Ep. 92: Transforming Pediatrics and Embracing Value-Based Care with Alex Koster

When discussing methods of paying for health care in the U.S., you'll often hear the terms fee-for-service and value-based care. What do they mean? And what value can value-based care models bring to pediatric patients and their families? 

We discuss these questions and more with Alex Koster, Associate Vice President of Value Transformation for Nemours Children's Health. 

Guests:
Alexander Koster, MA, CHCIO, CHD-E, AVP, Value Transformation, Nemours Children’s Health

Host/Producer: Carol Vassar

Views expressed by guests do not necessarily reflect the views of the host or management.

Subscribe, review or let your voice be heard at NemoursWellBeyond.org.

Transcript

VOICEOVER:

Welcome to Well Beyond Medicine, the world's top-ranked children's health podcast produced by Nemours Children's Health. Subscribe on any platform at nemourswellbebeyond.org, or find us on YouTube.

Carol Vassar, podcast host/producer:

Each week, we're joined by innovators and experts from around the world, exploring anything and everything related to the 80% of child health impacts that occur outside the doctor's office. I'm your host, Carol Vassar, and now that you're here, let's go.

Music:

Let's go, oh, oh. Well Beyond Medicine.

Alex Koster, Nemours Children's Health:
There's a lot of economic burden to the overall system that can be mitigated simply by engaging more in prevention and chronic disease management. It has a cascading effect that crosses through a lot of different areas beyond just the dollar spent at a healthcare facility.

Carol Vassar, podcast host/producer:

That’s Alex Koster, Nemours’ Associate Vice President of Value Transformation, making the case for a shift from the traditional U.S. healthcare payment system known as “fee for service” to models that base payment on quality healthcare outcomes, or value-based care. 

The Centers for Medicare and Medicaid Services, CMS, and the states have been trying out and modeling value-based care payment methods for decades. Medicare Advantage, for example? That’s value-based care. But applying value-based care models to the pediatric population looks different than it does for the 65-and-over group, an essential consideration for CMS in terms of Medicaid and for pediatric health care providers like Nemours Children’s Health. 

To learn more about of this, we tapped into Alex’s vast expertise to see how the approach and modeling of pediatric value-based care differs from that for adults, starting with a more in-depth overall definition of value-based care from someone who lives it and breathes it every day. Here’s Alex Koster.

Alex Koster, Nemours Children's Health:

Value-based care involves any of the alternative payment models that focus on value. That is quality, efficiency, access, and cost-effectiveness. So any of the models that reward those things instead of just volume of work, which is what our traditional, what we call fee-for-service model does. So, under value-based care, we actually get financial incentives for improving quality or preventing the need to go to the hospital instead of only receiving a payment for a child who was hospitalized.

Carol Vassar, podcast host/producer:

So it's more of a population health model if you will?

Alex Koster, Nemours Children's Health:

It is, it is a population health model.

Carol Vassar, podcast host/producer:

So capitation model, in many ways, is a value-based-

Alex Koster, Nemours Children's Health:

A capitation model is a value-based model. When the capitation is linked to quality, it really aligns well. So it's not just you're going to get paid a certain amount for a child that belongs to your medical home, but it's also there's expectations around prevention and managing what we would consider preventable utilization. For example, ER visits that didn't need to happen. Making sure people have their flu shots and their well visits, and their developmental screenings. And then when you do end up where, for example, you need to be in the hospital for whatever reason, making sure that we manage that experience both internally with efficiencies, but also handoffs in a way that encourage health. So we make sure that there's a handoff between the hospital and a primary care provider or home health service so a child doesn't need to come back into a hospital with a readmission that could have been prevented. Or, handoffs that allow the child to heal as quickly as possible and return to their real life, school, joy in sports, whatever.

So those models exist, there's a variety of different types of value-based care models. Some basically they add quality onto traditional fee-for-service reimbursement with bonuses for certain quality activities or utilization, all the way through to models where you cannot access shared savings for managing a population or you cannot access the full amount of funding that you're allocated to manage a population unless you achieve certain tiers of quality and prevention.

