Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Value-Based Care News

How Does Value-Based Reimbursement Affect Pediatric ACOs?

Accountable care organizations may lower costs for the pediatric population while also improving quality of care.

By Jacqueline DiChiara

- Value-based reimbursement and pay-for-performance incentives are positively influencing pediatric accountable care organizations (ACOs), according to research from JAMA Pediatrics. The new future of value-based incentives is perhaps all about specific incentive targeting for high-need patients.

accountable care organizations pay-for-performance

Data collected among 3,000 physicians and over 300,000 patients over a three-year period confirmed increased pediatric performance levels among primary care physicians. Researchers claimed care quality is improving.

But many other interventions at the disposal of an ACO may prove even more effective, claimed researchers Kelly Kelleher, MD, MPH, Sean Gleeson, MD, and William Gardner, PhD.

Research on how pediatric ACOs effectively change outcomes for children is not quite readily available, confirmed PKF’s press release. This perhaps makes it all the more significant.

“We believe this study is the first evaluation of a pediatric ACO. Our data demonstrate the potential for an ACO to minimize the growth in cost of care for a pediatric population, all while maintaining or improving quality of care,” wrote Kelleher, Vice President of Community Health Services at Nationwide Children’s.

READ MORE: NAACOS: Mandatory Bundled Payments Impede ACO Financial Success chatted with Gleeson, President of Partners for Kids (PFK), an Ohio-based pediatric ACO serving 300,000 Medicaid-eligible children, to learn more.

PFK's research fills a pediatric ACO void

Although ACOs are beginning to gain prominence within the pay-for-performance realm, ACO pay-for-performance studies are still generally run by health insurance companies, Gleeson says. ACO-managed research about pay-for-performance is perhaps not as common as it could – or should be, he claims.

“As ACOs are stepping up and influencing outcomes in the healthcare system more and more, we felt it was important for this type of an organization to really examine if this is an effective tool for influencing behavior to benefit children.”

“A lot of work around Pioneer ACOs have been Medicare-driven and very adult and elderly focused.”

READ MORE: CMS Reopens Next Generation ACO Application Request Portal

There is very little overlap between the Medicare and pediatric population, he asserts. Many Affordable Care Act regulations are targeted at older Medicare populations. Pediatrics work, more focused on the Medicaid population, is generally more influenced by activity at the state level, he says.

What impact does this research have on the industry?

PFK's research findings have several greater implications for the pediatric ACO community at large, especially regarding physician performance, Gleeson adds.

“The quality measures are moving in the right direction, a finding that we had across the entire population. We and others can take encouragement from the fact that the numbers are getting better and more kids are getting well-checks, immunizations, and the medications they need.”

The physicians and in-network providers are taking care of their patients for the right reasons, he explains – to take care of children and achieve better outcomes for kids.

READ MORE: CMS Calls on Stakeholders for Pediatric APM Development Input

The challenge is that complicated systems make it more difficult to hit outcome targets, he states.

Nearly a quarter of surveyed providers described pay-for-performance as “very difficult” or “extremely difficult” to implement, according to a 2014 McKesson study. Respondents cited a lack of standards and analytical tools. They also confirmed the need for improvement to the IT infrastructure.

“Oftentimes the systems in place are hard for patients and physicians to navigate. It requires extra effort to achieve the outcomes you’re looking for. Financial incentives can provide the assistance needed to invest in those extra efforts required to get the outcome people are working towards," says Gleeson.

It's not always a matter of money in, money out

But putting money into incentives may not necessarily guarantee improved outcomes. Some hospitals serving patients of a low socio-economic status are not reaping the financial rewards of pay-for-performance.

Medicare’s pay-for-performance program fails to adjust for patients’ socioeconomic status, said David U. Himmelstein, MD, FACP and Steffie Woolhandler, MD, MPH, FACP, both Lecturers in Medicine at Harvard Medical School.

Pay-for-performance “assumes that bonuses and penalties will prod substandard providers to improve or see their patients migrate to higher-quality options,” they stated. 

“Perhaps an even larger impact could be from support, the infrastructure, the quality improvement activity, and changing and improving processes within a physician practice.  Sometimes that can lead to even more significant improvements in quality outcomes,” says Gleeson.

“We’ve recognized we need to be providing more support to private practices. The hospital base practices often have the support they need that is not available to private, independent practices. As an ACO, we are working to support and provide the infrastructure and the surrounding assistance necessary for our practices to deliver even better outcomes.”

Where is pay-for-performance headed?

The new future of pay-for-performance, Gleeson explains, may involve more specific incentive targeting, especially for high-need patients.

“Some patients just don’t require the same amount of support from a physician office.  But others require a great deal of support. We are piloting the next version of pay-for-performance.”

“We’re targeting how to apply incentives for those patients that have been more disconnected from the health care system. Those are the patients that we, as a network, really need to reach out to – those who have not been receiving recommended care."

EHRs/EMRs are linked to high quality care

Quality of care is improving, albeit there are a number of reasons as to why, he claims. One big factor may be EHR adaption.

EHRs were used by a reported 80 percent of pediatricians in 2012, according to a study from the American Academy of Pediatrics. This is a nearly 30 percent increase from the organization’s 2009 survey.

“Certainly the greater adoption of Electronic Medical Records provides point-of-care reminder systems that make it easier for providers to deliver the care that a given patient needs,” Gleeson states.

“When key information is presented to the physician at the moment of care and the moment of decision-making, it makes it easier for physicians to deliver the kind of care they’re looking to provide the patients.”

There are opportunities the healthcare industry is collectively working toward to reduce the amount of care that does not provide value to patients, he says.

“We need to be constantly working on measuring. Are we making a difference? Are we doing things that are making a difference for patients?”

“To the extent that we can spend less time and effort on those services that aren’t making a difference, we can focus our efforts on the things that are really going to change outcomes for the children – and adults.”

There is indeed untapped opportunity within the pediatric care space for healthcare providers across both organizations and networks to unite and pool their resources together.

“Most children are healthy, by and large. The need for cooperation among providers is even greater in the pediatric world than in adult medicine because it just takes a larger population of patients for us to use our resources well.”


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