How Accountable Care Organizations Responded to Pediatric Incentives in the Alternative Quality Contract

Specialist use among privately insured children with disabilities

OBJECTIVE

To investigate primary care practice ownership and specialist-use patterns for commercially insured children with disabilities.

DATA SOURCES AND STUDY SETTING

A national commercial claims database and the Health Systems and Provider Database from 2012 to 2016 are the data sources for this study.

STUDY DESIGN

This cross-sectional, descriptive study examines: (1) the most visited type of pediatric primary care physician and practice (independent or system-owned); (2) pediatric and non-pediatric specialist-use patterns; and (3) how practice ownership relates to specialist-use patterns.

DATA COLLECTION/EXTRACTION METHODS

This study identifies 133,749 person-years of commercially insured children with disabilities aged 0-18 years with at least 24 months of continuous insurance coverage by linking a national commercial claims data set with the Health Systems and Provider Database and applying the validated Children with Disabilities Algorithm.

PRINCIPAL FINDINGS

Three-quarters (75.9%) of children with disabilities received their pediatric primary care in independent practices. Nearly two thirds (59.6%) used at least one specialist with 45.1% using nonpediatric specialists, 28.8% using pediatric ones, and 17.0% using both. Specialist-use patterns varied by both child age and specialist type. Children with disabilities in independent practices were as likely to see a specialist as those in system-owned ones: 57.1% (95% confidence interval [95% CI] 56.7%-57.4%) versus 57.3% (95% CI 56.6%-58.0%), respectively (p = 0.635). The percent using two or more types of specialists was 46.1% (95% CI 45.4%-46.7%) in independent practices, comparable to that in systems 47.1% (95% CI 46.2%-48.0%) (p = 0.054). However, the mean number of specialist visits was significantly lower in independent practices than in systems-4.0 (95% CI 3.9%-4.0%) versus 4.4 (95% CI 4.3%-4.6%) respectively-reaching statistical significance with p < 0.0001.

CONCLUSIONS

Recognizing how privately insured children with disabilities use pediatric primary care from pediatric and nonpediatric primary care specialists through both independent and system-owned practices is important for improving care quality and value.

Difficulty Obtaining Behavioral Health Services for Children: A National Survey of Multiphysician Practices

PURPOSE

In the United States, primary care practices rely on scarce resources to deliver evidence-based care for children with behavioral health disorders such as depression, anxiety, other mental illness, or substance use disorders. We estimated the proportion of practices that have difficulty accessing these resources and whether practices owned by a health system or participating in Medicaid accountable care organizations (ACOs) report less difficulty.

METHODS

This national cross-sectional study examined how difficult it is for practices to obtain pediatric (1) medication advice, (2) evidence-based psychotherapy, and (3) family-based therapy. We used the National Survey of Healthcare Organizations and Systems 2017-2018 (46.9% response rate), which sampled multiphysician primary and multispecialty care practices including 1,410 practices that care for children. We characterized practices' experience as "difficult" relative to "not at all difficult" using a 4-point ordinal scale. We used mixed-effects generalized linear models to estimate differences comparing system-owned vs independent practices and Medicaid ACO participants vs nonparticipants, adjusting for practice attributes.

RESULTS

More than 85% of practices found it difficult to obtain help with evidence-based elements of pediatric behavioral health care. Adjusting for practice attributes, the percent experiencing difficulty was similar between system-owned and independent practices but was less for Medicaid ACO participants for medication advice (81% vs 89%; P = .021) and evidence-based psychotherapy (81% vs 90%; P = .006); differences were not significant for family-based treatment (85% vs 91%; P = .107).

CONCLUSIONS

Most multiphysician practices struggle to obtain advice and services for child behavioral health needs, which are increasing nationally. Future studies should investigate the source of observed associations.

Patients at High Risk of Intervention for Pediatric Traumatic Liver Injury

OBJECTIVES

Nonoperative management of hemodynamically stable liver lacerations in pediatric trauma patients is a safe and effective management strategy for pediatric patients; approximately 90% will be successfully managed nonoperatively. No study has specifically identified risk criteria for the need for intervention versus observation alone. Our objective for this study was to determine risk factors from the physical examination, computed tomography scan, and laboratory results associated with intervention for liver laceration.

METHODS

We performed a retrospective cohort study using data from the Pediatric Emergency Care Applied Research Network Intra-abdominal Injuries Study public use data set. Data were collected prospectively at the time of enrollment; a limited data set was released for public use in 2014. Patients were included if they were diagnosed with a liver laceration by computed tomography scan. We used bivariable and multivariable analyses to determine associations of specific risk factors with intervention, defined as laparotomy, angiographic embolization, blood transfusion, death, or return to emergency department for any reason within 30 days.

RESULTS

Of the 12,044 patients in the Intra-abdominal Injuries Study, 282 were diagnosed with a liver laceration. All patients were hospitalized, and 99 (35.1%) underwent an intervention. Variables were then eliminated if more than 10% of cases were missing data. Multivariable logistic regression identified the following independent risk factors for intervention: white blood cell count greater than 15 K/mcl (adjusted odds ratio [adjOR], 2.83; 95% confidence interval [CI], 1.43-5.63), pelvic fracture (adjOR, 2.50; 95% CI, 1.02-6.10), liver injury greater than grade 2 (adjOR, 2.16; 95% CI, 1.06-4.40), Glasgow Coma Scale score less than 15 (adjOR, 4.77; 95% CI, 2.27-7.63), and hematocrit less than 32% (adjOR, 4.79; 95% CI, 2.00-11.46).

