Even as leaders across the entire spectrum of the U.S. healthcare delivery system strategize to move their patient care organizations forward from the historical volume-based delivery and payment system to the emerging value-based one, the leaders of clinically specialized organizations are puzzling their way forward into the new healthcare. Nowhere is that more of an intriguing proposition than in pediatric care, where historical clinical and organizational siloing, challenging payment systems and mechanisms, and cultural differences, all combine to pose special obstacles to innovation.
But, in two states thousands of miles away from each other—Ohio and Oregon—leaders of physician organizations are finding important ways to break through the patterns of the past.
In a nutshell, says Harris, “We’re trying as pediatric providers to really advance population health and participate more in value-based programs.”
What has the CHA’s journey been like? “It’s not uncommon for independent practicing physicians to band together through similar contracts with some of the big system players,” Harris says. “And there are combined adult and children’s care IPAs out there; but we found that, for pediatricians, who only care for children that the goals, utilization strategies, quality metrics, and approaches to care are different enough, that the adult care initiatives are driving things that aren’t clinically relevant. So in 2007, we decided to split off from the combined adult and children’s care networks, and that allowed us to focus on kids and really advocate for them. One of the big differences is, with adults, there’s a lot of hospital and specialty care utilization, but with children, there are fewer times when hospitalization is avoidable.” Instead, she and her colleagues have been focused on integrating behavioral and physical healthcare, on developmental services for children, and on complex care coordination.
“Capacity of services for children is one of the challenges, and that’s partly due to, when we think about our healthcare system and investment in services, those don’t rise to the top of the cost categories, so they often don’t get the needed attention,” Harris says. “So our ability to advance the medical home delivery approach has been a big focus; we’ve been able to advance medical home care, especially patient-centered pediatric medical home delivery, where we’ve been able to integrate behavioral care into that. But the fee-for-service payment structure does not necessarily support complex care coordination. And pulling in a social worker for a warm handoff for a child who’s having an emotional breakdown—that’s one of the examples of services that aren’t built into fee-for-service care delivery and payment systems.” Instead, she says, the inevitable destination for value-based care delivery and payment in pediatric care is around capitated payment systems.
Harris says that the data and analytics around these initiatives are absolutely crucial. “As a provider group, we needed access organized clinical data and analytics, and that’s where we really needed Philips—to be able to coalesce data from eight different electronic medical records (EMRs) into one place, and look proactively at where the care gaps are for preventive, for screening, where we need coordinated care approaches, and to be able to combine clinical and claims data,” she says, referencing the organization’s partnership with analytics vendor Philips (the Philips Population Health Management solution, formerly Wellcentive). “Being able to aggregate and report the right kind of data to support this work is critical,” she says.
Caring for tens of thousands of children in both the Oregon Medicaid managed care program, Care Oregon, and in commercial accountable care organizations (ACOs), “We have a lot of different categories of quality measures, spanning preventive care, screenings, utilization, such as ED, measures that span care coordination, chronic diseases, etc.,” Harris notes. “So we have a menu set of 20 key pediatric quality measures. And that quantity itself is one of the challenges.”
Meanwhile, with regard to the IT challenges involved in continuing to move forward, Harris notes that “One of the big learnings we’ve had working with health IT solutions is how common it is for the focus to be around hospital- and specialty-centric structures. But there’s a lot of opportunity in primary care.” Meanwhile, with Oregon state officials moving forward to reform the state’s Medicaid delivery structures, Harris and her colleagues are determined to move ahead with alacrity to meet the future of pediatric care, which they agree will involve increasing care coordination, facilitated by strong IT and analytics.
In Dayton, Ohio, an initiative focused on MD-driven quality work
Meanwhile, 2,300 miles to the east, Lisa Henderson, executive director, has been helping to lead a revolution around quality, at Dayton Children’s Health Partners (DCHP), a clinically integrated network that came together five years ago and that is affiliated with Dayton Children’s Hospital, and also involves collaboration with Anthem Blue Cross and Blue Shield. DCHP encompasses 12 independent community practices, as well as the hospital; and those 12 practices in turn encompass 125 community-based pediatricians, caring for 150,000 patients. It is the only pediatrics-focused network in Ohio.
“Every network is different,” says Henderson. “We do get together with other clinically integrated networks across the country, as well as participate in the national children’s hospital association (leaders from DCHP and CHA have been in communication with each other). In their case, she says, “Our hospital wanted to develop quality of care-based partnerships with community physicians.” And, out of that effort, physicians were involved from the very beginning, becoming the core of the steering committee, and being involved in all initiatives. “In 2018, we signed our first value contract with Anthem, a shared-savings program involving all participating primary care practices, focused on HEDIS measures,” Henderson reports. The focus of quality improvement efforts has been around increasing the frequency of well-child visits and averting ED visits, “which can have a huge impact on quality of care. We’re shared-savings, upside-only right now in that contract.”
Is two-sided risk a possibility down the road? “We definitely have that option, and as we continue to develop our information systems and processes, it becomes more of an option down the road,” Henderson says.
Among the key learnings? Educating practicing pediatricians on the concepts of population health, in order for everyone to move forward together.” All this work continues forward, in both Ohio and Oregon, with no limit on the potential for further advances along multiple dimensions. In other words, the horizon for the development of integrated, population health-based pediatric care delivery is a bright one—with onward, upward potential.