Children's Hospitals Today - Summer 2016 - 6

hospitalrounds TRANSFORMING CARE Learning in a pediatric Medicaid ACO Here's how one hospital is adapting to a value-based environment. By Eric Christensen, Ph.D.; Pamala VanHazinga, B.S.N., MBA; Eric Solnitzky, B.A. T o move costs toward a sustainable model of value of care over volume of care, Children's Hospitals and Clinics of Minnesota participated in an accountable care organization-like (ACO) demonstration project with the Minnesota Department of Human Services called the Integrated Health Partnership (IHP) since 2013. This opportunity for the hospital to partner with the state would improve the cost and quality of care while building the organization's capacity to succeed in future value-based environments. There are a handful of ACOs for exclusively pediatric populations, like Partners for Kids in Ohio, Texas Children's Health Plan and the IHP in Minnesota. From a quality and financial perspective, the IHP experience has been positive for Minnesota Children's. It achieved shared savings each year and met most of the quality targets, which means it delivered greater value. Impacting utilization IHP is financially responsible to meet cost and quality targets for about 22,000 pediatric Medicaid patients. The state retrospectively attributes patients to health systems based on their health care utilization patterns during the prior year. While the IHP makes informed assumptions about which patients are likely to be attributed to the organization, nothing is certain until the state determines attribution. It's important to note that attribution is not enrollment-attribution is between the state and the health systems. Patients don't know they are part of the project. While that's not ideal, Minnesota Children's is working 6 CHILDREN'S HOSPITAL S TODAY Summer 2016 to change this situation while the IHP continues to operate. The IHP team hypothesized that the longer a patient was attributed to the organization, the more impact it should have on his or her health care utilization. But what does attribution really mean? Patients are attributed if they're in the hospital's health care home, or if they received the majority of their primary care at one of Minnesota Children's clinics. Therefore, a patient's attribution length is a proxy for consistent primary care, which the organization has supported with ambulatory care coordination, implemented in 2013; and an emergency department (ED)/inpatient case management model, which was implemented in 2014. Implications for attribution length The organization found that continuous attribution of more than two years was associated with a 41 percent decrease in inpatient days. Attribution was associated with a 23 percent increase in outpatient visits, 4 percent increase in ED visits, and a 15 percent increase in pharmaceuticals. While the increase in ED visits was disappointing, the outpatient visit increase was consistent with medical home models. The IHP team also examined the impact of attribution length on inpatient readmissions and found longer attribution was associated with a reduction in the patient-level, 30-day readmission rate from 8.9 percent to 6.2 percent. Consistent primary care seems to lessen the likelihood that patients will present to other hospitals' emergency departments where their history is unknown and they are more likely to be admitted. Reducing costs The net effect of these utilization changes was a 16 percent reduction in total cost after two years of attribution. This percentage was impacted by the number of patients' body systems with a chronic condition. There was no savings for those with zero to two body systems with a chronic condition, compared to 33 percent savings for those with three to four, and 25 percent savings for those with five or more systems with a chronic condition. As only about 30 percent of patients remain attributed for more than two years, attribution stability is key. Minnesota Children's approached the demonstration project as a learning lab. The hospital still mostly provides volume-based services, but this project provides an opportunity to strengthen care coordination and analytic capabilities essential for operating within value-based incentives. What the hospital has observed for the Medicaid population is greater than what it may observe for populations with fewer socioeconomic challenges, but it's a place to start and learn how to thrive in a value-based environment. Eric Christensen, Ph.D., is a health economist; Pamala VanHazinga, B.S.N., MBA, is senior director, Clinical Services; and Eric Solnitzky, B.A., is manager, Payer Contracting, at Children's Hospitals and Clinics of Minnesota. Send questions or comments to magazine@childrenshospitals.org. childrenshospital s.org http://www.childrenshospitals.org

Table of Contents for the Digital Edition of Children's Hospitals Today - Summer 2016