- Medicare has led the healthcare industry as it shifts from fee-for-service to value-based care, with 30 percent of traditional Medicare reimbursements already paid under an alternative payment model.
The federal government plans to further transition Medicare to value-based care by linking one-half of fee-for-service payments to accountable care organizations (ACOs), value-based purchasing programs, and other alternative payment models by 2018. However, the emphasis on Medicare populations, which are 65 years old or older, has left pediatrics struggling to apply value-based care to a very different population.
“It kicked off with the Medicare Shared Savings Program in the adult ACO world, but hasn’t necessarily trickled down in a meaningful way to the pediatric side, such as meaningful metrics and things that would help us move the needle in terms of quality and value for the pediatric population,” explained Tyler Leishman, Executive Director at the Pediatric Care Network in Colorado.
The quality measures used to reimburse Medicare providers for high-quality, cost-efficient care do not necessarily translate to a pediatric population. Controlling high blood pressure and recovering from heart attacks are not common treatment plans for patients under 18 years old.
Yet, private payers working with pediatricians and pediatric specialists to move to value-based care oftentimes try to apply these types of measures to the younger patient population since pediatric-specific measures are not widely available.
When the quality measures did not work for value-based incentive payments, some payers avoided integrating pediatrics into value-based care models.
“All of us, whether private practice, at the hospital, or specialists, were seeing increased pressure to reduce the total cost of care,” Leishman recently told RevCycleIntelligence.com. “Payers have started to develop a number of products aimed at reducing that total cost of care. However, some of those products exclude our physicians and some exclude the children’s hospital as well.”
Payers were missing an opportunity to lower the costs and improve the care for a growing population in Colorado.
“We've seen a huge growth in the Medicaid population here,” he explained. “We're a Medicaid expansion state. Close to 50 percent of the kids in this state have government insurance and that’s a financially and otherwise complex and difficult population to manage, not only in the hospital setting, but in the primary care setting as well.”
With a rising Medicaid population, providers in the Denver healthcare market started to question how they would manage care for the diverse group while lowering costs under fee-for-service payments.
“With all those different challenges presenting themselves, we saw an opportunity to form something that would really help all parties prepare for the future of healthcare, start collectively developing value-based models, and start partnerships with the payers to develop those in a way that’s pediatric-specific,” he said.
With collaboration in mind, Leishman and his peers in the Denver area established the Pediatric Care Network, a clinically integrated network of over 1,400 providers and the Children’s Hospital Colorado. The network aimed to define value-based care in the pediatric space.
“We know that collectively, as a network, we needed to transform our delivery system to prepare for the coming changes in the payment system,” he stated.
To start the collaborative journey to value-based pediatrics, the network focused on increasing data sharing to gain a comprehensive view into the pediatric care continuum.
Data sharing leads to better caring
Reducing healthcare costs is a main pillar of value-based care. But data siloes prevent providers from understanding total costs of care, especially after their patients leave the office.
The Pediatric Care Network intended to break down the data siloes between private practices, hospitals, and other pediatric care centers, explained Noah Makovsky, MD, a community pediatrician and the network’s Board of Managers Chair.
“At the end of the day we really have to start looking at the total cost of care,” he said. “When we are sitting in our smaller, private practices, we can control the cost within our walls to the best of our ability and, in general practice, you send kids out to specialists. You send them to care centers. You send them to hospitals for admissions. Those are some significant cost centers.”
“If we were not working in collaboration with those cost centers, it makes it very difficult to move that cost needle,” he continued. “This conversation and giving us the opportunity to get to the table like this is allowing us to potentially move that needle.”
In addition to better understanding the costs across the continuum, data sharing also helped providers in the network to improve patient risk stratification.
“Where we're going to cut cost is keeping kids in their communities for their care,” Leishman added. “That means keeping kids out of the hospital as best we can and utilizing our data infrastructure in order to understand our populations better.”
“Some of the things that we're looking to is using that data to understand the patients and the families better and stratifying populations based on different risk factors, disease types, and things like that to understand that families have different levels and different types of care coordination needs,” he stated. “We can’t fulfill those needs and, in turn, lower costs and improve their experience without that data connection and that backbone to the network.”
