What’s Happening at Boston Children’s?
December 19, 2010
Posted by chcablogadmin in : ACO Update
With the Federal Healthcare Reform legislation reportedly having been heavily modeled after that passed by the Massachusetts legislature about two years ago, CHCA ACO Update thought it would be helpful to learn about what is happening at Children’s Hospital Boston. Wendy Warring, Senior Vice President, Network Development and Strategic Partnerships, spoke with us about that. What we learned follows.
State leaders have suggested that they plan to introduce legislation proposing substantial payment reform, and it is likely to be in the form of global or bundled payments. While there has been considerable activity by way of hearings on various aspects of payment reform, no policies have been issued, nor have any specific proposals been passed. The Hospital has, nevertheless, taken on a number of initiatives in anticipation of the move to a more value-based purchasing approach by both the State’s Medicaid program as well as commercial payers, to help further improve the cost and quality effectiveness of programs, and to establish and further enhance relationships with referring physician groups, many of whom have taken on risk based arrangements with private payers. Some of the initiatives are structural/operational and some are strategic.
From an operational standpoint, the Hospital is working with several primary care practices on shared savings projects to lower the cost of care for their patients in risk-based products. The practices with which it is working vary in size and the scope of their connection to the Hospital and its physicians, but the shared savings approach is currently driven most aggressively by practices that have accepted risk on at least 50% of the pediatric populations they serve. There is no shared governance structure in place yet, nor is there joint liability for patient care, but affiliation agreements between the Hospital, its physicians and the practices are targeting defined savings and devising management incentives to complete the projects. Not only is the amount of savings achievable a strong factor in the selection of a shared savings project, but the extent to which the project builds a culture of joint accountability is also weighed heavily. Projects in process and under consideration include those that seek to reduce episode of care costs in connection with conditions such as asthma, scoliosis, lipid control, diabetes and appendicitis. More generally, joint projects will continue to pursue reduced ED demand and utilization, as well as inpatient admissions and readmissions.
Work with primary care practices is also focused on developing joint clinical protocols and processes (collaborative care models) and on enhancing connections with established medical homes to evaluate opportunities to improve population health through more advanced use of information systems and joint proactive outreach to specific populations of children. In the area of developing joint clinical protocols and processes, the Hospital is piloting various initiatives that seek to better target (and reduce) the need for subspecialty support (in neurology, cardiology and imaging, for example). In enhancing connectivity, the Hospital has established various mechanisms for electronically pushing information to its referring providers (discharge summaries, ED encounter information and ambulatory subspecialty visit note) and is providing easier access to clinical data through a provider portal and automated link known as the “magic button.” The Hospital and its physicians have also begun to address the plans of certain community based hospitals to form Accountable Care Organizations that accept substantial risk in their payer relationships. It is in discussions with one regarding management of its pediatric programs under some form of sub-capitation, although this is quite preliminary. Concretely, as a benefit to all referring providers who have accepted risk, as of December 1, the Hospital has moved to differential pricing for its community-based satellites, lowering its prices for radiological and ambulatory surgical services by as much as 20%.
On the Medicaid side, the Hospital is working with several managed care plans to improve care coordination and efficiency of care for their predominantly Medicaid membership; the background is agreement that lowering the cost of caring for Medicaid members is essential to sustainable reductions in rates and prices. Based on shared data analysis, the plans and Hospital are likewise focused on projects that target areas of significant expenditure with feasible alternative care strategies—e.g., the reduction of emergency department visits, including improved management of asthma-related ED visits and the cost of care for high-risk asthma patients. They are also pursuing administrative simplifications to remove these costs. Specific savings targets have been set in association with each project.More strategically, the Hospital is planning, in concert with at least one Medicaid managed care plan, to present the MassHealth (Medicaid) program with options to move fee for service pediatric patients, including high risk patients, into the managed care plans. Not only would this simplify the program administratively, but it will allow the Hospital, its physicians, and the health plans to introduce complex care management protocols that target a segment of the Medicaid pediatric populations with the highest medical expenditures. In accepting the management of some risk, it will also align financial incentives among the health plans, physicians and the Hospital.
The following are among some of the additional structural initiatives that are under way:
- Building a data warehouse – Blue Cross claims data have already been loaded. The Hospital is in the process of loading claims data from other payers and network partners.
- Exploration of methodologies for managing high risk populations.
- Study of and experimentation with bundled payments – The Hospital is evaluating the time and cost involved with craniofacial treatments covering the period from initial assessment to the end of treatment. Further, the Hospital has experience with global payments for care provided to international patients and is evaluating if it is adequately accounting for costs and risks associated with caring for such patients.
- Creation of a team to evaluate innovative payment models.
- Installation of shared savings programs with primary care physicians that incentivize them to redirect care to community hospitals when appropriate (this falls under both the structural/operational and strategic categories).
Editor’s Note: We plan to continue visiting with other hospitals over the coming months to inform you about what they are doing to prepare for and assume leadership in the emerging pay-for-performance environment. Based on all of the initiatives under way at Children’s Hospital Boston, we plan to talk with them again in a few months to learn of and report on what we know will be good progress on the initiatives outlined above.
You may also access the newsletter (ACO Update_12-20-10) as a document to print and share within your hospital.
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