Background
Stakeholders in Allegheny County, Pennsylvania, proposed to develop a new pathway for Medicaid payment reform that improves the quality of care for medically complex children while reducing the overall cost of that care. Through this process, a set of replicable methods and strategies that other stakeholders can use as a roadmap for designing, implementing, and evaluating similar and/or related payment reforms were demonstrated and documented.
Healthcare Challenge
Recent payment reform efforts have given rise to promising models for improving the value of health care. Yet little is known about which payment approaches can best address the unique challenges of caring for our most vulnerable populations. From 2012 through 2015, stakeholders in Allegheny County, Pennsylvania, developed a new pathway for Medicaid payment reform that improved the value of care for children with medically complex conditions.
Goals
The goal was to see if this project could improve the value of care for UPMC for You children with medically complex conditions. The project was successful at meeting that goal, as well as reaching other process markers of success related to stakeholder engagement, shared decision making, institutional change and improved care coordination.
Implementation Approach
The UPMC High Value Care for Kids model was facilitated within UPMC's integrated delivery and financing system with the leadership and resources of these partners:
- UPMC for You, the largest Medicaid physical health managed care organization (MCO) in the region
- Community Care Behavioral Health Organization, the behavioral health MCO for all Medicaid recipients in Allegheny County
- Children's Hospital of Pittsburgh of UPMC, the largest local provider of services for children with medically complex conditions
- Children's Community Pediatrics (CCP), a pediatric practice that is an affiliate of Children's Hospital
- General Academic Pediatrics (GAP) in the University of Pittsburgh Physicians group, a pediatric practice
- Families of children with medically complex conditions
This project comprised three components:
- Funding for care coordination and other needed clinical services and shared savings.
- Information sharing and transparency, including reports with service utilization, cost, and quality.
- Consumer-directed accounts to cover nonclinical goods and services that families identified as important to them.
Results
Within the UPMC for You pediatric member population, 10 percent of members who had consistently high costs were identified: about 1,300 children and adolescents with diverse medical conditions in Allegheny County. Of that population, a total of 263 children and youth who were patients at one of four UPMC pediatric practices (three CCP practices and GAP) were identified as the target. It was recognized that this group would present the greatest potential to impact families on a personal level, while also achieving cost savings. Practice-based care coordination deepened the staff's understanding of the unique needs and challenges these families face, such as financial barriers and special accommodations for their child. This understanding, in turn, improved the level of assistance and care given to the child. Families reported that they felt supported by the project. They appreciated the availability of consumer-directed funds for products and services to improve the health and quality of life of their child. Many of these factors helped to reduce parental stress in caring for their child and contributed to an overall better quality of life for the family unit.
The financial impact of UPMC High Value Care for Kids was significant: in-patient medical care, emergency department visits, home care, and specialist services saw the greatest reductions in cost. There was an annual reduction of 9.1 percent in overall expenditures.
This project was successful in demonstrating and documenting a set of replicable methods and strategies to be used by other stakeholders as a roadmap for designing, implementing, and evaluating similar value-based payment models. Learn more about these strategies and methods below.