Bringing value-based care to the youngest patients

Pediatrics has been at the forefront of preventive medical practices such as immunizations, screenings, care coordination with specialists and meeting defined health goals.

Measurable prevention is a major cornerstone of providing value-based care, so it would seem the approach would pair well with pediatrics. But it’s not that simple, because there is a wide range of populations and health needs to be considered within pediatrics.

“We’re talking about a handful of different types of patients, newborns, preschoolers, all the way to adolescents and young adults,” said Jeffrey Bernstein, MD, a pediatrician at Pediatric and Adolescent Care of Silver Spring in Maryland, which is part of Privia Health. “Value-based care is going to look different for each of those populations.”

Privia Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

With support from the Privia network, Dr. Bernstein and his colleagues have made a compelling case for the benefits of a value-based care approach in pediatrics, even with serious obstacles to overcome. By leveraging EHRs and aiding physicians in dealing with the complexities of payers’ evolving requirements, Privia locations such as Pediatric and Adolescent Care of Silver Spring are improving outcomes for children and families.

“The approach emphasizes screenings for things that really do matter both for individuals and population health,” said Dr. Bernstein. “There’s more meaningful outreach and consideration for patients outside of our in-person and virtual visits—reminders, follow ups, better overall tracking and more coordination of care.

“We can make sure that care from other entities, whether specialists or at a hospital, is done in the right way, and in the most efficient and appropriate manner, rather than just generating fees for visits,” he added.

But it takes a great deal of building and fine-tuning to arrive at a place where value-based care can have a meaningful impact for pediatric patients.

The biggest challenge for the value proposition is the long-term timeline to get measurable outcomes. This can often take years, and even decades, for certain metrics to offer trends, said Dr. Bernstein.

“A real technical challenge lies in data management,” he said. “People have tried to use claims data but there are many ways in which it falls apart. It’s incomplete and not necessarily reflective of what's actually happening with both patients and populations. People get care in different places under different payers and different situations.”

Dr. Bernstein offered the example of tracking hepatitis B vaccines, because often the first dose is administered in the hospital right after a baby is born. That can place the vaccine under the hospital bill, or a global payment, and may go on the mother’s insurance. That may lead to cases where the first hepatitis B shot isn’t tracked for the child.

“Rather than claims, that immunization will likely end up on an EHR,” said Dr. Bernstein. “That’s a big reason why it’s essential to have a great EHR, to have that data in one place and easily be able to input into it.

“The result is better care with a strong EHR,” he added, noting “you can use them to do recalls and monitoring, have rosters of people with conditions or in need of certain preventive cares, and to be able to categorize and retrieve that data, both for reporting and for keeping up their care.”

Negative childhood experiences are among the clearly known drivers of poor health in adults. But with positive experiences, well-being is improved. That’s among the imperatives for health systems such as Privia to use EHRs and other value-based approaches to advance health equity.

“If we can improve experiences within the health systems, those improved outcomes transfer to all parts of society,” said Dr. Bernstein. “A lot of the chronic illnesses and conditions that we deal with have immense impact on and are also affected by social drivers of health, especially obesity, behavioral and mental health issues. If we can get ahead of them as early as possible, we can make real improvements.”

Getting family members to become responsive and involved in the types of communications that follow, using EHRs and value-based care approaches, is also essential.

“We do realize it can be overwhelming, all of the questionnaires, screenings, visits, immunizations, but we make it clear that it’s to maintain health in the long term, and avoid crises and unnecessary ER visits,” said Dr. Bernstein. “Gaining that trust can happen when you meet people where they are at. Not only are we dealing with the youngest patients, but we are also working with their decision-makers. Establishing clear communication is vital.”  

Screenings are a major pillar in Dr. Bernstein’s practice as they often become entry points for detailed conversations about the care needs a child might have. Screening for autism and depression, for example, can be combined with the tracking and follow-up possibilities brought through EHRs and enable physicians to provide more comprehensive and specific care.

“Some things in a screening for autism might make us stop and say: Do we need to talk about this more?” said Dr. Bernstein. Parents may respond, “Oh, I'm glad you brought that up. We were wondering but were kind of afraid to ask.”

Such screenings “can extract discussions that might not have come up,” Dr. Bernstein noted.

EHRs also can help notify physicians and their care teams if a patient has visited an emergency room, or stayed at a hospital, which then sets up specific follow-ups on those instances.

“We may be able to make sure they don’t have to return to the ER,” said Dr. Bernstein. “Let’s say it was an asthma flare-up that sent them to the ER. We can then bring them in and fine tune their treatments to keep that from happening again.”

Dr. Bernstein noted that his practice can shift to value-based care, while still allowing enough bandwidth for him and his colleagues to focus on patients, due to the support from Privia. The single tax ID physician-led medical group gives physicians the stability of a larger group while preserving their independence.

“I don't think it's reasonable to function in a value-based world, particularly with the payment models, without being part of a larger organization,” said Dr. Bernstein. “You need the resources and leverage, as well as people to work with payers.

“Value-based components in payer contracts are very complex,” he added, noting that “value-based care and payment models are further along in the adult world because of Medicare, but we as pediatricians can really gain a lot from the experience of the organization in managing value-based care.”

“The ways pediatric practices might achieve or qualify for incentives and rewards might include meeting or exceeding patient population thresholds for defined preventive or disease-related quality measures,” Dr. Bernstein said. “In pediatrics, these are predominantly preventive care—well visits, immunizations, screenings—but might also be acute or disease defined measures such as appropriate antibiotic use, strep testing, asthma care.”

Other ways include savings in overall cost of care for patients or cohorts of patients, as well as being part of a larger, multi-specialty organization that may qualify for rewards and incentives if their organization collectively is successful in meeting quality measure, outcome or shared savings goals and thresholds.

“Once achieved, financial rewards, benefits or incentives might be paid in a variety of models and often a combination of these from a payer”: a per member per month payment for all attributed patients as a lump sum to the practice, organization or physician, payment of a portion of shared savings, and—by achieving success in meeting quality measures, outcome or shared savings goals and thresholds—a practice might have a certain percentage “bump up” in their fee-for-service schedule from a payer, Dr. Bernstein explained.

Movement toward value-based care in pediatrics will likely continue to be a slow process. And while fee-for-service will also continue as value-focused initiatives grow and evolve, it’s important for physicians to use all the tools available to support patients as best as they can.

“You have to realistically live in both worlds and make sure that right now, what aligns is what's good care for the patient,” said Dr. Bernstein. “That needs to coincide with a good and livable practice for the physician. Everything should go together and make sense, and not be at the expense of one another.”   

Learn more with the AMA about value-based care, including ways to improve data sharing and best practices for payment methods.