Clinical integration in pediatrics

This contributed Q&A is the third in a content series as a lead-in to Becker’s 9th Annual CEO+CFO Roundtable: Nov. 9-11, 2020.

During this premier gathering of the country’s most distinguished and accomplished healthcare executives, Becker’s will present the inaugural Future of Pediatric Healthcare Forum in collaboration with Phoenix Children’s and other terrific pediatric leaders.

Phoenix Children’s is honored to work with Becker’s in elevating the conversation of pediatrics as a substantive component of the overall healthcare value chain. Over the next several months, we are excited to bring you a robust offering of informative and insightful pediatric content. We encourage healthcare leaders to engage in the dialogue and participate in The Future of Pediatric Healthcare Forum by RSVP'ing your spot here.

In 2013, Phoenix Children’s debuted one of the nation’s first pediatric-only clinically integrated networks (CIN): Phoenix Children’s Care Network (PCCN). Four years later, PCCN became the first pediatric CIN in the U.S. to achieve URAC accreditation, which recognizes the network’s commitment to high-quality care, strong patient outcomes and cost efficiency for patients, their families and the community. Today, PCCN has become an alliance of nearly 1,000 pediatric primary care providers and subspecialists, all unified around a commitment to provide Arizona’s children the care they need to live healthy lives.

Over the past seven years, pediatric CINs have captured significant attention as healthcare transforms from fee-for-service to a value-based care model. During that time, PCCN has evolved, too, with an expanded network, a comprehensive care management program, an initiative to serve families of medically complex children, increased attention to behavioral health services, new payment models, and a host of other improvements to deliver on the promise of the CIN.

In this Q&A, Phoenix Children’s leadership discusses the unique aspects of a pediatric CIN, the sphere of managed care in children’s health and PCCN’s ongoing innovation amid a rapidly changing value-based care model.

Question #1: According to the American Hospital Association, clinical integration is “needed to facilitate the coordination of patient care across conditions, providers, settings, and time in order to achieve care that is safe, timely, effective, efficient, equitable and patient-focused. To achieve clinical integration, we need to promote changes in provider culture, redesign payment methods and incentives, and modernize federal laws.”

Does this definition accurately convey the pediatric CIN environment?

Dr. Carter: One key component missing from the definition is the integration of technology into the network. Technology is absolutely essential for measuring care quality, evaluating trends, identifying gaps in care delivery or communication and improving outcomes. Phoenix Children’s robust tracking and reporting infrastructure makes this data accessible and actionable. It also enables ongoing measurement of patient engagements and outcomes.

Renee Clarke: From a financial standpoint, pediatric CINs need to redesign payment methods and incentives in order to accomplish the goals of clinically integrated care. The reality, however, is that providers and payors haven’t yet found the right solution in the pediatric space.

In Arizona, the Medicaid program, which is run by Arizona Health Care Cost Containment System (AHCCCS), supports the shift to value-based care. Like us, their focus is on long-term health and well-being of children. However, most payors view value-based care and clinical integration in the context of Medicare. They look at early year-one savings as well as continued savings in each subsequent year. This framework simply doesn’t translate well in pediatrics. The investments we make in children’s health don’t always yield immediate cost savings – it’s a much longer-term return on investment.

Question #2: Managed Care is defined by Medicaid as “a health care delivery system organized to manage cost, utilization, and quality.” How does PCCN differ from an adult CIN?

Dr. Carter: The difference comes down to the ability to reduce costs and utilization over a one-year period.

Here’s how this might play out: Let’s consider an adult internal medicine provider who’s treating a morbidly obese patient with high blood pressure, high cholesterol, poorly controlled type 2 diabetes and a medicine cabinet full of prescription medications for these conditions. With the right interventions, this patient may lose weight, reduce their blood pressure and cholesterol and decrease medication use. This may create immediate savings in healthcare costs.

But with kids, it’s different. Even though obesity is currently an epidemic in children, most obese 6-year-olds don’t have the same comorbidities seen in obese adults. If I, as a pediatrician, help an obese child achieve a healthy weight in a one-year time period, I may not be saving a payor any money in the short term. In fact, achieving this success will likely require spending money in the short term for things like nutritionist services, more frequent doctor visits and other connected services.

When we ask payor partners to participate with PCCN, we’re asking for an investment in a healthier population over the long term. This is an easier sell to Medicaid, but much more challenging to sell to a commercial payer whose membership changes from year to year.

Question #3: Let’s talk about kids with chronic conditions and efforts to provide better longer-term care.

Dr. Carter: Thankfully, the vast majority of kids are strong and healthy. If the goal of the CIN is population health, then it makes sense to focus on preventive services that keep these kids healthy – like wellness checks and vaccines.

There is a smaller percentage of children who have special medical needs. Their care is often much more costly. It’s also considerably harder for the parents of these children to navigate the healthcare system, as they’re often trying to juggle multiple specialists, services and appointments at any given time.

