The Pediatric Accountable Care Organization: Incentivizing a Family-Centered Approach

Mother and Child (Robert Bevan, 1894)

Late last year, the American Academy of Pediatrics (AAP) issued a report recommending that pediatricians screen new mothers for postpartum depression during the 1-, 2-, 4-, and 6-month well baby visits.  Most pediatricians believe that screening for postpartum depression is within the scope of pediatric practice, because “[a]ddressing maternal depression in a timely and proactive fashion is essential to ensure healthy early brain and child development and readiness to succeed.”

There has been some debate about whether such screening is reimbursable.  The AAP believes that it is (or should be) and recommends that pediatricians seek reimbursement using “[t]he Current Procedural Terminology (CPT) code 99420 [for "Administration and interpretation of a health risk assessment instrument"] … recognizing the [Edinburgh Postpartum Depression Scale (a 10-question screen completed by the mother)] as a measure for risk in the infant’s environment, to be appropriately billed at the infant’s visit.”

Because it would be integrated into a reimbursable well visit, and because of the limited amount of time it takes, reimbursement concerns may not be an insurmountable barrier to postpartum depression screening.  (Even more streamlined than the Edinburgh Scale is a two-question screening tool that, while not specifically designed for use with new mothers, has proved effective at identifying postpartum depression.  The two questions are as follows: “Over the past 2 weeks: 1. Have you ever felt down, depressed, or hopeless? 2. Have you felt little interest or pleasure in doing things?”  Answering yes to one or both of these questions is a positive screening result.)

When the screening identifies a potential problem, though, reimbursement concerns likely are a formidable barrier to treatment delivery.  The AAP acknowledges that pediatricians are not qualified to treat postpartum depression (and many mothers might not want them to in any event) and recommends that pediatricians refer new mothers with positive screening results to qualified providers and other resources in their community.  This recommendation is a good one, as far as it goes, and probably all that can be expected in our current fragmented healthcare system, but it is a long way from ideal, whether you put yourself in the shoes of the provider– or the family.

Shenzhen International Garden and Flower Expo Park, image by Veipaofms

Might the much-talked-about accountable care organization be a means to the end of fairly compensating pediatricians and their staff for the hard work entailed in quickly and seamlessly moving mothers into care?  Just as Section 3022 of the Patient Protection and Affordable Care Act allows adult medical providers to form ACOs for the purpose of receiving incentive payments tied to savings to Medicare, under Section 2706 states can allow pediatric medical providers to form ACOs to receive payments tied to savings to Medicaid.  While the AAP claims that “[g]reater savings are found in managing care for adults and not children[,]“ Nationwide Children’s Hospital in Columbus, Ohio, the “largest pediatric accountable care organization in America,” disagrees, claiming that “[p]ediatrics offers perhaps the biggest opportunity to bend the long-term cost curve in health care.  While the savings may be less immediate, there is evidence that many of the pervasive, and costly, chronic diseases of adulthood can be successfully prevented in childhood, for example obesity.”

Providers establishing pediatric ACOs will need to confront a number of pediatric-specific structural issues.  As Mark Waxman and Larry Vernaglia point out in a recent Health Law Reporter article, while “children grow out of childhood and, therefore, potentially the [pediatric ACO] structure[,]” many conditions are “best treated by the same team over the life of the individual.”  In addition, “pediatric populations do not exist in vacuums; generally, they live in families and these families also receive medical care.  A [pediatric ACO] may need to coordinate closely with an ACO that provides care to the entire family.  … For example, if wellness programs were targeted at the whole family (e.g. nutrition, exercise, environmental, etc.) they likely would be more effective than if they address the child in isolation.”  Postpartum depression is just one of many conditions that call for care coordination not just on the patient’s behalf but also on the patient’s family’s behalf– and pediatric ACOs should be structured with this in mind.

PPACA and the Growing Shortage of Pediatric Subspecialists

Photo by roen via Flickr

Over the course of this year, a spate of articles and op eds have highlighted a growing shortage of pediatric subspecialists.  Earlier his month, Amy Mansue, CEO of Children’s Specialized Hospital here in New Jersey, addressed the problem in a very interesting post on the National Association of Children’s Hospitals’ With All Our Might blog.  Ms. Mansue describes a recent visit to Capitol Hill during which she discussed the implementation of the Patient Protection and Affordable Care Act, explaining to the staffers that:

[t]he differences between strategies to address the needs of the newly insured children versus strategies to address the needs of adults couldn’t be more different.  Start with the basic fact that there is a critical shortage of specialists in pediatrics, where the biggest issue facing adults is how to access primary care. There can be a utilization of physician extenders in the short run until more primary care physicians are trained; there is no similar ‘quick fix’ in pediatrics.

Pediatric neurologists and developmental-behavioral pediatricians are in especially short supply.  A survey of children’s hospitals conducted by the National Association of Children’s Hospitals and Related Institutions in December 2009 revealed average wait times of 9 weeks for an appointment with a pediatric neurologist and 13 weeks for an appointment with a developmental-behavioral pediatrician.  An earlier study published in Pediatrics found that, in addition to enduring long waits, parents and children also travel long distances to see these specialists–on average 73 miles to see a subspecialist in neurodevelopmental disabilities and 44 miles to see a developmental pediatrician.

This is concerning for a host of reasons, including the importance of early, appropriate intervention to the future success of children with developmental delays.  As I discussed previously here and here, the “right” medical diagnosis can be key to accessing needed services, as can a thorough written evaluation and a doctor willing to advocate on a child’s behalf.  This is true whether a family is fighting for publicly-provided disability benefits or special education services or to get a private insurance plan to pay for medically necessary therapies.

What explains the subspecialist shortage?  As Ms. Mansue puts it, “it is all about math.  There is no incentive to go through an additional decade of training to get paid less than what a pediatric nurse practitioner is now demanding in my home state of New Jersey.”  Congress has tried to change the equation.  PPACA provides for loan forgiveness of up to $35,000 per year for up to three years for pediatric subspecialists who “work for a provider serving in a [Health Professional Shortage Area] or medically underserved area, or among a medically underserved population that has a shortage of the specified pediatric specialty and a sufficient pediatric population, as determined by [HHS], to support the specified pediatric specialty.”  But funding for this measure has not yet been appropriated.  The federal government has also attacked the problem through its Children’s Hospitals Graduate Medical Education Payment Program, which provides funding for specialty training for pediatricians.  According to a recent New York Times op ed, however, this program’s funding is also uncertain, suggesting that an end to the shortage of pediatric subspecialists may not be in sight.