Value-based care models have established a firm foothold among healthcare organizations serving adult patients, but have been slower to grow in the pediatric world. The thinking is that children tend to be healthier and account for a relatively smaller portion of healthcare spending, so the need for payment reform is less compelling.

That said, a growing number of pediatric clinically integrated networks (CINs) and accountable care organizations (ACOs)  have sprung up around the country in the past several years  — 20-40 by some estimates, of the hundreds and hundreds of networks for adult care. These organizations are beginning to demonstrate that pediatric care is fertile ground for the improvements in quality and cost that value-based care promises.  

Like ACOs, clinically integrated networks are collections of primary care and specialty practices that coordinate care in order to improve quality and trim unnecessary costs. Many pediatric CINs are anchored by children’s hospitals, so they’re popping up in larger cities like Boston, Philadelphia, Phoenix, and Seattle.  While the goals and methods of CINs and ACOs are similar, ACOs were established under federal law within the Medicare/Medicaid program and initially focused mostly on adult patients insured by those programs.  

“Pediatric value-based care is about working toward population health, which means doing prevention and promotion work as well as managing those children who are high risk and complex,” says Ryan Calhoun, senior director of Connecticut Children's Care Network at Connecticut Children's, a CIN that launched in January of this year, but begins its value-based contracts on January 1, 2020.  “We see a lot of those patients in the hospital, but we are now working upstream to keep them from going to the hospital. The goal is to make sure that our patients have healthy lifestyles and that they transfer those healthy habits into adulthood.” 

athenaInsight recently spoke to three pediatric clinically integrated networks to understand what pediatric value-based care looks like in the relatively early stages.  

In search of clean, timely, integrated data 

“Data integration is the backbone of any clinical integration effort,” says Tyler Leishman, executive director of Pediatric Care Network, a three-year-old collaboration among community pediatric providers, University of Colorado School of Medicine specialists, and Children’s Hospital Colorado. “It's a real challenge to integrate data across multiple platforms, harmonize that data, and then push it back seamlessly into the provider's workflow for a true view of the patient’s longitudinal record,” he said. 

Like other pediatric CINs, Pediatric Care Network providers use many different electronic health records  — 15 to be exact — so creating a comprehensive picture of the medical care of individuals and populations can be tough.  The network has one primary population health management tool.  However, because of the many different data sources, the network must still cobble together claims data (which is infamously stale), practices’ pre-adjudicated claims data on an every-other-week basis, daily reports from hospitals of ED visits and admissions, and some basic EHR data that is uniform across systems, such as vital signs and medication lists.  Pediatric Care Network also has a direct data feed from the state’s immunization database and its own homegrown asthma registry.  

Connecticut Children's Care Network has contracted with a vendor that offers a population health management tool that joins together data from claims systems and the EHRs of member practices and the hospital.  “We’ll be able to leverage the data, build reports, and monitor the care,” explains Calhoun. “Our care coordinators will be able to see what is happening with individual patients and engage with families to improve the health of their child.”  

While access to data is critical, so is building confidence in the information among providers, according to Luke Harris, senior director of operations and population health management at Children’s Mercy Integrated Care Solutions (CMICS).  CMICS is a wholly-owned subsidiary of Children’s Mercy Kansas City that leads and operates a pediatric clinically integrated network called Children’s Health Network. For two months, CMICS staff meet weekly with practices new to the network to explain the performance data they’ve collected and answer any questions.  The transparency not only instills trust in the data, but also brings out providers’ competitive nature, often leading to improvements in care, says Harris. 

Putting the data to work 

But Harris and the others interviewed for this story know that competitiveness alone can’t bend the cost and quality curves. The Connecticut Children's Care Network is using care coordinators from its hospital and the Office for Community Child Health to help manage the care of patients who are identified as high risk (or heading toward high risk) as well as those with chronic conditions like asthma or diabetes.  

“We will make sure to let the practice know who we’re concerned about and work with staff to do an assessment of their challenges, their family environment, and their needs,” says Calhoun. “And then, based on what they need, we will provide support to them by connecting them to services, potentially getting a home visit, and coordinating care with the entire care team.”  

Meanwhile, at the Pediatric Care Network in Colorado, each member practice is required to create a quality improvement team and meet monthly with one of the clinically integrated network’s four quality improvement specialists. 

The discussions focus on performance across various metrics, including immunization, well child visits, asthma management, and ED utilization. “We review trends and discuss opportunities and best practice interventions to improve performance at the provider level,” explains Leishman. 

One notable area of success was bumping up vaccination rates for human papilloma virus (HPV). “We coached providers on how to have effective conversations with parents about the importance of the vaccine and we helped practices assess and improve their scheduling and vaccine administration workflows so that patients received two vaccines by their thirteenth birthday.  In addition, we developed a vaccine management toolkit for practices that guides them operationally and financially to aid in improving vaccine compliance rates.” 

Learning communities are a key component 

Improving care quality is one of the goals of Connecticut Children's Care Network’s “learning communities,” which are monthly or bimonthly educational sessions — eligible for continuing medical education and maintenance of certification credits. Experts teach on a variety of topics — how to better manage certain conditions within a primary care setting, for example, or the latest advances in treatments for different diseases, and how to improve well child visits. 

For pediatrician Sally Ginsburg, M.D., of Pioneer Valley Pediatrics in Longmeadow, Massachusetts, the educational component is one of the features she’s most looking forward to, as it will be a community of peers all focused on pediatrics.   

“In smaller practices, you can become a little isolated and get into habits that may not be aligned with the latest recommendations,” says Ginsburg. “The learning communities will mitigate the risk of not keeping up with best practices.” 

Changing the way providers are paid 

Value-based care payment models run the gamut from pay-for-performance to episodes of care/bundled payments to shared savings to full capitation — or some combination of those and other models.  The clinically integrated networks profiled here have a variety of payment arrangements. 

Connecticut Children's Care Network has engaged in fee-for-service contracting with a value-based component on top of the contract. This includes “upside” shared-savings contracts and pay-for-performance contracts, which reward physicians for meeting pediatric-specific quality measures. In addition, if costs do not increase beyond an agreed upon target, the network and its practices split the savings with the payer. 

In Colorado, the practices belonging to Pediatric Care Network have moved into value-based contracting with an “overlay of incentive opportunities,” as Leishman puts it.  “We have not engaged with payers around downside risk yet — in which we’d share in the savings but also be responsible for some of the loss if spending goes above a target,” says Leishman. “We are not pushing for that until we feel like the models enable us to provide better care for patients and that the mechanism will reward us for the work that we’re doing. Because so many of these arrangements are based on the adult world, they don’t yet translate well to pediatrics.” 

Vicki Ritterband is a frequent contributor to athenahealth's Knowledge Hub.