Statement of the Problem: Health Reform, Value-Based Purchasing, Alternative Payment Strategies, and Children and Youth With Special Health Care Needs

Health Equity and Children With Medical Complexity/Children and Youth With Special Health Care Needs: A Scoping Review

A scoping review was conducted to systematically map the research on children with medical complexity and children and youth with special health care needs (CYSHCN) surrounding health equity. Fifteen articles were reviewed with focus on: access to care, quality of life and well-being, and insurance challenges/financing. Findings suggest CYSHCN require more and different types of services than those for typically developing children and youth, yet the current system is not ensuring access to these services. It is important to understand the unique perspectives, challenges, and opportunities of and for this population to better inform policy, research, and practice.

Pediatric Outpatient Noncontrast Brain MRI: A Time-Driven Activity-Based Costing Analysis at Three U.S. Hospitals

BACKGROUND. MRI utilization and the use of sedation or anesthesia for MRI have increased in children. Emerging alternative payment models (APMs) require a detailed understanding of the health system costs of performing these examinations. OBJECTIVE. The purpose of this study was to use time-driven activity-based costing (TDABC) to assess health system costs for outpatient noncontrast brain MRI examinations across three children's hospitals. METHODS. Direct costs for outpatient noncontrast brain MRI examinations at three academic free-standing pediatric hospitals were calculated using TDABC. Examinations were categorized as sedated MRI (i.e., sedation or anesthesia), nonsedated MRI, or limited MRI. Process maps were created to describe patient workflows based on input from key personnel and direct observation. Time durations for each process activity were determined; time stamps from retrospective EMR review were used when possible. Capacity cost rates were calculated for resource types within three cost categories (labor, equipment, and space); cost was calculated in a fourth category (supplies). Resources were allocated to each activity, and the cost of each process step was determined by multiplying step-specific capacity costs by the time required for each step. The costs of all steps were summed to yield a base-case total examination cost. Sensitivity analysis for sedated MRI was performed using minimum and maximum time duration inputs for each activity to yield minimum and maximum costs by hospital. RESULTS. The mean base-case cost for a sedated brain MRI examination was $842 (range, $775-924 across hospitals), for a nonsedated brain MRI examination was $262 (range, $240-285), and for a limited brain MRI examination was $135 (range, $127-141). For all examination types, the largest cost category as well as the largest source of difference in cost between hospitals was labor. Sensitivity analysis found that the greatest influence on overall cost at each hospital was the duration of the MRI acquisition. CONCLUSION. The health system cost of performing a sedated MRI examination was substantially greater than that of performing a nonsedated MRI examination. However, the cost of each individual examination type did not vary substantially among hospitals. CLINICAL IMPACT. Health systems operating within APMs can use this comparative cost information for purposes of cost reduction efforts and establishment of bundled prices.

Moving From Spending to Investment: A Research Agenda for Improving Health Care Financing for Children and Youth With Special Health Care Needs

Children and youth with special health care needs (CYSHCN) use disproportionately more health care resources than non-CYSHCN, and their unique needs merit additional consideration. Spending on health care in the United States is heavily concentrated on acute illnesses through fee-for-service (FFS). Payment reform frameworks have focused on shifting away from FFS, addressing health outcomes and the experience of care while lowering costs, particularly for high resource utilizers. The focus of payment reform efforts to date has been on adults with chronic illnesses, with less priority given to investment in children's health and life course. Spending for children's health is also considered an investment in their growth and development with long-term outcomes at stake, so research questions should focus on where and how such spending should be targeted. This paper discusses high-priority research topics in the area of health care financing for CYSHCN in the context of what is currently known and important knowledge gaps related to investment for CYSHCN. It proceeds to describe 3 potential research projects that can address these topics, following a framework informed by the priority questions identified in a previous multistakeholder research agenda development process. We focus on 3 areas: benefits, payment models, and quality measures. Specific aims and hypotheses are offered, as well as suggestions for approaches and thoughts on potential implications.

