Editor’s Note: Dr. Paige Bhansali (she/her/hers) is a resident physician in pediatrics at The Boston Combined Residency Program at Boston Children's Hospital and Boston Medical Center and a business school student at Harvard Business School. Her background is in strategy consulting and health policy research, and her interests lay at the intersection of alternative payment models and health care delivery innovation. –Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics
As value-based care models, including accountable care organizations (ACOs), have proliferated across the adult healthcare ecosystem, pediatric clinicians—including myself—have awaited their expansion into the pediatric population. Such models create shared responsibility among payors and providers for patients’ cost and/or quality outcomes. However, perhaps most relevant to patient care, these value-based care models can also provide clinicians the flexibility to develop cost-effective care and care coordination programs outside of the typical fee-for-service schedule.
Within pediatrics, children and youth with special health care needs may particularly benefit from these types of models, given their high levels of unmet needs and disproportionate share of health care costs.
In an article and accompanying video abstract being early released in Pediatrics this week entitled, “Cost, Utilization, and Patient and Family Experience With ACO-Based Pediatric Care Management,” Dr. Katherine Schiavoni and colleagues at Harvard Medical School evaluate whether a primary care–based care management program can simultaneously improve cost, health outcomes, and patient/family experience—the 3 components of the Triple Aim (what healthcare should achieve)—for >1,300 high-risk pediatric patients inside a large academic health system with both commercial and Medicaid ACO contracts (10.1542/peds.2022-058268).
The authors compared outcomes for patients enrolled in the care management program with those who were eligible for but not yet enrolled in the program. They looked at:
- Patient utilization and costs over time
- Perceived quality of care coordination services
- Unmet needs
- Patient/family experience
The authors found that patients enrolled in the program had lower total medical expenditures of $645 per member per month, which persisted after enrollment. Given that the program cost $120 per member per month, this meant that the program led to a >3:1 return on investment.
In other words, the program was not only effective in keeping patients healthier and out of the hospital, the savings from preventing acute care utilization paid for the program’s operational costs and provided further cost savings for the ACO!
The authors note that this study is the first to evaluate a broad pediatric care management program based in pediatric primary care for both commercial and Medicaid populations.
In an invited commentary entitled, “Pediatric Care Management Programs: The Evidence Gap Remains,” Drs. Kao-Ping Chua and Sean Gleeson from the University of Michigan and the Ohio State University, respectively, provide thoughtful insight (10.1542/peds.2023-063241). Specifically, they note that the observed association between enrollment in the program and decreased costs and utilization may not be causal. Children may have enrolled in the program during a period of high utilization, and that this high utilization was unlikely to continue, regardless of program enrollment. Additionally, they point out that healthcare costs and utilization are an indirect reflection of a child’s health status and shouldn’t necessarily be extrapolated to indicate improved health outcomes. It’s also worth noting that prior evaluations of pediatric care management programs have not shown consistent reduction in costs or utilization, so this raises the question of whether the results of this program can be replicated.
Nonetheless, this study offers a promising view of the impact and financial sustainability of pediatric care management programs based in primary care settings.