CONCLUSIONS

We identified 5 high-risk criteria associated with intervention for traumatic liver laceration in pediatric patients. Prospective studies are necessary to validate these results before using them to determine disposition of pediatric patients with traumatic liver injuries.

Design and effects of outcome-based payment models in healthcare: a systematic review

INTRODUCTION

Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects.

METHODS

We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs.

RESULTS

We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth.

DISCUSSION

Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.

Impact of Accountable Care Organizations on Utilization, Care, and Outcomes: A Systematic Review

Since 2010, more than 900 accountable care organizations (ACOs) have formed payment contracts with public and private insurers in the United States; however, there has not been a systematic evaluation of the evidence studying impacts of ACOs on care and outcomes across payer types. This review evaluates the quality of evidence regarding the association of public and private ACOs with health service use, processes, and outcomes of care. The 42 articles identified studied ACO contracts with Medicare ( N = 24 articles), Medicaid ( N = 5), commercial ( N = 11), and all payers ( N = 2). The most consistent associations between ACO implementation and outcomes across payer types were reduced inpatient use, reduced emergency department visits, and improved measures of preventive care and chronic disease management. The seven studies evaluating patient experience or clinical outcomes of care showed no evidence that ACOs worsen outcomes of care; however, the impact on patient care and outcomes should continue to be monitored.

Socioeconomic Background and Commercial Health Plan Spending

BACKGROUND

Risk-adjustment algorithms typically incorporate demographic and clinical variables to equalize compensation to insurers for enrollees who vary in expected cost, but including information about enrollees' socioeconomic background is controversial.

METHODS

We studied 1 182 847 continuously insured 0 to 19-year-olds using 2008-2012 Blue Cross Blue Shield of Massachusetts and American Community Survey data. We characterized enrollees' socioeconomic background using the validated area-based socioeconomic measure and calculated annual plan payments using paid claims. We evaluated the relationship between annual plan payments and geocoded socioeconomic background using generalized estimating equations (γ distribution and log link). We expressed outcomes as the percentage difference in spending and utilization between enrollees with high and low socioeconomic backgrounds.

RESULTS

Geocoded socioeconomic background had a significant, positive association with annual plan payments after applying standard adjusters. Every 1 SD increase in socioeconomic background was associated with a 7.8% (95% confidence interval, 7.2% to 8.3%; P < .001) increase in spending. High socioeconomic background enrollees used higher-priced outpatient and pharmacy services more frequently than their counterparts from low socioeconomic backgrounds (eg, 25% more outpatient encounters annually; 8% higher price per encounter; P < .001), which outweighed greater emergency department spending among low socioeconomic background enrollees.

CONCLUSIONS

Higher socioeconomic background is associated with greater levels of pediatric health care spending in commercially insured children. Including socioeconomic information in risk-adjustment algorithms may address concerns about adverse selection from an economic perspective, but it would direct funds away from those caring for children and adolescents from lower socioeconomic backgrounds who are at greater risk of poor health.

Addressing Adverse Childhood Experiences Through the Affordable Care Act: Promising Advances and Missed Opportunities

Adverse childhood experiences (ACEs) occur when children are exposed to trauma and/or toxic stress and may have a lifelong effect. Studies have shown that ACEs are linked with poor adult health outcomes and could eventually raise already high health care costs. National policy interest in ACEs has recently increased, as many key players are engaged in community-, state-, and hospital-based efforts to reduce factors that contribute to childhood trauma and/or toxic stress in children. The Affordable Care Act (ACA) has provided a promising foundation for advancing the prevention, diagnosis, and management of ACEs and their consequences. Although the ACA's future is unclear and it does not adequately address the needs of the pediatric population, many of the changes it spurred will continue regardless of legislative action (or inaction), and it therefore remains an important component of our health care system and national strategy to reduce ACEs. We review ways in which some of the current health care policy initiatives launched as part of the implementation of the ACA could accelerate progress in addressing ACEs by fully engaging and aligning various health care stakeholders while recognizing limitations in the law that may cause challenges in our attempts to improve child health and well-being. Specifically, we discuss coverage expansion, investments in the health workforce, a family-centered care approach, increased access to care, emphasis on preventive services, new population models, and improved provider payment models.

Use of Low-Value Pediatric Services Among the Commercially Insured

BACKGROUND

Claims-based measures of "low-value" pediatric services could facilitate the implementation of interventions to reduce the provision of potentially harmful services to children. However, few such measures have been developed.

METHODS

We developed claims-based measures of 20 services that typically do not improve child health according to evidence-based guidelines (eg, cough and cold medicines). Using these measures and claims from 4.4 million commercially insured US children in the 2014 Truven MarketScan Commercial Claims and Encounters database, we calculated the proportion of children who received at least 1 low-value pediatric service during the year, as well as total and out-of-pocket spending on these services. We report estimates based on "narrow" measures designed to only capture instances of service use that were low-value. To assess the sensitivity of results to measure specification, we also reported estimates based on "broad measures" designed to capture most instances of service use that were low-value.

RESULTS

According to the narrow measures, 9.6% of children in our sample received at least 1 of the 20 low-value services during the year, resulting in $27.0 million in spending, of which $9.2 million was paid out-of-pocket (33.9%). According to the broad measures, 14.0% of children in our sample received at least 1 of the 20 low-value services during the year.

CONCLUSIONS

According to a novel set of claims-based measures, at least 1 in 10 children in our sample received low-value pediatric services during 2014. Estimates of low-value pediatric service use may vary substantially with measure specification.