Assessing and Addressing Social Determinants of Health Among Children and Youth With Special Health Care Needs

Over several decades, a field of research has emerged to examine social and environmental factors that contribute to health inequities among children and youth with special healthcare needs (CYSHCN), with the goal of reducing inequities through identifying and mitigating these social determinants of health (SDH). The Children and Youth with Special Healthcare Needs National Research Network (CYSHCNet) national research agenda development process, described in a companion article, recognized SDH, as experienced by CYSHCN, and the effects on health inequity and child and family outcomes as a high priority area. Important gaps named included which strategies best identify and mitigate the effects of negative SDH and which outcomes are most meaningful to families receiving SDH-focused interventions. In this area, the highest priority questions were the following: 1) How can SDH be routinely addressed in the course of care for CYSHCN? 2) Which interventions most effectively integrate SDH to improve child and family outcomes? Here, we discuss the impact of SDH on CYSHCN, efforts to screen for and intervene upon SDH in this population, and gaps in the current research on SDH specific to CYSHCN. We make several recommendations for research studies that will move the field forward. This work should achieve a greater understanding of patterns and impacts of SDH experienced by CYSHCN. It will also contribute to optimizing identification of SDH and improving interventions to achieve equity in health outcomes identified by patients and families as important to them.

Paediatric alternative payment models: emerging elements

PURPOSE OF REVIEW

The aim of this study was to summarize emerging elements of paediatric alternative payment models (APMs), identify strategies to address barriers in implementing paediatric APMs and share policy approaches.

RECENT FINDINGS

The unique health needs of children and adolescents must be considered as paediatric value-based care and APMs are developed. The longer time period for achieving cost savings, relatively few existing model tests and challenges with cross-sector data-sharing and pooled financing are barriers to the adoption of paediatric APMs. The Integrated Care for Kids (InCK) model and some state-based efforts are testing whether an integrated service delivery model combined with paediatric APMs can reduce expenditures and improve care and outcomes. However, the relative paucity of models makes it difficult to identify the most effective strategies and overall impact of paediatric APMs.

SUMMARY

Emerging paediatric APMs include the following key elements: developmentally appropriate approaches, paediatric-specific quality and cost measures, a focus on primary care, special considerations for children with complex healthcare needs and cross-sector integration of data, workforce and financing. A variety of strategies, rooted in cross-sector partnerships, can be pursued to address implementation barriers and ultimately support paediatric care transformation.

Remote Monitoring of Patient- and Family-Generated Health Data in Pediatrics

In this article, we provide an overview of remote monitoring of pediatric PGHD and family-generated health data, including its current uses, future opportunities, and implementation resources.

Evidence Based Practice in Systems of Care for Children with Complex Mental Health Needs

Purpose: Community-based social work with families and youth with complex behavioral health needs highlights challenges to incorporating empirical evidence into routine practice. This article presents a framework for integrating evidence in community-based Systems of Care for these children and their families.Method: This article reviews research on various approaches to integrating evidence into children's behavioral health and community-based care and contextualizes it within dominant paradigms of Systems of Care (SoC) and Wraparound principles.Results: Based on this review, this article proposes the Evidence-Based Practice in Systems of Care (EBP in SoC) model. The model describes how to incorporate evidence into every aspect of community-based SoCs for children with mental health concerns.Discussion and Conclusion: Discussion of the model will focus on implications of using the framework for practitioners, mental health organizations, communities, and state and federal administration and policymaking.

Principles of Financing the Medical Home for Children

A well-implemented and adequately funded medical home not only is the best approach to optimize the health of the individual patient but also can function as an effective instrument for improving population health. Key financing elements to providing quality, effective, comprehensive care in the pediatric medical home include the following: (1) first dollar coverage without deductibles, copays, or other cost-sharing for necessary preventive care services as recommended by Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents; (2) adoption of a uniform definition of medical necessity across payers that embraces services that promote optimal growth and development and prevent, diagnose, and treat the full range of pediatric physical, mental, behavioral, and developmental conditions, in accord with evidence-based science or evidence-informed expert opinion; (3) payment models that promote appropriate use of pediatric primary care and pediatric specialty services and discourage inappropriate, inefficient, or excessive use of medical services; and (4) payment models that strengthen the patient- and family-physician relationship and do not impose additional administrative burdens that will only erode the effectiveness of the medical home. These goals can be met by designing payment models that provide adequate funding of the cost of medical encounters, care coordination, population health services, and quality improvement activities; provide incentives for quality and effectiveness of care; and ease administrative burdens.

