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AAP president-elect candidates discuss medical home, payments :

August 25, 2016

The AAP National Nominating Committee has named Colleen A. Kraft, M.D., FAAP, and Michael T. Brady, M.D., FAAP, as candidates for AAP president-elect. The winner will serve as the 2018 AAP president. Voting begins on Oct. 21 and concludes on Nov. 21.

The candidates were asked “How can the pediatrician and the medical home survive and thrive in this new era of rapidly evolving payment structures?”

Michael T. Brady M.D., FAAP

Columbus, Ohio

Regardless of whether it is an accountable care organization or another payer structure, emphasis will be on population health rather than disease management. The pediatrician-led medical home is optimally positioned for any of these new payment models. Pediatricians have always championed preventive health care through health and developmental screening, immunizations and anticipatory guidance — while the medical home has been recognized for comprehensive, family-centered and cost-effective care.

However, in order to address the full gamut of needs of patients and families, payment to the medical home must be adequate so that pediatricians can spend appropriate time with families and so ancillary services can be supported.

Those ancillary services will grow in importance, especially in the population health framework. The medical home must expand beyond primary care to include mental health, nutritional, home visitation and social services. The “medical home neighborhood” will need to recognize social determinants of health and manage them in conjunction with social service agencies. This partnership is crucial since many factors that impact health are beyond the realm of the pediatrician.

None of this will work without adequate payment to the medical home. Given that there is clear evidence documenting that the medical home is cost-effective, this shouldn’t be a hard sell. Since the medical home model will be valuable for patients of all ages, AAP should partner with the American Academy of Family Physicians and the American College of Physicians. Working together, we can secure the financial future of the medical home and reemphasize the importance of the pediatrician.


Colleen A. Kraft, M.D., FAAP

Cincinnati, Ohio

Our pediatricians on the ground understand “No margin, no mission.” We believe that pediatricians are the best trained physicians to care for children, and that the pediatric medical home team contains the professionals that provide comprehensive care for children. The fee-for-service model did not pay for many elements of that important team-based care; phone calls, after-hours calls and visits as well as other services could traditionally be billed but were often not paid. Many pediatricians who offered evening and weekend hours cut these back because there was no additional payment for these family-centered, cost-saving services.

Enter MACRA, MIPS, P4P, Shared Savings and other models designed to cut costs in adult care. The AAP needs a strong voice in the implementation of these payment models, which are not designed to improve care for children. Bonus dollars tied to processes (e.g., after-hours care) and outcomes should be built into pediatric financing models. The AAP could highlight innovative partnerships with medical home “extenders,” like home visitors, Head Start and school-based health centers, to allow pediatricians to extend their reach without incurring additional cost. Promising practices like direct contracting for primary care services with employers, contracting through pediatric super groups and health networks, and telehealth within the medical home could be tested and spread nationally, with pediatric subject matter experts available for consultation.

Pediatricians understand what services are needed to optimize child health. Payment for these pediatric services during a time of changing payment models should be a priority for the AAP.

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