’s equally important to have good relationships with CBOs or referrals will go nowhere. Mercy found that many CBOs were already at full capacity and needed incentives to fund their engagement with new referrals. So, Mercy funded partnerships with key organizations that helped cover critical needs, providing CBOs with yearly contracts that included upfront money for staffing, technology, or programs, etc.
Mercy’s case managers submit around 346 referrals per month in about 30 seconds per referral. CBOs are required to add to the patient record by closing the loop. Areas of help have included food, affordable medication, inhalers, diapers, clothing, utility assistance, rent, and so on. Mercy is also looking at patterns of prescription fulfillment to determine any obstacles that would benefit from targeted outreach.
Mercy’s value-based program leaders have found that patient stories are among the most powerful tools for selling the impact of the program. Mercy is also looking to engage researchers to help measure the value of various interventions, ranging from clinical markers to immunization rates to different HEDIS measures.
Optimizing emergency department (ED) utilization in pediatric value-based care
Nemours Children’s Health System is a large multi-state pediatric health system with freestanding children’s hospitals in over 70 different care locations and a hub in Central Florida. The health system is highly focused on population health and children advocacy and invested in what it calls “care well beyond medicine.” Its website is the largest provider of pediatric educational content in the world.
Today, Nemours is taking on risk and shared savings in multiple pay-for-performance contracts. It continues to work on its risk adjustment processes and care management while, optimizing its, managing high-cost patients, and reducing avoidable ED visits. Those priorities shape the business and the buildout of its EHR and its analytics department.
To reduce ED visits Nemours looks at claims data, avoidable ED visits across facilities, and other analyses of provider and care patterns, including seasonal trends around flu. In addition, Nemours makes extensive use of health information data, care setting capacity, and triage.
Nemours is able to assess that data in near-real time and enable’ care coordinators to assess avoidable ED visits over time which can create powerful insights. For example, during the pandemic, Nemours could see a significant spike in flu-related ED visits and compare that to vaccination rates which were suboptimal.
In turn, that sort of information helps inform conversations with families. Providers can talk about primary care and other medical home engagements to reduce mis-utilization of the ED long-term and steer non-emergent care into other categories and settings.
One learning from Nemours’ analyses was that families often go to the ED for non-emergent needs because they are sent there by primary care providers who don’t have the capacity to see them. That insight helped Nemours turn to new care delivery options like urgent care and telehealth visits and improve its performance in value-based contracts.
Another key learning has been the importance of understanding the specific circumstances of patients and their actual care alternatives. It’s easy to assume what’s driving patient choices but that can overlook the reality on the ground.
To that end, Nemours has also found it helpful to shift from monitoring whole populations to focusing on smaller cohorts of high utilizers. This gives physicians guidance to have more appropriate conversations with specific families and leads to significant drops in ED utilization. Now, Nemours plans to scale such learnings to its entire intervention team so that the broader population can receive better care.
Integrating behavioral health in pediatric value-based care
In addition to its work with CBOs, Children’s Mercy is also focusing on the holistic health and wellbeing of children as fundamental to achieving value-based care goals. This reinforces the importance that behavioral healthcare plays as a critical leg in the holistic health stool with clinical care and social care. To that end, Mercy recently embarked on an initiative to partner more effectively with local behavioral health service providers.
Going into that initiative, Mercy did not know how many of those organizations already had experience with value-based contracts. Learning that was the case, Mercy built its new relationships with those providers in such a way that each could help the other perform better within their respective value-based agreements.
Such collaboration takes trust but it also takes shared data and analytics. Behavioral health providers are not integrated like other care providers in the larger care community. Unlike the pediatric primary care practices in the Mercy network, they lack access to EMR data. An early challenge has been breaking down the barriers to that information flow.
Today, behavioral health organizations increasingly share with Mercy who their active patients are and what types of services they’re receiving. Mercy can then. This helps identify opportunities to support those patients from different angles.
As a result, when a patient is admitted now, Mercy’s inpatient social worker can see that a relationship exists with a behavioral entity and what kind of services are being provided. For legal and regulatory reasons, it’s important to treat substance use disorder as completely independent from the arrangement. However, all other data exchanges comply fully with HIPAA from a healthcare operations perspective. This helps Mercy provide better care and coordinate follow-up with the behavioral health organization after discharge to let them know the patient has been to the ED.
Mercy is also using incentives, similar to what it is doing with community-based organizations, to support their partnerships. But in this case, the incentives are focused on engagement with the Mercy network. Accordingly, Mercy provides technologies and tools that help those behavioral care providers access Mercy’s platform. And Mercy is also co-developing strategies with their partners to improve overall care. Improving access and coordination reduces the total cost of care which helps both sides succeed in their own value-based arrangements.
Managing costs and risks
Innovaccer has provided much of the data and platform solutions being used to support these value-based programs. Innovaccer’s work with these leading practitioners has unearthed learnings in that regard.
In particular, data is critical for making value-based programs and initiatives work. Nemours, for example, leverages claims-based data from payers and is able to ingest EHR-based data from across its clinically integrated network, even though that data comes from multiple different EMRs. Nemours further takes in other sources of information from targeted functions, exchanges, alerts, and counter-notifications, as well as payer quality reports.
Access to this data helps Nemours develop patient care insights. It also helps create a longitudinal view of some of its patients, especially for those who move between Medicaid and commercial payers.
Data is also critical for risk adjustment strategies. Nemours ensures that its risk averages make sense even with medically complex children in the patient population. DM also monitors its recapture rate trend closely with alerts and prompts that are integrated into clinical workflows. DM looks for information gaps around patients who are high risk and engages with them to understand their needs better and respond accordingly.
Mercy’s use of data is similar. Mercy ingests data from its EHR and other sources to track care management status and look at clinical risk and spending. This helps Mercy see how it manages costs across different functions like pharmacy and inpatient utilization, determine whether patients are getting put into care management programs, and decide whether they’re receiving appropriate coordination and outreach.
Recommendations for future implementation and research
As pediatric care providers know, children are not just little adults. Higher-cost child patients are not usually chronically ill and simply in need of better care management, they likely have a very serious acute disease like cancer or a need for an organ transplant or have experienced a catastrophic condition that will require an extended and costly stay. This creates enormous cost outliers compared to the general population. On the flip side, little short-term impact comes from prevention measures yet a care provider who helps a child can also help an entire household and even impact a community such as a school.
Pediatric value-based care has the potential to transform healthcare delivery, improve patient outcomes and experience, fortify families and communities, and dramatically reduce total costs by prioritizing prevention, early intervention, care coordination, social determinants of health, and behavioral health. Continued investment, research, and innovation are critical for helping pediatric value-based care succeed.
To that end, some recommendations follow.
Health systems and providers should invest in and build out their pediatric value-based care models. This requires a focus on data, care coordination, risk management, utilization, and coordination with CBOs.
Policymakers should embrace the long-term benefits of pediatric value-based care initiatives and fund them accordingly. They should take the lead on encouraging or incenting the coordination of services across clinical, social, and behavioral health lines, and establish better information sharing and closed-loop referrals. They should also assess the social and behavioral care gaps in their communities.
Researchers must take the lead in developing and refining quality measures that support payment models aligned with the health needs of children. They should also conduct impact analyses on health outcomes, costs, and the potential for bringing initiatives to scale. They can also examine the needs of specific pediatric populations and propose value programs tailored to them, such as cancer care.
Perhaps more than other types of care, pediatrics anchors the communities that care providers serve. Moreover, pediatric care offers the opportunity to influence health for a lifetime. That puts added value on the importance of addressing holistic care needs for the child, the family, and the community.
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