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Value-based collaboration: partnering with networks, ACOs.

When Jason Vargas, MD, first moved to the Phoenix area 13 years ago, he found an atmosphere of distant relationships between general pediatricians like him, subspecialists, and hospitals. Getting patients a referral to a subspecialist could take months, and communication among providers was often weak, Dr. Vargas said.

Today, things are vastly different thanks in large part to the clinically integrated network of which Dr. Vargas and 950 area providers are a part.

"I've never had as close of a relationship with subspecialists as I do now," said Dr. Vargas, who practices in Glendale, Ariz. "A great side effect of creating this network is that the professional dialogue we have allows for better communication. The sort of relationships that are fostered make our lives easier, help make patient care better, and will pay dividends ultimately."

Phoenix Children's Care Network (PCCN), established in 2014, coordinates health care across multiple providers and settings in the Phoenix area, including half of all general pediatricians and 80% of pediatric subspecialists practicing in Maricopa County. The network is a value- and risk-based system that provides financial incentives to participating providers and health systems that meet established quality metrics. Patients have access to 950 providers within the network, including primary and specialty care sites of service, urgent care locations, surgery centers, and Phoenix Children's Hospital.

Meanwhile, 2,000 miles away, another unique payment model is changing the way pediatric care is delivered in the Columbus, Ohio area. Partners For Kids (PFK) is a pediatric accountable care organization (ACO) that coordinates care between Nationwide Children's Hospital and more than 1,000 doctors. Through its 20-year evolution, PFK has successfully assumed full financial and clinical risk for children under age 19 enrolled in Medicaid managed care. This means PFK is responsible for paying for the costs of all patient care, no matter how much or where that care occurs.

The two models illustrate how pediatricians are affiliating with value-centric networks while keeping their independence, said Timothy Johnson, senior vice president of pediatrics at Valence Health, a consulting firm that helps health providers transition to value-based care.

With MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) "it's going to be difficult for individual pediatricians to do what is required in a value-based medical system because they just don't have the resources," Mr. Johnson said in an interview. "That doesn't mean they can't be independent. It means they are going to have to band together in some way, whether with a health system, with other practices. It is extremely important for pediatricians to start thinking about how to do that."

Going from splintered to unified

Like most communities, care delivery in the Phoenix area was relatively fractured prior to 2014. To bring everyone together, Phoenix Children's started with community outreach and education.

"From the very first, there was an engagement of the community, because we're only going to be successful if we do it together," said Chad Johnson, PCCN senior vice president and executive director. "Then it was really getting together a core group of pediatricians, some subspecialists, and some hospital folks to talk about, 'What does this mean? And how can we come together to share common values and common goals?' There was a lot of coming to the table to share ideas."

Along with building trust among providers, project leaders had to overcome operational hurdles. This included creating a process for 110 practices to collectively negotiate contracts, operate under a new structure, and adhere to quality metrics, he said.

"Operationally, you have to take 110 different ways of doing things and try to merge them into one common way as you develop these new contractual risk-based models," he said. "At the same time, we had to transition people away from what they were used to as a purely fee-for-service model. It was a very big operational transition."

To bolster engagement by community pediatricians, PCCN developed a physician-governance approach, assigning participating providers leadership responsibilities. Participating physicians then worked to create the benchmarks by which doctors are measured against. To date, provider performance is tracked against 14 primary care and 34 specialist metrics encompassing engagement, safety, quality, and transparency.

PCCN leaders also had to ensure that participating in such a network was beneficial for busy doctors, said Dr. Vargas, who is chair of the PCCN Network and Utilization committee and a member of the network's board of managers.

Asking physicians to change their framework, track patient data, and meet metrics, all while potentially losing money if they fail to hit benchmarks is not the most popular proposition, he said. So PCCN created advantages for member doctors, such as nighttime pediatric triage, a negotiated discount for professional services, IT support, streamlined access to specialists, and more avenues to communicate with subspecialists.

