CHAPTER 12

Population Health for Pediatricians

Michael Weiss, DO, FAAP

Population Health: What and Why?

Population health has been defined in many ways. In simple terms, population health is about keeping a defined population healthy through proactive, preventive measures that minimize fragmented, inefficient care and improve clinical outcomes while reducing the overall cost of care.

During pediatric training and throughout their career, pediatricians appropriately spend most of their time developing and refining the knowledge and technical skills required to provide high-quality care to patients. Pediatricians learn about disease, enhance communication skills, and learn procedures, such as endotracheal intubation, lumbar puncture, and intravenous catheter placement techniques.

Over the past 3 to 4 decades, increasing emphasis has been placed on understanding how effective and efficient our delivery of health care is and how we measure these outcomes. This new focus filters down to frontline pediatricians, who must develop a clear understanding of much more than clinical care. Pediatricians need to understand health care payment methodologies, clinical quality metrics, care model design improvements, and care coordination programs. A fundamental understanding of these concepts is now a vital component of successfully caring and advocating for infants, children, adolescents, and young adults. This chapter reviews some of the main population health concepts and facilitates the successful navigation of the complex health care system, helping pediatricians provide improved care for their patients and families.

In the frequently quoted works, To Err Is Human and Crossing the Quality Chasm, the Institute of Medicine (now known as the Health and Medicine division of the National Academies) brought to light the prevalence of preventable medical errors and the disparity in quality of care across the United States. These reports estimated that 44,000 to 98,000 preventable deaths annually at a cost between $17 billion and $29 billion attributable to lost income and additional care necessitated by errors. Further, Institute of Medicine concluded that “The U.S. health care delivery system does not provide consistent, high-quality medical care to all people.” In 2009, Atul Gawande, MD, MPH, a Boston-based surgeon and health policy researcher, published “The Cost Conundrum,” in which he brought to light the wide variation in health care spending and outcomes across the United States. For 1 region in south Texas, he pointed to nearly double the national average per-capita spending on health care with no demonstrable improvements in quality versus the rest of the country. This, along with data from the Commonwealth Fund (Figures 12.1 and 12.2), brought to the public eye that the trajectory of health care spending in the United States was unsustainable and, more importantly, that patients were not receiving better-quality care as a result of the spending. Subsequently, the notion of the Triple Aim of better health for populations, better care experiences, and lower per-capita costs was introduced by the Institute for Healthcare Improvement (and more recently enhanced by others to become the Quadruple Aim by adding joy of practice). The concept of accountable care organizations then evolved from the Patient Protection and Affordable Care Act. This framework has served as the template for population health work across the country, in which the focus is on caring for populations of patients with proactive, team-based care, using accurate and timely data to effect positive clinical and service-based outcomes (see Chapter 21).

Figure 12.1. Growth in health spending as a share of the economy.

Reprinted with permission from Lambrew JM. Getting ready for health reform 2020: what past presidential campaigns can teach us. The Commonwealth Fund website. www.commonwealthfund.org/publications/fund-reports/2018/jun/getting-ready-health-reform-2020-presidential. Published June 26, 2018. Accessed August 22, 2019.

Figure 12.2. Health care system performance compared with spending.

Reprinted with permission from Schneider EC, Sarnak DO, Squires D, Shah A, Doty MM. Mirror, mirror 2017: international comparison reflects flaws and opportunities for better U.S. health care. The Commonwealth Fund website. www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-2017-international-comparison-reflects-flaws-and. Published July 14, 2017. Accessed August 22, 2019.

Health Care Payment Methodology and Practice

A basic understanding of the funding stream for the care patients receive is an important step toward improving quality, care coordination, and clinical outcomes. By far, the largest payers for children’s health care in the United States are Medicaid and the Children’s Health Insurance Program (CHIP), which cover nearly 30 million and 9 million children, respectively. Children qualify for the programs based on the income level and the number of members in their family. Qualifications vary by state and are usually based on a percentage of the federal poverty level. CHIP serves as a supplement to assist those families who may not qualify for Medicaid. Coverage for basic care, called early and periodic screening, diagnosis, and treatment, or EPSDT, such as immunizations, developmental screening, and health maintenance visits, is mandated by these programs.

Private insurers make up most of the remaining payers. Private payment may occur through a preferred provider organization (PPO) or a health maintenance organization (HMO). With a PPO plan, patients are usually able to access any health professional covered by their insurance without the need for a specific referral that would be reviewed for clinical necessity in an HMO. High-level procedures and interventions may still require approval before they can be completed (eg, magnetic resonance imaging scans, surgeries). In an HMO plan, patients are encouraged to access their chosen or assigned primary care professional (PCP) for most conditions. If the PCP believes specialty care is required, an authorization request is generated and reviewed by the health plan for medical necessity before the patient can access the specialty care. Much debate exists over the preferred approach, as each has positive and negative components. The PPO provides more freedom of choice and ease of access, while the HMO creates an accountability and actionable data stream to the PCP of who serves as the medical home for patients. Data from regions where HMOs have been prevalent for some time show that quality and cost containment are enhanced in the HMO environment.

Within these insurance coverages there are also a variety of methods whereby payment to health professionals and hospitals can be made. In the traditional approach, known as fee for service, a health professional is paid based on a prearranged fee schedule for each encounter that occurs. Bundled payments, which are less common in pediatrics (particularly in the ambulatory setting), are set payments that are made for episodes of care. For example, for a joint replacement procedure, a bundled payment would include preoperative evaluation, surgery (including any required hardware), and postoperative care, including physical therapy and any durable medical equipment.

