Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina.
Duke Department of Pediatrics, Duke University, Durham, North Carolina.
JAMA Netw Open. 2023 Aug 1;6(8):e2327264. doi: 10.1001/jamanetworkopen.2023.27264.
Despite momentum for pediatric value-based payment models, little is known about tailoring design elements to account for the unique needs and utilization patterns of children and young adults.
To simulate attribution to a hypothetical pediatric accountable care organization (ACO) and describe baseline demographic characteristics, expenditures, and utilization patterns over the subsequent year.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used Medicaid claims data for children and young adults aged 1 to 20 years enrolled in North Carolina Medicaid at any time during 2017. Children and young adults receiving at least 50% of their primary care at a large academic medical center (AMC) in 2017 were attributed to the ACO. Data were analyzed from April 2020 to March 2021.
Primary outcomes were total cost of care and care utilization during the 2018 performance year.
Among 930 266 children and young adults (377 233 children [40.6%] aged 6-12 years; 470 612 [50.6%] female) enrolled in Medicare in North Carolina in 2017, 27 290 children and young adults were attributed to the ACO. A total of 12 306 Black non-Hispanic children and young adults (45.1%), 6308 Hispanic or Latinx children and young adults (23.1%), and 6531 White non-Hispanic children and young adults (23.9%) were included. Most attributed individuals (23 133 individuals [84.7%]) had at least 1 claim in the performance year. The median (IQR) total cost of care in 2018 was $347 ($107-$1123); 272 individuals (1.0%) accounted for nearly half of total costs. Compared with children and young adults in the lowest-cost quartile, those in the highest-cost quartile were more likely to have complex medical conditions (399 individuals [6.9%] vs 3442 individuals [59.5%]) and to live farther from the AMC (median [IQR distance, 6.0 [4.6-20.3] miles vs 13.9 [4.6-30.9] miles). Total cost of care was accrued in home (43%), outpatient specialty (19%), inpatient (14%) and primary (8%) care. More than half of attributed children and young adults received care outside of the ACO; the median (IQR) cost for leaked care was $349 ($130-$1326). The costliest leaked encounters included inpatient, ancillary, and home health care, while the most frequently leaked encounters included behavioral health, emergency, and primary care.
This cohort study found that while most children attributed to the hypothetical Medicaid pediatric ACO lived locally with few health care encounters, a small group of children with medical complexity traveled long distances for care and used frequent and costly home-based and outpatient specialty care. Leaked care was substantial for all attributed children, with the cost of leaked care being higher than the total cost of care. These pediatric-specific clinical and utilization profiles have implications for future pediatric ACO design choices related to attribution, accounting for children with high costs, and strategies to address leaked care.
尽管儿科基于价值的支付模式势头强劲，但对于如何针对儿童和青少年的独特需求和利用模式来调整设计要素，人们知之甚少。
模拟一个假设的儿科责任医疗组织（ACO）的归属，并描述随后一年的基线人口统计学特征、支出和利用模式。
设计、地点和参与者：本回顾性队列研究使用了北卡罗来纳州医疗补助计划（Medicaid）在 2017 年期间的儿童和青少年（1 至 20 岁）的索赔数据。2017 年至少有 50%的初级保健在一家大型学术医疗中心（AMC）接受的儿童和青少年被归属于 ACO。数据分析于 2020 年 4 月至 2021 年 3 月进行。
主要结局是 2018 年绩效年度的总医疗费用和医疗利用情况。
在北卡罗来纳州参加医疗保险的 930266 名儿童和青少年（6-12 岁的儿童 377233 名[40.6%]；女性 470612 名[50.6%]）中，有 27290 名儿童和青少年被归属于 ACO。共有 12306 名非裔美国儿童和青少年（45.1%）、6308 名西班牙裔或拉丁裔儿童和青少年（23.1%）和 6531 名白人非裔美国儿童和青少年（23.9%）被包括在内。大多数被归属于 ACO 的个体（23133 人[84.7%]）在绩效年度至少有 1 次索赔。2018 年的医疗总费用中位数（IQR）为 347 美元（107-1123 美元）；有 272 人（1.0%）几乎占总费用的一半。与医疗费用最低四分位数的儿童和青少年相比，医疗费用最高四分位数的儿童和青少年更有可能患有复杂的医疗状况（399 人[6.9%]比 3442 人[59.5%]），并且离 AMC 更远（中位数[IQR 距离，6.0[4.6-20.3]英里比 13.9[4.6-30.9]英里）。总医疗费用发生在家庭（43%）、专科门诊（19%）、住院（14%）和初级（8%）护理。超过一半的被归属于 ACO 的儿童和青少年在 ACO 之外接受了护理；漏报护理的中位数（IQR）费用为 349 美元（130-1326 美元）。最昂贵的漏报治疗包括住院、辅助和家庭保健，而最常漏报的治疗包括行为健康、急诊和初级保健。
这项队列研究发现，尽管大多数被归属于假设性的 Medicaid 儿科 ACO 的儿童居住在本地，医疗保健次数较少，但一小部分患有复杂疾病的儿童长途跋涉寻求医疗服务，频繁且昂贵地使用基于家庭和专科门诊的医疗服务。所有被归属于 ACO 的儿童都有大量的漏报护理，漏报护理的费用高于总医疗费用。这些儿科特定的临床和利用模式对未来儿科 ACO 的设计选择具有影响，包括与归属、为高成本儿童提供护理以及解决漏报护理的策略有关。
