We've seen the tremendous impact better-coordinated, more accountable health care can have in the Medicare program when done right — dropping costs and improving the quality of services for folks older than 65. Can doctors replicate those results when caring for low-income children? Researchers in Ohio set out to answer that question, and the recently released results were somewhat of a mixed bag.
Those involved in the Partners for Kids pediatric accountable care organization — serving some 300,000 Medicaid-eligible kids in the Buckeye State — were able to reduce costs over the five-year study period ending in 2013. Yet, improvements in quality were merely modest, says Kelly Kelleher, M.D., lead author of the study recently published in Pediatrics. Other organizations hoping to replicate some of the success of a program like Partners for Kids may have trouble doing so unless they forge regional partnerships.
"We had really good partnerships with the state Medicaid office and the managed care plans in doing this," says Kelleher, who is also vice president of community health services at Nationwide Children's Hospital in Columbus. "People without those relationships are going to struggle to do this because the margins are a lot narrower with children."
Partners for Kids, which includes some 900 physicians in addition to the sponsoring hospital, tracked quality and costs for its patients between 2008 and 2013. All told, the ACO slowed the rate of cost growth compared with others in the market at just $2.40 per patient, per year. That's compared to a rate of $6.47 per member for managed care plans, and $16.15 annually for fee-for-service Medicaid patients. One key intervention used to find those savings, Kelleher says, was "aggressive care coordination," embedded within the hospital or clinic. Rather than the typical managed care method of making sure patients take their meds or attend follow-up appointments over the phone, the ACO had care coordinators working within the patient's team of doctors and nurses. "There's a lot more integration," he says.
Also critical was forming tight relationships with obstetrics programs outside of the ACO to improve care before birth and avoid adverse outcomes stemming from early infant deliveries. "Prematurity is a big cost-driver in a pediatric population."
Meanwhile, the quality of care for patients in the ACO stayed relatively flat, based on indicators developed by the Agency for Healthcare Research and Quality. Kelly questions the merits of those metrics, and says those involved with Partners for Kids are aiming to start a national conversation about metrics that gauge quality of life, such as days of school missed, being able to dress themselves, or time spent in a wheelchair. Plus, it's hard to measure quality in a five-year study when a healthy adulthood years later is one of the effort's benefits.
"We're a long-term institution; we've been in the neighborhood for 125 years. We know that the biggest savings are going to be generated down the road, as these kids get older. And so, if we're keeping them healthy now, it's not about short-term savings," Kelleher says.