Using the information from across providers, the Pediatric Care Network connects patients and their families with a care coordination team that can address specific medical and socioeconomic needs.
However, accessing the right data from all providers has not been easy for the clinically integrated network.
“It’s a difficult process,” Makovsky said. “It’s an expensive process and it’s one that, as private practices, we really felt like we needed some help.”
While the children’s hospital and a vast majority of the specialists in the network had implemented an Epic EHR system, private primary care practices in the network were operating on a patchwork of different EHR systems, Leishman explained.
“When you get out into the primary care community, there are roughly 30 different EHRs in use across the group of pediatric practices in the State of Colorado and 20 percent of the practices are still on paper charts,” he reported.
The mixture of different EHR systems and manual charting presented a major challenge when the Pediatric Care Network started to aggregate, integrate, and harmonize data.
“We needed to get to a place where we were truly integrating EHR clinical data because that’s how we were going to start moving the needle,” he said.
To gather and harmonize EHR data, the network implemented a data platform that gathered and normalized billing and coding data from across practices, the children’s hospital, and a handful of independent laboratories in the Denver market.
“We needed something to put that into a big data warehouse for us,” he explained. “Then, we could utilize that to establish certain metrics and combine that data with the adjudicated claims data coming back from the payers.”
With the data supporting pediatric-specific quality measures, the Pediatric Care Network was able to build the case for value-based contracts.
The network currently operates one value-based contract that is based on a shared savings model with a prospective per-member-per-month payment structure. If providers meet quality and cost standards, they can share in the savings and receive value-based incentive payments.
Providers are also negotiating with three other payers to develop additional value-based contracts.
“We think we've got a pretty good setup in place here in the market to continue to expand that,” Makovsky said. “We have a quality committee through our Pediatric Care Network, which is focused on looking at the next quality measures that we can implement within practices to hopefully be able to do the same thing – increase the quality and decrease the costs over time.”
The network is also in a good position to expand value-based contracts to independent practices.
Collaboration brings independent, private pediatricians to the value-based care realm
The collaborative nature of Pediatric Care Network has been instrumental in engaging independent pediatricians with value-based care, Makovsky pointed out.
“From a pediatrician’s viewpoint, as healthcare continues to evolve and become a very complicated business, people like myself really enjoy what we do as private pediatricians,” he said. “We are hoping that we will be able to continue that for many years into the future.”
“But we realized that going at this alone was unlikely a successful road for us to go down,” he continued.
Small practices do not usually have access to the capital or resources to implement value-based care models, the Government Accountability Office recently reported. Just making an EHR system interoperable would cost about $20,000, which adds to costs of hiring additional staff needed to handle more care coordination activities.
The financial pressure of transitioning to value-based care caused about 58 percent of providers in a 2016 Deloitte survey to say that they are considering joining a larger healthcare organization.
These value-based care challenges especially troubled the Denver healthcare market, which contains a strong independent pediatric primary care base, Leishman stated.
The independent nature of the pediatric primary care base in Denver hindered the private practices from implementing value-based care, which requires extensive collaboration.
“It was not too many years ago when here within the Denver market, quite a few very strong private pediatric practices didn't sit down at the table and talk about all the same issues that each one of us was dealing with and how we were going to navigate healthcare moving forward,” stated Makovsky. “We would send out patients and eventually they would come back to us. There was a disconnect in terms of the responsibility of what’s happening to our patients as they moved through the system.”
While Makovsky noted that the desire to collaborate has increased since he started practicing 15 years ago, he pointed to the Pediatric Care Network as the driver of value-based care for independent and private practices.
“We came to the table to start having discussions and a lot of that was surrounding the change in the environment from volume-based care to value-based care,” he said. “It has taken all of us some time to get up to speed to understand what that would mean to our individual practices or to the hospital.”
“But at the end of the day, we certainly all realized that collaborating and creating what became the Pediatric Care Network would be our vehicle to help us navigate the future of healthcare, at least here in Denver, Colorado,” he added.
Through the network, private practices and solo providers could engage with payers in value-based contracts like their peers in hospitals and larger organizations and ultimately improve the value of pediatric care across all provider types.
“We love taking care of kids and we want to continue doing that, but we can do it in a way that provides the best care in the most efficient way with the best experience possible,” he stated.