How Provider Relationships Shape VBC Pediatric Quality Measures

If value-based care in pediatric healthcare truly is the future of value-based care, payers need to leverage strong provider relationships to establish effective pediatric quality measures in order to improve their pediatric value-based care performance, Horizon’s executive vice president for healthcare management and transformation Allen Karp illuminated.

Over six in ten adults across 25 states have reported having at least one adverse childhood experience (ACE), according to the Center for Disease Control. Nearly one in six adults had experienced four or more ACEs. 

These environmental factors have the potential to orient the child toward poor health decisions for the rest of their life, leading to conditions such as heart disease and depression. ACEs also end up costing billions of dollars in healthcare spending.

Horizon, a Blue Cross Blue Shield company located in New Jersey, responded to these statistics with a new pediatric value-based care model. As a result, over the past five years, the company has seen an influx of providers taking on more risk, including downside risk.

But in order for Horizon to establish quality measures for a value-based care system in pediatric healthcare, it needed to have strong relationships with their providers.

To achieve that level of trust and cooperation, payers must offer three assets to the payer-provider relationship, Karp shared in an interview with Health Payer Intelligence.

First, payers must share data. This is not new information for most payers, but different payers will accomplish data-sharing in different ways.

For Horizon, having a health information exchange (HIE) has been key to effective data-sharing for the pediatric value-based care program. Not only does the payer allow providers to see claims data, but it also allows providers to access more clinical information on each patient through the HIE.

In addition to the HIE, the Horizon analytics team creates reports for providers, which can be specified based on provider inquiries, allowing them to drill down on the information that will best support their pediatric value-based care. These reports are shared with providers each month and a Horizon team walks through the data with each provider to ensure it is comprehensible and actionable.

“Effectively, what we're trying to do is create decision support systems for our physicians, so that they have all the information they need to make those decisions. And again, we have the capability to drill down and give them any additional information that they request,” Karp explained.

“We feel that data integration and data sharing is critical for physicians to be able to operate under these value-based programs. Without the information, it's very difficult to make any change.”

Second, payers must offer incentives for the provider to hit the payer-established pediatric quality metrics.

For Horizon, the pediatric value-based care models operate on shared savings upside risk payment models.

That being said, the payer has established what it calls a “pathway to risk,” which aims to move more providers into downside-risk payment models over time.

When a provider has been in the upside-risk pediatric value-based care program for a certain amount of time, the payer can start to ease providers into downside-risk value-based contracting. They do so by putting about a five percent downside-risk corridor on the total cost of care.

“We want to walk before we run, and we want them to understand what they need in order to be able to manage that risk going forward,” Karp clarified. “We effectively are on the journey with the physicians. We provide the support for them and we want to be sure that they can handle the risk.”

At times, however, the state gets in the way of providers being able to move into risk arrangements. Usually, the organized delivery system (ODS) license is only for full risk arrangements, but Karp finds that it still slows the process down.

Lastly, payers must allow for provider input, particularly for activities like setting quality measures for the pediatric value-based care program as opposed to the adult value-based care program.

Horizon invited provider input in three primary ways.

To kick off the value-based care program, the Horizon team put together a panel of local providers, hospital administrators, and Horizon representatives. This was essential to gaining provider buy-in on value-based care with the payer. 

Horizon also created service teams that now meet with the physicians on a quarterly basis to share and discuss population health data. This opens up a conversation about the opportunities and gaps in care.

Horizon’s annual value-based provider conference allows providers who are engaged in the Horizon value-based care program to see a population health perspective of their role.

With these three assets in place and a trusting relationship with their providers, Horizon was able to work with its network to establish attainable, meaningful pediatric value-based care program quality measures. 

What payers have to recognize when shifting their pediatric healthcare programs into a value-based contract is that there are key differences between adult and children quality measures, explained Karp.

“We have a separate value-based care program for pediatrics and adults because, obviously, the quality metrics are different and the cost is different,” Karp explained.

“It is a shared savings upside program, where we have the quality metrics services screen, and then if the quality metrics are hit there is an additional payment, over and above what they would get on a fee for service level, to incentivize the physicians to both hit quality metrics and provide affordable care by hitting cost targets,” Karp continued.

When the payer released its value-based care program results in December 2019, its report focused on three provider-supported quality measures: immunizations, weight counseling, and weight monitoring.

“We focused on these measures because we want to ensure that the children in our program are getting the appropriate vaccines to prevent diseases, as well as caring for children that are high risk and need more complex care,” Karp mentioned. “We also worked with our physicians, as we did for the adult value-based programs, to get their input as to the appropriate quality measures that would drive towards better quality, lower cost.”

But these are not the only quality measures that Karp relied on to ensure that the program is achieving its intended purpose. 

Providers also directed the payer to look at metrics surrounding asthma and chronic acute conditions, such as upper respiratory illnesses.

For Horizon, the impact of building a trusting provider relationship and reforming its definition of quality measurements for pediatric value-based care has led to a positive return on investment.

“We have seen a significant reduction in cost. We have seen an improvement in the quality metrics, which we reported on,” Karp concluded. “We have been able to, in addition to just the financial arrangements, be more aligned with outcomes versus just the number of visits.”