Children’s hospitals swim against the tide to improve the health of their patients and communities

As the nation’s pediatric hospitals strive to keep kids healthy, they face obstacles that reflect the difficulty of enacting structural changes in care delivery.

Even pediatric hospitals that are eager to engage in value-based payment (VBP) models can have a hard time establishing the type of network that allows them to affect the holistic health of children in their communities.

At Wilmington, Delaware-based Nemours Children’s Health, for example, “we leverage our care coordinators across our primary care practices to try and help support and connect those families so they can navigate through the various resources that are available to them,” said Karen Wilding, chief value officer. “But we all recognize that falls short [of] the larger opportunity that we have.

“It really is a bigger call to action around how we get other stakeholders that are just as passionate about children and the impact that they can have, and how we make sure the narrative is well-known to those [so that] as you think about investments in these areas, they understand the long-term trajectory and eventual ROI.”

Speaking on a panel of pediatric hospital leaders during a recent webinar hosted by U.S. News & World Report, Wilding contrasted the search for an ROI in population health management with VBP initiatives that are more specific to the traditional delivery of healthcare.

“When we talk about an avoidable congestive heart failure diagnosis and admission [for] an adult, we can attach a dollar amount to that immediately,” she said. “But when we talk about being able to address food insecurity or transportation for a family, that’s a hard cost sometimes to calculate, which is why we don’t always get the investment that is needed to justify that,” she said.

A quest for better data

Constraints on interoperability are an impediment to the type of care transformation some VBP proponents seek. Pediatric hospitals work to interface with schools and community-based organizations (CBOs) that can reach at-risk children, but that effort would benefit from better data exchange.

“We’re all limited by what information we have access to,” Wilding said. “All of us operate EMRs and clinical systems, and those are relatively advanced from where we were a decade, 15 years ago. Many of us have population health tools that we are leveraging.

“But we are really at the mercy of payers to help give us insights on our population and across the care continuum. When you come into Medicaid or into commercial plans, which is what we serve routinely, we don’t have that luxury to have standardized data. It makes it very complex to architect value-based programs.”

Children’s Hospital Los Angeles has navigated the metropolitan area’s web of more than 75 independent school districts, trying to establish agreements that allow for collaborative care with school clinics, said Mona Patel, MD, vice president for ambulatory operations.

“There are very significant challenges when you’re looking at data sharing and contracts and legal and compliance and regulations between the Department of Education and healthcare,” she said.

The hospital is working to bring virtual urgent care services to schools.

“For our innovation team leaders, it was a long time to get through those contracts and discussions of how you learn and share data and do that, but we’re on the cusp of being able to engage in that way,” Patel said.

Other initiatives entail integrating behavioral health between the school and the hospital’s specialists and establishing case management protocols to help school nurses meet the needs of students with diabetes.

How to pay for it all

There was a bit of disagreement among panelists over how to fund systemic innovation in care delivery.

“Capitation is a perfect testing ground for innovation if we’re smart about it,” said Jeffrey Anderson, MD, senior vice president and chief population health officer with Cincinnati Children’s Hospital.

Cincinnati Children’s has a Medicaid capitated contract with 120,000 beneficiaries, Anderson noted.

“We’ve been really lucky to have our finance leadership at the hospital allow us to use some of those dollars to innovate and try things,” he added.

Funds have gone toward incorporating Legal Aid Society services, for example, and improving health equity among patients with diabetes and asthma.

“We can’t do that in a fee-for-service model,” Anderson said. “The math would be unusual at best.”

Michael Lee, MD, executive director and medical director in the Department of Accountable Care and Clinical Integration at Boston Children’s Hospital, agreed that capitated models present an opportunity to rethink care delivery. But they also bring pitfalls.

“If you save money, budgets go down over time, and that doesn’t really fix anything for anybody,” Lee said. “Putting cost risk on pediatricians when the outcomes are delayed is also a mechanism of capitation that doesn’t sit well with most pediatricians.”

In Massachusetts, he noted, one Medicaid payment model involves sub-capitation, in which an accountable care organization offers capitated payments to participating primary care practices. More intensive and specialized care is not subject to capitation.

Such an approach “is a great effort to see what the balance of capitation is that can make a difference,” Lee said. “Revenue is still revenue … and the CFOs and the budget people are still counting how much volume you do for that revenue.”

A different ballgame

Metrics that are used to gauge quality and outcomes for healthcare models serving adult beneficiaries may not be applicable to pediatrics.

“The challenge in pediatrics [is that] a lot of the outcomes that we look at, it’s the long game,” Patel said. “You’re going to see [patients] over many, many years. Innovating with the capitation rates, thinking about different nuanced models that integrate social system arrangements with schools and CBOs and beyond” is vital.

In addition, she said, children’s hospitals should be “really starting to define what quality means in pediatrics — thinking about the complex populations, really starting to define quality of life and all of those different aspects. And then starting to lead the charge in that space.”

Although progress in bolstering the health of a pediatric population can be sporadic, the effort will continue and new lessons will be incorporated.

“I love this conversation, and it highlights a lot of really important work, but I think it also highlights the massive amount of stuff we don’t know,” Anderson said. “All of us [panel participants] come from academic institutions as well as institutions that are trying to improve population health. I feel like it’s our responsibility to also be studying this as we go, to learn as we go, so that down the road we’re going to do this better, but we’ll also use what we learn to inform health policy so that the policies change.”