"With so many schedules, professional, and academic pressures on our daily professional lives, we have wanted to make sure that there were practical value-added benefits to members," he said. "I think right now that the benefits outweigh the administrative burdens."

A changing payer relationship

As a network, PCCN works with payers to assume the risk that insurers have historically taken. Payers continue to handle the administrative and billing side of the equation, while the network controls the medical management and care coordination of the patient population, Mr. Johnson said.

"We feel we can do it much more efficiently, much more effectively, and we feel it's better care for the patient when we're the one controlling that," he said. "The insurance companies don't disagree."

The network partners with Medicaid and commercial payers and has a direct-to-employer agreement with a major employer in conjunction with an adult partner system /network. Early performance efforts by the PCCN have been rewarded by shared savings disbursements from two payers, according to PCCN officials. The network has also met or exceeded state Medicaid pediatric quality targets and consistently contained medical expenses below expected medical cost trends for its managed pediatric populations.

Building a population health model

For more than 2 decades, PFK in Ohio has taken a novel care delivery approach that has focused on value and community partnerships.

Back in 1994, Nationwide Children's Hospital partnered with community pediatricians to create PFK, a physician/hospital organization with governance shared equally. Today, PFK has assumed full financial and clinical risk for pediatric managed Medicaid enrollees, and is the largest and oldest known pediatric ACO.

But the organization was not successful overnight, said Sean P. Gleeson, MD, PFK president. "Within the organization, there has been really a long-term leadership team that has been committed to the model and committed to population health. This type of a model doesn't deliver immediate success. It's a long-term proposition."

A key hurdle was collecting timely, complete, and accurate data for the patient population, Dr. Gleeson said, adding that working with data and understanding changing trends is an everyday challenge. Interacting with busy physicians and securing their time and cooperation also has been an obstacle.

"The lessons learned for us is that we really need to approach them understanding that there is a limited amount of time that practices can invest in infrastructure or invest in the processes of care," he said. "We have to approach things knowing that [doctors] are going to struggle with the amount of time necessary to engage in large projects, so it needs to be chopped up into bite-sized pieces that they can consume on the run, so they can keep their practices running well."

PFK efforts have paid off in terms of lowering costs and improving care. Between 2008 and 2013, PFK achieved lower cost growth than Medicaid fee-for-service programs and managed care plans in the Columbus, Ohio, area (Pediatrics. 2015 Mar;135[3];e582-9).

Fundamentally, the model has remained the same over the years, Dr. Gleeson said, but in 2005, PFK made the decision to expand and take responsibility for all the Medicaid-enrolled children in the region.

"It really gives a much broader field of view and perspective on patients in the region," he said. "We know that they are all our responsibility so we take more of a population health type of approach, working with any physician who is caring for those children."

Guidance for other practices

Dr. Gleeson encouraged other pediatricians interested in transitioning to value-based care to start by evaluating their data. Take a hard look at the quality of care you provide and begin to measure it, he said. For smaller practices, consider joining a larger group or network that will allow pediatricians to engage in collaborative work, he added.

Dr. Vargas stressed that change is coming whether pediatricians are prepared or not. Aligning with the right partners will be the difference between sinking or staying afloat in the value-based landscape.

"Payers are moving toward value-based models, and it is not practical for the general pediatrician to be able to provide the infrastructure and professional resources necessary" he said. "To maintain our professional livelihood as independent pediatricians, and to continue to provide the individually crafted, quality care our families are accustomed to, we will have to align ourselves with organizations that value the experience and insight of the independent pediatrician to deliver that care."

agallegos@frontlinemedcom.com

On Twitter@legal_med

Caption: Dr. Jason Vargas

Caption: DR. GLEESON

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Author:Gallegos, Alicia
Publication:Pediatric News
Article Type:Report
Date:Oct 1, 2016
Words:1549
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