Utilization Review And Pediatrics: The Shift To Value Based Care

Pediatric free-standing health systems are uniquely different from adult hospitals not only in direct patient care delivery, but in a variety of ways bearing on the business end of providing health care. As the landscape of reimbursement has consistently changed over the years, so too have the ways in which we view utilization review and management. Many of the underlying standards and principles of efficient utilization review for hospitals is underpinned by the Centers for Medicare and Medicaid Services (CMS). While there are certainly some children insured by Medicare and some insurers who adhere strictly to Medicare practices, there are profound differences.

Managed Care Organizations (MCOs) most often are contracted to provide administrative support as well as to assist those enrolled in meeting necessary health maintenance standards, disease management and overall coordination of care. Government funding of children’s healthcare is dominated by state Medicaid plans. The Utilization Management team on the payer side seeks to manage costs, while the Utilization Reviewteam on the hospital side is focused on ensuring full reimbursement at the correct level of care. As pediatric hospitals are some of the last remaining recipients of fee for service (FFS) contracts, the focus of interactions between the two sides of this equation has been around medical necessity, determinations of approved days, countering denials with appeals and working to ensure all clinical information is transmitted successfully between the two sides.

As the environment of health care reimbursement has already shifted for adult hospitals, pediatric health systems are moving more fully into value-based care, which will significantly impact the way in which Utilization Management is conducted. Payment models are moving through upside risk, shared savings and into full capitation. Along with thosechanges comes the need to look at care differently – to shift from acute episodic care and to focus more intently on illness prevention and health maintenance. In pediatrics, this is starkly different than adult medicine. Children’s health is more often negatively affected by congenital illnesses, environmental factors beyond the patient’s control and accidents/trauma. Movement away from the hospital and into primary care results in a more holistic view of child and family. While congenital illnesses cannot be changed, some common consequences of pediatric chronic illnesses can be impacted.Pediatric health care is uniquely positioned in many ways to support and manage these changes. For example, the American Academy of Pediatrics has published standards for well child visits, immunization schedules and screenings, such as for lead levels at prescribed intervals. These frequent contacts with primary care also have a desired benefit of detecting sequalae of illnesses, other diagnoses and new issues early in the child’s course. Other aspects of pediatrics makevalue-based care a bit more difficult, such as social determinants of health that impact not just the patient but the entire family.