How Children's Hospitals Can Gain Social Awareness Via ACOs

Five-year-old Jasmine’s family hears from her pediatrician’s office a lot more often than they used to, and they discuss topics ranging far beyond Jasmine’s health and development. That is because Jasmine (a fictional example) sees a doctor in a health network that has a different kind of contract with her insurance provider, designating it as an Accountable Care Organization (ACO), and as a result it takes a broader view of its role in preventive care than most.

Health policy experts anticipate that ACOs will improve population health under the Affordable Care Act, but demonstrating the value of pediatric ACOs remains a challenge. Policy researchers at The Children’s Hospital of Philadelphia are among those leading a public conversation about how pediatric hospitals and health systems can address social factors affecting health within ACO structures, now that some of the first research on the effect of pediatric ACOs on the use and costs of healthcare resources has begun to emerge.

Jasmine’s Story: How Accountable Care Organizations Could Support Preventive Care

Jasmine’s story illustrates both how ACOs work, and the hope for how they could improve population health through prevention. Two years ago, she was admitted to the hospital from the emergency room with a severe asthma attack after her inhaler had run out and her family was temporarily unable to refill the prescription. Now fully recovered from that scare, as a Medicaid-insured patient seeing a doctor at an ACO, she has a case manager who calls her parents on a regular basis. The case manager checks to find out if Jasmine has a fully stocked inhaler, asks about the household’s nutrition and safety, and assists by providing resources to the low-income family to deal with any hardships.

The pediatrician’s office was able to invest in case management services because its contract as an ACO means Medicaid pays for Jasmine’s services at a rate based on the total cost of her care (with added incentives for reducing the health network’s overall average costs). The idea is that the time the case manager spends supporting Jasmine’s preventive care not only keeps Jasmine healthy and out of the hospital, but is less expensive than paying for that avoidable hospital stay. This contrasts with the usual insurance payment model in which Medicaid pays a health network specific reimbursement fees for specific approved services, which would not include a case manager and many other non-biomedical supportive services.

New Research Shows Value of a Pediatric ACO

However high the hope that ACOs should work just as in Jasmine’s example, there is not yet much data on whether they are having their intended effect in terms of costs of healthcare resources and care quality improvement for children. So far, most data about the impact of ACOs (which do show success in cost savings) focus on older adults with chronic conditions receiving Medicare. That is beginning to change, with a new study published in JAMA Pediatrics from researchers at Children’s Hospitals and Clinics of Minnesota.

“We found this study really exciting because while there has been a lot of interest in ACOs, there’s been little research on the value of pediatric ACOs,” said Maggie Eisen, MLSP, MSS, a project manager in PolicyLab at The Children’s Hospital of Philadelphia, co-author of an editorial accompanying the study.

In their commentary, Eisen and her co-author, PolicyLab Director David Rubin, MD, MSCE, continued the study authors’ discussion about how pediatric hospitals and health systems can take social factors affecting children’s health into account as part of their care, especially within an ACO structure. The study itself demonstrated that children who received care from the Minnesota health system’s ACO overall required fewer resources and less spending for inpatient care, but participation in the ACO declined over time — by half after one year, and by 70 percent after two years.

How Pediatric Hospitals in ACOs Can Address Social Determinants of Health

The authors acknowledged the study was not designed in a way that could identify why patients dropped out of the ACO, and it did not collect data about social determinants of health in this population. They raised a question of whether health systems could achieve further cost reductions by improving patient retention in an ACO with strategies that take social factors into account.

“It is important they acknowledge that things that happen outside the walls of a hospital really have an impact of what happens inside the hospital and an ongoing impact on lives of children once they’re discharged,” Eisen said.

If hospitals and health systems wish to begin to identify the causes of gaps affecting usage of preventive care, Eisen and Dr. Rubin wrote, then data collection about social factors will be essential. The data could guide what prevention services the providers offer and how they target them to keep patients engaged.

“As children’s hospitals and health systems organize into accountable care organizations, the implication is that they will need to develop strategies to address social factors that impact a child’s care,” said Dr. Rubin, who is also medical director of Clinical Integration in CHOP's Office of Clinical Quality Improvement, and a professor of Pediatrics at the University of Pennsylvania. “That does not mean they will need to go it alone; rather, they will succeed if they can engage community partners who have more experience in addressing social services for families and who are collaboratively willing to address these problems in a much more integrated way,” he added.

Hospitals and health networks may resist implementing many prevention-based social interventions due to concerns over the strength of evidence. Medical-legal partnerships, in which patients or their families are assisted with obtaining needed legal and social services, for example, have positive anecdotal or observational evidence, but few rigorous studies. But when providers and insurance companies are collaborating with a shared commitment to improving preventive care, as in an ACO, they could begin to collect stronger evidence about which interventions work best — the kind of rigorous evidence that the Minnesota team was among the first and most prominent to publish.

“We hope that this study will be the first of many that seek to align the evidence of public health interventions with value propositions as we move toward improving quality in integrated health care delivery,” Dr. Rubin and Eisen wrote.