Opportunities on the road to value-based payment for children with chronic respiratory disease

The transition from a fee-for-service payment system to value-based payment system gained momentum in the US in 2010 with the passage of the Affordable Care Act and continues to progress rapidly. Market research estimates that value-based payment models will surpass fee-for-service by 2020. This change offers both great opportunity and great risk to the medical care of the heterogeneous populations of children with chronic respiratory disease. The fee-for-service model has driven the emergence of a healthcare delivery infrastructure markedly misaligned with the medical needs of children with chronic respiratory disease. A change to value-based payment models offers the opportunity to create systems better aligned with the complex and varied care needs of these children. However, rapid change without input from the relevant stakeholders could yield an infrastructure even more misaligned with the needs of children with chronic respiratory disease than the current one and threaten access to high quality medical care for these populations. Through the lens offered by three fictional case studies, this review: (1) illustrates current and evolving payment models; (2) describes limitations of these payment models; and (3) suggests a novel way to envision and evaluate value-based payment models for children with chronic respiratory disease.

General Pediatricians and Value-Based Payments

BACKGROUND AND OBJECTIVE

In an effort to transform the health care system, payers and physicians are experimenting with new payment models, mostly in an effort to move from a volume-based system to one based on value. We conducted a national survey to evaluate pediatricians' experience with and views about new value-based models of payment.

METHODS

An American Academy of Pediatrics 2016 member survey was used to assess provider and practice characteristics, provider experience with value-based payments (VBPs) (through accountable care organizations [ACOs] or pay for quality performance), and provider views about new payment models. We used descriptive statistics and multivariable logistic regression models to examine relationships between experience and views.

RESULTS

The survey response rate was 48.7% (n = 786 of 1614). Of practicing general pediatricians, 52% reported experience with VBP, 32% believed payment for quality metrics have a "positive impact" on pediatricians' ability to provide quality care for patients, and 12% believed ACOs have a positive impact. Adjusting for covariates, respondents experienced with payments for quality metrics (adjusted odds ratio: 2.01; 95% confidence interval 1.26-3.19) and ACOs (odds ratio: 6.68; 95% confidence interval 3.55-13.20) were more likely to report a positive impact.

CONCLUSIONS

Although experience and views vary, just more than half of surveyed pediatricians report receiving some form of VBP. Pediatricians reporting this experience are more likely to feel that these payment models have a positive impact on patient care when compared with pediatricians without this experience.

Building the Case for Quality Improvement

Great improvements have been made by quality improvement teams. National trends towards using quality and value metrics in reimbursement suggest that physicians and advanced practitioners caring for children and adolescents will benefit from knowing and using quality improvement methods. These methods will also help as transparency of quality data becomes more commonplace.

Status Complexicus? The Emergence of Pediatric Complex Care

Discourse about childhood chronic conditions has transitioned in the last decade from focusing primarily on broad groups of children with special health care needs to concentrating in large part on smaller groups of children with medical complexity (CMC). Although a variety of definitions have been applied, the term CMC has most commonly been defined as children and youth with serious chronic conditions, substantial functional limitations, increased health and other service needs, and increased health care costs. The increasing attention paid to CMC has occurred because these children are growing in impact, represent a disproportionate share of health system costs, and require policy and programmatic interventions that differ in many ways from broader groups of children with special health care needs. But will this change in focus lead to meaningful changes in outcomes for children with serious chronic diseases, or is the pediatric community simply adopting terminology with resonance in adult-focused health systems? In this article, we will explore the implications of the rapid emergence of pediatric complex care in child health services practice and research. As an emerging field, pediatric care systems should thoughtfully and rapidly develop evidence-based solutions to the new challenges of caring for CMC, including (1) clearer definitions of the target population, (2) a more appropriate incorporation of components of care that occur outside of hospitals, and (3) a more comprehensive outcomes measurement framework, including the recognition of potential limitations of cost containment as a target for improved care for CMC.

Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway?

Children with medical complexity (CMC) have multiple chronic conditions and require an array of medical- and community-based providers. Dedicated care coordination is increasingly seen as key to addressing the fragmented care that CMC often encounter. Often conceptually misunderstood, care coordination is a team-driven activity that organizes and drives service integration. In this article, we examine models of care coordination and clarify related terms such as care integration and case management. The location of care coordination resources for CMC may range from direct practice provision to external organizations such as hospitals and accountable care organizations. We discuss the need for infrastructure building, design and implementation leadership, use of care coordination tools and training modules, and appropriate resource allocation under new payment models.