In the new accountable care paradigm, models involving population-based payment, also known as capitation, are much more prevalent. In these models, health professionals are paid a fixed per-member, per-month fee for caring for their patients. One advantage of this methodology is that patient attribution is very clear (addressed later in this chapter). Regardless of the number of times a patient is seen, the monthly payment for services is fixed. This model is aligned with population health principles in that prevention and proactive care are emphasized to create better quality and keep health care costs in check. In these models, services such as immunizations, mental health, and injectable medications are often carved out of the monthly payment and paid for on a fee-for-service basis due to the high cost involved.

As a complement to these payment methodologies, especially with a population-based payment approach, value-based care is being universally incorporated. This usually involves additional financial incentives for demonstrating clinical quality outcomes and appropriate resource use for a defined population for which the health professional is responsible. (Quality metrics are explored later in this chapter.)

The bottom line for pediatricians is to take the initiative to recognize the specifics of how their population of patients is being funded and implement strategies to ensure clinical and operational success. This understanding allows pediatricians to provide the best possible care for patients, advocate for appropriate and comprehensive pediatric-specific insurance coverage, and meet the business requirements of a practice.

Understanding Quality Metrics

Defining clinical quality in medicine has been a long-standing challenge. It has been defined as identifying the correct diagnosis and initiating appropriate treatment that results in resolution of the condition. It has also been defined as the receipt of a prompt appointment with the physician of choice in a friendly, welcoming environment, followed by timely communication and follow-up. Both outcomes are part of the quality spectrum because clinical success and service excellence are dually important.

The other challenge has been how to identify pediatric- specific metrics that are clinically meaningful and objectively measured, and which interventions by the physician responsible for the patient can effect positive change. Measures have evolved over time from process focused to outcome focused, with new emphasis on patient-reported outcome measures (Table 12.1). Clearly, the emphasis of various interventions is on the ultimate benefit to the patient, rather than completion of the intervention itself.

Abbreviations: CAHPS, Consumer Assessment of Healthcare Providers and Systems; EHR, electronic health record; Hb, hemoglobin.

There are several evidence-based, nationally accepted pediatric Healthcare Effectiveness Data and Information Set (HEDIS) measures that are endorsed by the National Committee for Quality Assurance, National Quality Forum, Pediatric Quality Measure Program, and others. Each measure shares a similar format that includes a description of the clinical issue being addressed, patient inclusion and exclusion criteria, and documentation and coding requirements (Table 12.2). These measures are often part of value-based payment programs sponsored by health plans and organized medical groups and, in the information superhighway era, may be cited in the public domain to compare physicians, hospitals, and medical groups to national or local benchmarks.

Quality metrics are not without limitations. For almost every measure there are certain nuances that may pose potential challenges. For example, in the Appropriate Treatment of Children With Upper Respiratory Infection (URI) measure (see Table 12.2), a child may be seen by the primary care physician, diagnosed with a viral URI, and appropriately not given an antibiotic. Later the same day, the family may seek care by another primary care physician, who prescribes an antibiotic, and the child is now viewed as out of compliance with the measure. The physician with accountability acted appropriately but does not receive the correct credit for doing the right thing.

A second general category of quality metrics revolves around appropriate use of clinical resources. Measures in this domain typically include the frequency of emergency department (ED) visits, use of high-cost imaging studies (ie, magnetic resonance, computed tomography), or inpatient admissions for so-called ambulatory- sensitive conditions. For instance, ED visits for asthma may be preventable if a child is appropriately prescribed an inhaled corticosteroid, educated on proper spacer use, and given an asthma action plan. Appropriate resource metric results are typically compared with regional or national benchmarks.

Another category of quality metrics revolves entirely around patient and family experience (previously referred to as patient satisfaction). Typically, patients receive a written or telephone-based survey to assess the perceived level of care they received. The standardized Consumer Assessment of Healthcare Providers and Systems Clinician and Group (CG-CAHPS) survey is most commonly employed. Questions cover multiple domains that address service, timeliness of care, communication, and shared decision making. A representative CG-CAHPS question is: “Did your provider explain things in a way that was easy to understand?”

Greater emphasis in this area is demonstrated by the fact that most value-based programs include patient and family experience as up to 30% of the overall rating of a health professional.

Understanding these metrics, how they can be used to improve care, and how to address the technical and operational challenges associated with them is now an imperative for pediatricians in all disciplines. These metrics have additional utility, as they relate to office-based quality improvement activities and Maintenance of Certification.

Care Coordination Fundamentals

In 1967 the American Academy of Pediatrics first described the notion of the patient-centered medical home. Subsequently, in 2007, a joint statement endorsing the medical home concept was published by the American Academy of Pediatrics, American Osteopathic Association, American College of Physicians, and American Academy of Family Physicians. The patient-centered medical home concepts were updated in 2017 (Box 12.1). Cooley et al cited enhanced pediatric medical home capabilities as a harbinger of improved quality and lower cost of care. With the increasing demands of electronic health records (EHRs), quality metric performance, and other administrative duties, understanding and implementing appropriate care model design principles into one’s practice is a necessity. Four such concepts are patient attribution, risk stratification, use of data and analytics, and the care team.

^a Codes subject to change; current as of 2020.

Abbreviations: ED, emergency department; HEDIS, Healthcare Effectiveness Data and Information Set; ICD-10-CM, International Classification of Diseases, 10th Revision, Clinical Modification; URI, upper respiratory infection.

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