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Pediatric ACO creates ‘medical neighborhood’ for low-income Ohio children
Key clinical point: Pediatric ACOs can conserve health care funds while providing quality care. Major finding: The per-patient/per-month cost...
A changing payer relationship
As a network, PCCN works with payers to assume the risk that insurers have historically taken. Payers continue to handle the administrative and billing side of the equation, while the network controls the medical management and care coordination of the patient population, Mr. Johnson said.
“We feel we can do it much more efficiently, much more effectively, and we feel it’s better care for the patient when we’re the one controlling that,” he said. “The insurance companies don’t disagree.”
The network partners with Medicaid and commercial payers and has a direct-to-employer agreement with a major employer in conjunction with an adult partner system/network. Early performance efforts by the PCCN have been rewarded by shared savings disbursements from two payers, according to PCCN officials. The network has also met or exceeded state Medicaid pediatric quality targets and consistently contained medical expenses below expected medical cost trends for its managed pediatric populations.
Building a population health model
For more than 2 decades, PFK in Ohio has taken a novel care delivery approach that has focused on value and community partnerships.
Back in 1994, Nationwide Children’s Hospital partnered with community pediatricians to create PFK, a physician/hospital organization with governance shared equally. Today, PFK has assumed full financial and clinical risk for pediatric managed Medicaid enrollees, and is the largest and oldest known pediatric ACO.
Dr. Sean P. Gleeson
A key hurdle was collecting timely, complete, and accurate data for the patient population, Dr. Gleeson said, adding that working with data and understanding changing trends is an everyday challenge. Interacting with busy physicians and securing their time and cooperation also has been an obstacle.
“The lessons learned for us is that we really need to approach them understanding that there is a limited amount of time that practices can invest in infrastructure or invest in the processes of care,” he said. “We have to approach things knowing that [doctors] are going to struggle with the amount of time necessary to engage in large projects, so it needs to be chopped up into bite-sized pieces that they can consume on the run, so they can keep their practices running well.”
PFK efforts have paid off in terms of lowering costs and improving care. Between 2008 and 2013, PFK achieved lower cost growth than Medicaid fee-for-service programs and managed care plans in the Columbus, Ohio, area (Pediatrics. 2015 Mar;135[3];e582-9).
Fundamentally, the model has remained the same over the years, Dr. Gleeson said, but in 2005, PFK made the decision to expand and take responsibility for all the Medicaid-enrolled children in the region.
“It really gives a much broader field of view and perspective on patients in the region,” he said. “We know that they are all our responsibility so we take more of a population health type of approach, working with any physician who is caring for those children.”
Guidance for other practices
Dr. Gleeson encouraged other pediatricians interested in transitioning to value-based care to start by evaluating their data. Take a hard look at the quality of care you provide and begin to measure it, he said. For smaller practices, consider joining a larger group or network that will allow pediatricians to engage in collaborative work, he added.
Dr. Vargas stressed that change is coming whether pediatricians are prepared or not. Aligning with the right partners will be the difference between sinking or staying afloat in the value-based landscape.
“Payers are moving toward value-based models and it is not practical for the general pediatrician to be able to provide the infrastructure and professional resources necessary,” he said. “To maintain our professional livelihood as independent pediatricians, and to continue to provide the individually crafted, quality care our families are accustomed to, we will have to align ourselves with organizations that value the experience and insight of the independent pediatrician to deliver that care.”
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