Pediatricians partner with hospitals for value-based models

When Jason Vargas, MD, first moved to the Phoenix area 13 years ago, he found an atmosphere of distant relationships between general pediatricians like him, subspecialists, and hospitals. Getting patients a referral to a subspecialist could take months, and communication among providers was often weak, Dr. Vargas said.

Today, things are vastly different thanks in large part to the clinically integrated network of which Dr. Vargas and 950 area providers are a part.

^{Courtesy Dr. Vargas}

Pediatrician Dr. Jason Vargas visits with a patient as his Glendale, Ariz. practice. Dr. Vargas' small practice is part of a clinically integrated network with 900 other providers in his area.

Phoenix Children’s Care Network (PCCN), established in 2014, coordinates health care across multiple providers and settings in the Phoenix area, including half of all general pediatricians and 80% of pediatric subspecialists practicing in Maricopa County. The network is a value- and risk-based system that provides financial incentives to participating providers and health systems that meet established quality metrics. Patients have access to 950 providers within the network, including primary and specialty care sites of service, urgent care locations, surgery centers, and Phoenix Children’s Hospital.

Meanwhile, 2,000 miles away, another unique payment model is changing the way pediatric care is delivered in the Columbus, Ohio area. Partners For Kids (PFK) is a pediatric accountable care organization (ACO) that coordinates care between Nationwide Children’s Hospital and more than 1,000 doctors. Through its 20-year evolution, PFK has successfully assumed full financial and clinical risk for children under age 19 enrolled in Medicaid managed care. This means PFK is responsible for paying for the costs of all patient care, no matter how much or where that care occurs.

The two models illustrate how pediatricians are affiliating with value-centric networks while keeping their independence, said Timothy Johnson, senior vice president of pediatrics at Valence Health, a consulting firm that helps health providers transition to value-based care.

With MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) “it’s going to be difficult for individual pediatricians to do what is required in a value-based medical system because they just don’t have the resources,” Mr. Johnson said in an interview. “That doesn’t mean they can’t be independent. It means they are going to have to band together in some way, whether with a health system, with other practices. It is extremely important for pediatricians to start thinking about how to do that.”

Going from splintered to unified

Like most communities, care delivery in the Phoenix area was relatively fractured prior to 2014. To bring everyone together, Phoenix Children’s started with community outreach and education.

Mr. Chad Johnson

Along with building trust among providers, project leaders had to overcome operational hurdles. This included creating a process for 110 practices to collectively negotiate contracts, operate under a new structure, and adhere to quality metrics, he said.

“Operationally, you have to take 110 different ways of doing things and try merge them into one common way as you develop these new contractual risk-based models,” he said. “At the same time, we had to transition people away from what they were used to as a purely fee-for-service model. It was a very big operational transition.”

To bolster engagement by community pediatricians, PCCN developed a physician-governance approach, assigning participating providers leadership responsibilities. Participating physicians then worked to create the benchmarks by which doctors are measured against. To date, provider performance is tracked against 14 primary care and 34 specialist metrics encompassing engagement, safety, quality, and transparency.

PCCN leaders also had to ensure that participating in such a network was beneficial for busy doctors, said Dr. Vargas, who is chair of the PCCN Network and Utilization committee and a member of the network’s board of managers.

Asking physicians to change their framework, track patient data, and meet metrics, all while potentially losing money if they fail to hit benchmarks is not the most popular proposition, he said. So PCCN created advantages for member doctors, such as nighttime pediatric triage, a negotiated discount for professional services, IT support, streamlined access to specialists, and more avenues to communicate with subspecialists.

“With so many schedules, professional, and academic pressures on our daily professional lives, we have wanted to make sure that there were practical value added benefits to members,” he said. “I think right now that the benefits outweigh the administrative burdens.”