Why the Future of Value-Based Care Begins with Children's Health

Awareness of the power of investing in children's health

“Children’s health is the most powerful lever we have to influence the health of the next generation, and, ultimately, to influence the economy of this country,” Moss argued.

Improving children’s health will make the lives of the next generation healthier.  

To support this point, Moss discussed the CDC-Kaiser ACE Study, one of the most extensive studies examining childhood adverse childhood experiences (ACEs) and later-life health and well-being. ACEs include instances of abuse, neglect, and household challenges such as incarcerated parents, substance abuse in the household, and emotional and physical neglect or abuse.

"Adverse childhood experiences are comprised of all the bad things that can happen to you in childhood,” Moss noted.

Results from the study showed that almost two-thirds of children had at least one ACE.

“So, we’re not talking about some isolated, disparate, distinct group, or some odd demographic,” Moss pointed out. “This is you and I.”

The results of the study also demonstrated how these early childhood experiences continued to impact health even later in life.

“Compared to those with no ACEs, those with four or more ACEs were twice as likely to smoke, seven times as likely to be alcoholics, six times as likely to have had sex before age 15, and twice as likely to have cancer or heart disease by the time they became adults,” explained Moss.

“These experiences, they change brain neurobiology. They change the cognitive, social, and emotional framework in which people live,” Moss furthered. “They cause risky behaviors to be adopted early in life. They get imprinted for a lifetime, and they cause severe persistent problems throughout the life of the adult.”

Early childhood experiences can impact long-term health, so intervening in childhood and addressing these ACEs early on can eliminate adverse health outcomes in the future, leading to a healthier next generation.

Transform payment models for children's health

The current payment structure for children’s health is unsustainable and does not promote health.

“It is backwards and misaligned," emphasized Moss. "Every day, financial incentives are aligned 180 degrees opposite of where we want to be."

Providers are not paid to promote social interventions or address the social determinants of health in their member population despite outstanding evidence of their impact on children's health. 

A study out of Nemours examined the impact of social interventions on childhood asthma and showed markedly different rates of hospital admissions for asthma-related problems.

“Social interventions work. The complexion of what it meant to have asthma in Delaware markedly changed under the auspice of this study,” explained Moss. “There was no new drug. There was no big biomedical intervention or understanding of physiology or biology that made this change. It was simply an understanding of the context of the disease and a willingness to intervene outside the medical care system.”

Moss further articulated that this work was not done solely with the health system. Partnering with other social organizations helped to promote a community-wide investment towards bettering childhood asthma and helped provide support where Nemours could not.

“Partnerships are absolutely critical. We’re not experts in education, poverty, and all the social issues that are major components of health. We can’t do this stuff,” Moss noted. “We can get the people that can do it together. I believe that’s what health systems should be, at least in the children’s world. We can get the parties in the room and make these things happen.”

Despite the outstanding evidence of the effectiveness of social interventions on better children’s health that Nemours’ asthma research articulated, current healthcare reimbursement does not align with this model. Providers are not incentivized to promote health outside of the health system.  

Research has even shown a return on investment (ROI) for these social inventions. The Abecedarian Preschool Project aimed to demonstrate the benefits of early childhood intervention. According to Moss, the study group was given two meals a day, a snack, periodic basic medical checkups, basic pediatric care, sick and well care, and education around healthy behaviors and lifestyles.

Results from the study showed that children in the intervention group had lower systolic blood pressure, decreased likelihood for hypertension, and no metabolic syndrome. The intervention group also showed improved behavioral outcomes later in life, such as an increased likelihood to exercise regularly and decreased likelihood of smoking. These children also had higher high school graduation rates, were less likely to be convicted of a crime or incarcerated, and had a higher median annual income after a 35-year follow-up.

The return on investment calculated from the study was 13 percent.

“If you’re getting 13% a year on your 401K, you’re probably on a beach somewhere,” Moss joked.

Such a considerable financial impact demonstrates the need for the healthcare industry to think creatively about how it pays for children's health.

“Efforts like this are only going to be sustainable when the financial incentives are aligned. Right now, if we do any of this stuff, it’s a cost to the health system. It comes off the bottom line. Not only is there no return on investment, but the better it works, the bigger hit we take financially,” Moss said. “The more effective it is, the more kids we keep out of the hospital, the more kids don’t come into the emergency department, the more it hurts us in the wallet.”

As a result, Moss discussed how Nemours is taking steps to move towards a fully capitated risk model so their health system can heavily invest in the social determinants of health.

“We want to lead the way to the world we want to live in,” he noted.

Part of this transformation requires shifting the way providers define their patient population.   

“When my patient becomes every kid out there, that dictates behavior,” Moss emphasized.

Fundamentally change and expand the definition of health

In addition to transforming the definition of their patient population, Moss argued that the industry needs to redefine what constitutes health.

"We spend about three and a half-trillion dollars annually on healthcare, roughly a fifth of our gross domestic product. Almost every penny of that three and a half-trillion dollars goes towards paying for exactly the opposite of what we want,” he said. “We want health. Instead, we pay for volume and complexity.”

Only about 10 percent of an individual’s health is attributed to the medical care they receive. A majority of one's health is a result of their social circumstance, environment, and behavior, including education, freedom from poverty, safety, and avoidance of adverse childhood experiences.

Moss argued that even if the healthcare system perfects the way it delivers care, that is only a small portion of what actually contributes to an individual’s health.

“We equate health with medical care,” he noted. “We medicalize problems in this country. We’ll spend half a million dollars by the time you hit the ICU, but we won’t spend 20 dollars on housing, an air conditioner, or something that might prevent the problem in the first place.”

Changing the definition of health to include the social determinants of health could radically transform the way care is delivered and the way it is financed.

In Moss' vision for the future, the definition of health undergoes expansion.

“Health will mean more than medical care, and we will address these social determinants of health,” he concluded. “We’re going to be spending a little bit more on children than we spend today, but the overall spending on healthcare goes way, way, way down.”