To address these issues in our population, we collaborated with a payor to develop a care management program that pairs parents of medically complex children with PCCN’s care management team. They work together to access the appointments, services, medication and devices these children need. The result is marked improvement in care coordination and patient family satisfaction. Our focus on timely and proactive care also has reduced unnecessary emergency visits and preventable hospital admissions, which brings costs down.

Question 4: Renee, a few years back, AHCCCS mandated that 50% of covered lives were under value-based contracts. How has this changed?

Renee: The mandate now requires 75% of covered services to be managed under value-based arrangements. However, the contracts aren’t uniform, so payors have some latitude in how they achieve this mandate. On one side of the spectrum, payors can offer incentives for providers who meet certain quality benchmarks, requiring little to no direct engagement between the payor and provider. On the other side, CINs partner with the payor to customize benchmarks and metrics to improve children’s health through a much more collaborative and engaged partnership. This is how PCCN prefers to work. In partnership with payors, we set meaningful targets and work together to achieve them.

Either approach fulfills AHCCCS requirements, but we believe that partnering with payors is far more effective in moving the needle for long term health.

Question #5: The AHA also mentions promoting changes in provider culture. Can you elaborate on culture and its impact on the effectiveness of clinical integration?

Dr. Carter: Culture is an imperative part of our work. We have increasingly been able to achieve meaningful buy-in from community pediatricians across our network. More and more, they’re embracing the aims of value-based care, seeing the value of being part of our CIN and understanding the ways in which it’s driving improvements in quality.

Question #6: As a leader in pediatric clinical integration, what is PCCN doing to innovate from the financial side?

Renee Clarke: We have successfully re-accredited with URAC, which is a major success. We’re also moving forward on several interesting innovations on the contract side.

We’re creating new contract solutions that focus on compensating pediatricians for providing the right services – not just for reducing costs. The bottom line here is to support our physicians in making the right medical decisions to improve children’s health and help them grow up to become healthy adults.

To that end, we can’t focus solely on reducing utilization because some services are absolutely essential for children. When you place too much attention on costs, you can go down the wrong path, so we engage our payor partners in these conversations and work together to strike the right balance.

In addition, PCCN is exploring contract models that could be offered directly to large employers. These models would allow customized solutions based on the needs of the children covered under employers’ policies.

Last, we’re creating specialty care-based plans that address specific disease states. The purpose here is to identify better ways to manage costly health conditions and ensure that providers are incentivized for providing appropriate care to create long-term health outcomes.

Question #7: As a leader in pediatric clinical integration, what is PCCN doing to blaze the trail from the clinical side?

Dr. Carter: One of our biggest achievements is that we have successfully staffed and funded our care management teams directly through the CIN contracts. Many of our peers provide care management teams, but they require funding from the parent health organization or children’s hospital.

Our care management model has led to many successes, particularly in closing gaps in care. We recently completed our second Gap-in-Care-A-Thon, a short-term but extensive effort to devote all of our care management resources to reach out to families whose children need their annual well visit. In an 11-week period, we made more than 12,000 outreach calls and scheduled more than 3,000 well visit appointments with pediatricians in our network.

Other CIN innovations include honing our care of medically complex patients. Just as an example, when a child with complex needs is discharged from the hospital and receives a follow-up call from our care management team within a short timeframe, the results are quite positive. On the flip side, we have run into problems when too much time goes by without communication after discharge, even if initial follow-up was completed. We’re working to figure out the right timing and frequency for connecting with these families as they move through the system of care.

Question #8: Can you talk about behavioral health integration at the CIN level?

Dr. Carter: We’ve made some nice inroads with behavioral health. Earlier this year, we launched a psychiatry faculty learning community, a 10-session training where Phoenix Children’s psychiatrists provide community pediatricians in our network with the tools and training they need to screen, diagnose and manage straightforward cases of anxiety, depression and ADHD. Given the significant shortage of pediatric behavioral health providers locally and nationally, pediatricians are eager to participate in this training. They want to be able help their patients directly when they can.

Another area where we’re integrating behavioral health services is our Center for Resiliency and Wellbeing. Our pilot effort includes some of the pediatricians in our network screening patients and families at well visits for toxic stress related to adverse childhood experiences or ACEs. Patients with a positive screen are referred to the Center. Among numerous other services, wellness nurses teach patients and families integrative techniques for reducing stress and calming the body and mind. Patients and families learn about healthy lifestyle habits that improve mental health. Licensed clinical social workers are on hand to provide counseling and connect families with community resources as appropriate. The goal is to help at-risk kids grow up to become strong, healthy, thriving adults who make a positive contribution to their communities.

Clinical integration, value-based care and care coordination are transformative agents in the healthcare value chain. In the pediatric space, they are an essential element in delivering world-class care to patients and families.

Phoenix Children’s is committed to the health and well-being of all children. We look forward to collaborating and sharing information, insights and best practices with the Becker’s community and patrons of Becker's 2020 CEO/CFO Roundtable: The Future of Pediatric Healthcare Forum.

If you enjoyed Clinical Integration in Pediatrics, please look for our next content piece: Access, Care and Quality in Pediatrics. We look forward to seeing you (virtually) in November!

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