Pediatric ACOs The Characteristics of Pediatric Populations and Their Impact on ACOs

Presented by Deborah Wells The opinions expressed in this presentation are mine and do not necessarily represent the opinions of the Children’s Hospital of Philadelphia

Factors for ACO Success  Improve chronic disease management  Treat populations of patients using evidence- based standards  Provide the full continuum of healthcare services  Have the support of a highly-motivated national payer with 50 million enrollees

“…the needs of individual patients are substantially shaped by life stage…” Eileen Salinsky

Children Are Not Small Adults AdultsChildren Primary Care Treatment and management of chronic diseases Focus on prevention Admission Diagnoses Heart disease, diabetes, pneumonia, stroke Newborn births, mood disorders, asthma, injury PhysiologyStable physiologyMaturing physiology Life stageSickest population is the elderlyFirst year of life especially critical Chronic Conditions Hypertension, diabetes, heart disease, obesity Asthma, behavioral health, obesity, poverty Complex Care Multiple chronic conditions and comorbidities Medically fragile children that have one or more complex chronic condition(s) that affect two or more body systems

Population Distribution AdultsChildren Highest cost patients Multiple chronic conditions such as heart disease and diabetes. With better management patients can drop to the middle tier – often elderly Rare and complex congenital or genetic diseases. Good management can keep them out of the ED and hospital but their conditions are generally life long; newborns with complications Chronic DiseaseLarge population with varying degrees of disease control, big opportunity for cost savings Relatively small population with 1 or 2 chronic conditions, less opportunity for savings Healthy patientsAbout 50% of adults have no chronic condition Most kids, with focus on prevention, growth & development Numbers117 million adults have at least one chronic condition There are 73 million children in the US – less than 20 million with chronic disease Healthy Chronic Disease High cost- high risk Healthy Chronic Disease CSHCN

Pediatric Quality Measures “…simply applying adult indicators to younger age ranges is insufficient.” AHRQ  Fewer evidence-based pediatric standards compared to adult  Difficulty developing standards for small sample sizes  Long lead time for outcomes

Highest Cost Children  Children with Medical Complexity (CMC)  Have multiple conditions affecting multiple body systems  Less than 1% of all children, yet account for over 30% of pediatric health care costs  Children with Special Health Care Needs (CSHCN)  Have or are at increased risk for a chronic physical, developmental, behavioral, or emotional conditions  Premature Infants  1 of every 8 infants born in the United States  Preterm birth cost the U.S. health care system more than $26 billion in 2005

Role of Family  Children depend heavily on their families, young children entirely dependent  When adult care givers fail to provide appropriate care, children cannot provide that care themselves  Need to support siblings of chronically ill children  Family and community factors strongly influence child utilization and health status; risk measured at least in part at the family or parental level

Social Environment  Children live in a different environment than adults and often receive care outside of traditional healthcare settings  Schools  Public Health Clinics  Sports  Summer Camp  Children who use early intervention, public health, and school- based clinics may appear healthier than they are based on provider records influencing risk adjustment

Financial Model  The return on investment for preventative care is long term.  Need larger populations to account for low numbers of children with disease  Prenatal care extremely important – adult care outside ACO sends most expensive patients into ACO  Some ACOs may not have access to specialists or specialized services (e.g. neonatal intensive care) or may not have enough children with a particular disease to warrant including them

Payers  Payers may be reluctant because of the relatively small opportunity for savings  Whereas there are national programs through Medicare for adults, each state’s Medicaid programs are different  Some pediatric ACOs exclude the most medically complex children  Very little is known about actual cost savings or quality improvement under the ACO model since there have been so few of them.

Technology  Customized quality metrics  Adult-focused EHRs  Don’t include documentation for familial factors  Gestational vs chronologic age  Growth and growth charts  Engagement technology  Adolescent privacy

Summary  Medially and socially, children are very different from adults. This differences have a big impact of the design of ACOs.  Population size  Quality metrics  Medically complex children  Availability of specialists  Technology

Questions