Cost Saving and Quality of Care in a Pediatric Accountable Care Organization

Discussion

PFK successfully improved the value of pediatric health care over time, primarily through cost containment. We believe this is the first evaluation of a pediatric ACO, and our data demonstrate the potential for an ACO to minimize the growth in the cost of care for a pediatric population compared with a state Medicaid FFS program (ie, Ohio).

The lower rate of cost growth achieved by PFK bodes well for the short-term success of PFK’s business model and other pediatric ACOs. PFK’s PMPM costs were consistently lower than those of other Ohio Medicaid MC organizations, with no overlap after 2008 in the confidence intervals surrounding the regression lines describing the growth. MC organization PMPM costs were higher than PFK and grew slightly faster than PFK PMPMs, but the latter difference was not significant, possibly due to the relatively brief period of comparative years. Over 5 years, PFK experienced a 15.1% increase in PMPM. How would this finding compare with national measures of Medicaid cost growth? To our knowledge, there is no single national estimate of spending increases per child enrolled in Medicaid for these years. However, each indicator of cost growth that we could locate reflects higher growth than occurred at PFK. The Consumer Price Index for health care services increased 17.1% during the same years as our study, whereas overall Medicaid spending per enrollee has been estimated to have increased from 3% to 4% per year on average over the 5 years of our study, which would be 16% to 22% increases over 5 years.

Quality measures of PFK care remained generally stable over our study period. Although there were several modest improvements in AHRQ quality indicators, because these measures were not specifically targeted by PFK, it is unclear whether these improvements resulted from our organizational initiatives. The quality of care improved for NICU days per 1000 PFK members and well-child visits. The PFK board specifically targeted these measures, however. They were addressed directly by multidisciplinary and multi-institutional quality improvement teams and resulted in improved outcomes. In contrast, asthma emergency department visits and HbA1c values did not improve, with the latter showing a small but significant deterioration.

In summary, the PFK model substantially reduced growth in the cost of care relative to the growth experienced by other Ohio Medicaid enterprises serving children. At the same time, quality of care measures held steady, with a mix of several small improvements and minor deteriorations. Therefore, PFK delivered on the promise of the ACO to reduce the rate of health care cost growth while maintaining or improving the quality of care.

We suggest that the PFK model achieved these results because pediatric ACOs are better positioned to bridge coordination gaps in care than either an individualized patient-centered medical home or an insurer could do alone; the ACOs are, in effect, the medical neighborhood for the medical home. Individualized medical practices are limited in their ability to track health care use across the system because their records reflect only visits to their individual practices or hospitals. Our recent data on quality of care for attention-deficit/hyperactivity disorder underscore this issue.¹⁷ In contrast, PFK manages care coordination, patient enrollment in digital communications and health record portals, coaching, and scheduling for many specialty pediatric patients area; it also provides pediatricians with report cards and follow-up data. Health plans are limited in their ability to influence practices and coordinate multiple quality initiatives because they invariably have only partial penetration of all children in the community. In Ohio, 5 different Medicaid MC organizations enroll pediatric members using different formularies, care guidelines, and care coordination models. For central and southeastern Ohio, PFK is able to provide a single set of provider guidelines for common conditions, a single set of collaborative activities for clinicians, and unified care coordination with pediatric specialty teams. As a physician/hospital organization, PFK is also more directly involved in the specialty care than a typical insurance company and can provide a unified voice on coordination and guidelines.

Although the low rate of medical inflation is important for sustainability, improvements in the value of health care should ideally be achieved by affecting both sides of the value equation. Value in health care can be achieved through improvements in quality as well as reductions in costs. It is disappointing that we did not identify a greater improvement in the quality of care. We believe there are several reasons for this outcome. First, the lack of widely accepted, clinically meaningful quality measures for pediatric ACOs limits the ability to demonstrate changes in quality. Second, the relative scarcity of many specialty pediatric conditions even in a population this size prevents reliable measurement of change in outcomes over time. Third, the AHRQ Pediatric Quality Indicators have serious limitations in terms of their ability to accurately measure preventable complications and admissions. In fact, a recent multicenter study recommended that they not be used as a comparative tool but rather as a screening tool to target more in-depth chart review.¹⁸ In addition, the PFK claims database contains a limited number of diagnosis and procedure codes with which to calculate the AHRQ Pediatric Quality Indicators. Finally, the experience in PFK is that quality changes require more time than cost savings in a large network. PFK administrators and clinicians have been able to rapidly identify cost reduction targets such as rapid repeat admissions, inappropriate use of high-cost drugs or procedures, and patients in need of specialty care coordination that had not been detected by MC organizations without pediatric expertise. However, quality improvement activities require building large-scale clinician quality collaborative projects with external partner agencies, educating patients over time, launching shared quality improvement databases, tracking outcomes, and, often, new leadership. All of these activities are essential infrastructure steps that should yield changes in quality outcomes over time, if they are sustained.^5,19 We plan to more robustly implement these infrastructure changes in PFK.

Although an additional 30 million Americans will have access to health coverage under the Patient Protection and Affordable Care Act, the difficult work of creating a system of better care, better health, and lower cost (what former Centers for Medicare & Medicaid Services administrator and pediatrician Don Berwick calls the “triple aim” of health care reform) will occur gradually. These reforms will come about through pilot projects designed to encourage innovation, increase effectiveness, and improve costs.

One of the primary vehicles through which the new law encourages such innovation is through provisions that establish ACOs in Medicare and, for pediatrics, in Medicaid/Children’s Health Insurance Program. The fact that pediatric ACOs were singled out from adult ACOs in the legislation reflects 2 points. First, it shows an understanding that pediatric care is a critical intervention point where, as a nation, we can shift from a culture of acute care to a culture of prevention in its most primary representation: children. Second, it reflects an appreciation for the different market forces in pediatric health care.⁸

Our results suggest that, at least for Medicaid, pediatric ACOs may be efficient models of reforming health care. At the same time, there are also challenges for improving pediatric quality of care and for measuring that quality. The National Committee for Quality Assurance is developing an accreditation and measurement proposal for ACOs, and PFK will be participating in its testing.