Pediatric hospitals face numerous challenges in a healthcare industry that is rapidly moving towards payment based on achieving quality outcomes rather than unit of service. Currently, pediatric hospitals must manage the health of a high-risk population having complex medical needs with no central data collection, no outcomes measures, and 51 different Medicaid programs attempting to define care and payment.
A model to address the challenges pediatric hospitals face in coordinating care
Patrick Magoon, President & CEO, Robert H. Lurie Children’s Hospital of Chicago presented a model to transform pediatric care to employees of Intelligent Medical Objects, Inc (IMO) at a recent company meeting. The model involves a collaboration of providers and community agencies, governed by a lead entity, which receives a care coordination payment with a portion of the payment at risk for meeting quality outcome targets within its population.
Below are the transcriptions from Patrick Magoon's presentation at IMO:
Caring for a high risk population that drives Medicaid spend
“Forty percent of the kids in our beds would be categorized within clinical risk groups six through nine,” explains Magoon. “These are the kids with very complex congenital problems. If they survive, they have long, expensive lives to care for.” Funding is predominantly provided by Medicaid.
“These kids represent 6% of all pediatric Medicaid recipients in Illinois, and they drive 30% of all Medicaid spend,” he said. “Nationally they represent 6% of all children, driving 40% of all Medicaid spend.” It’s a very expensive category to treat.
Collaborating to establish a national responsibility and designated network
Fifty-one children’s hospitals in the U.S. have been working for three years to convince Congress to establish a designation of children’s hospital networks to take national responsibility for managing these children. Lurie Children’s Hospital, led by Magoon, has been part of this effort. The hospital recruited over 70 ancillary providers, including Federally Qualified Health Plans, Community Mental Health Organizations and a variety of physician groups, who could form a network to provide coordinated care for 20,000 children in the Chicago area.
Magoon explains the difference between Medicaid and Medicare, and the need for a designated entity to manage the pediatric population. “Under Medicare, you have quality indicators, national data collection, quality and outcomes expectations, and one program no matter where you are in the country. Under Medicaid, you’ve got 51 programs, no central data collection, and no outcomes measures,” he said. “This makes it difficult to treat a child who is a Wisconsin Medicaid patient in Illinois.”
Currently, the large number of Medicaid programs and lack of data sharing and outcomes measures makes it difficult to perform longitudinal analysis of the use of resources and actuarially project costs for the pediatric population.
Saving Medicaid $13 billion over ten years
Magoon, working with Dobson DaVanzo & Associates, has determined that they can save the federal government $13 billion over ten years by having a designation to mange the pediatric population. His plan is to start by providing coordinated care to 20,000 children in the Chicago area, and then extend this model across the country.
“All of my counterparts are suffering through this same kind of challenge,” he explains. “If you look at our future, we’re going to be paid for how effectively we manage a population of kids.”
Coordinating Care Across the Enterprise
The technology exists to help Magoon meet this challenge. “We need to develop a data link with our partners, a way to connect and share clinical information,” says Magoon.
He gives an example of what Lurie Children’s Hospital has been doing and the hurdles faced. “We have been implementing the Epic Community Care program with 130 pediatric practices across Chicago,” says Magoon. Several groups have come together to form a super group. “One practice has 6 pediatricians and they all have different definitions in how they describe care. They all order lab tests differently and call different medical imaging studies by different names,” he explains.
IMO’s dictionaries and vocabularies facilitate data sharing in the Epic system, and support approximately 85% of all electronic health record (EHR) systems in use in the United States. In addition IMO’s clinical and computer scientists have developed a host of solutions including a telehealth platform designed to import biometric data from telehealth devices into the electronic health record for real time monitoring and management of children with disabilities. Technologies like IMO’s are a key part of the solution to providing coordinated care.
Trying to aggregate data and coordinate across settings while evaluating the spend over time in order to determine the efficiency and effectiveness of care delivery can seem a daunting challenge. Magoon stresses the importance of relationships in making the model work. “We’re marching down the pathway now to solidify those relationships.”
Protecting the future of research and resources for pediatric care
The success of the pediatric hospital network model could have long-term effects on the future of pediatric care. The children’s hospital group is where 90% of all pediatric research is done across the country, and where half of the national supply of pediatricians and two-thirds of the supply of pediatric specialists are trained.
“If we’re not successful in our mission, all of those resources, all of the benefits of that research, and the training of the next generation of physicians will be severely harmed,” says Magoon. “So it’s our responsibility to do all that we can to put together these networks, to drive value, to keep savings internally, and invest them in our mission.”
“That’s really the challenge we have before us,” he concludes. “How do we make the pediatrician and his office an integral part of everything that happens to the child, no matter where that child is. How do we demonstrate to our payers that we’re effectively managing our pharmacy spend, that the therapies we provide are effective, that we are doing the right thing.”
“It’s a bit of a challenge, but it’s worth doing for the right reasons.”