And Nemours has a variety of these at once. We have an array of different value-based care agreements with insurance companies that span the spectrum of different models. And we have some that apply only to the hospital we have, most of them are for primary care, we have some for commercial insurers, we have many for Medicaid. And we monitor our performance and how we're doing not only on quality, but also managing the costs of those patients.

Carol Vassar, podcast host/producer:

So, this in many ways is a way of taking down the cost but still maintaining or even increasing the quality of care that is provided to children. Is that a fair assessment?

Alex Koster, Nemours Children's Health:

It is absolutely true because cost, ultimately, what we're thinking about is healthcare dollars spent to reimburse for services aren't necessarily linked at all to good quality. You can have very high cost invested in the child because they're not managing their asthma, and they're going to the ER over and over and over again. That means you have high cost, but there's no reflection on quality. The reality is much less expensive medications and the management and ensuring the child is taking their controller medications and following up with someone to confirm that their asthma outbreaks are improving, that's actually much better quality, but it isn't related to higher cost. It actually reduces the cost considerably.

And asthma happens to be an area we focus on a lot because that is in the pediatrics scenario where there's a lot of what we would consider preventable utilization of healthcare services, and it has impacts that generate, I'm going to call it bad dollar spend costs elsewhere. If you have preventable conditions that are not managed, you now have impact on academic performance, on employability, on household stability, not just for the child's future prospects but the immediate prospects for a parent that has to take off and miss work a lot and that might jeopardize their employability. And so there's a lot of economic burden to the overall system that can be mitigated simply by engaging more in prevention and chronic disease management. It has a cascading effect that crosses through a lot of different areas beyond just the dollar spent at a healthcare facility.

Carol Vassar, podcast host/producer:

This makes so much sense to anyone who's ever worked a budget and ever had a sick child. What are the barriers that prevent us from getting to a fully value-based kind of system or series of models across Nemours and across the healthcare system?

Alex Koster, Nemours Children's Health:

So across Nemours, a lot of it is related to readiness to deal in pediatrics with value. We are not necessarily front and center, nationally, of healthcare focus and nor percentage of spend.

Carol Vassar, podcast host/producer:

Pediatrics, you mean?

Alex Koster, Nemours Children's Health:

Pediatrics, and so a lot of the models that exist, are well-evolved for the Medicare population and are being invented for pediatrics. And so we still get, I'm going to call it, contract templates from insurance companies that are like, this is a standard contract we use, and half the metrics will be adult, or they won't factor in specifics around pediatric. Our highest cost conditions, in terms of dollars, are not within the realm of immediate preventability.

It's not to say that society couldn't do things to prevent them, but children who are born prematurely, you get them at the point of birth. Preventability exists with the parent, like how could we intervene before they're born to see if we can reduce prematurity or low birth weight? Children who develop different cancers, who have very lengthy hospitalizations, or children who need transplants, or children who are born with cerebral palsy or conditions like that. The way you manage those is around the experiences that they get within this high-acuity setting. Can you address efficiencies in a health system? Can you improve handoffs to reduce readmissions? But ultimately, that area of spend is not what I'd call traditionally preventable within how we think of an annual contract cycle.

We do have enormous opportunities within other conditions like asthma, like deterioration with diabetes that is not well managed and things like that where we need to focus around those areas because they're heavily impactable by what we do, not only within the health system but with community partners. And we really can drive a lot of improved outcomes through strategies there, but the models weren't designed around that. And so part of it is we have to bring our payers along and propose models that do this.

Now, even within that, there are a lot of opportunities. There are a lot of incentives in quality. Medicaid is making a lot of their increased rates contingent on quality targets or on value programs. So rather than getting just annual increases to your reimbursement, they're saying you will get more dollars if. And helping to partner with the different Medicaid agencies around those models is another opportunity because some of them are very creative. We actually have payers looking at things like incentivizing us to close racial gaps in prevention outcomes. They put their money where the idea is, where the ideals of equity are, and they reward us, and they measure us, and we can measure ourselves. And we have other payers who are looking at ways to incentivize the capture of social determinants information about our patients so that they understand that it adds an administrative burden to a health system to do this work, even though it's absolutely the right work. And they're coming to partner and say, well, we will help offset some of that if you do the work.

And so there are some creative things happening, but we're not as mature as Medicare models that are out there that have been out there for years, where you can measure all of the organizations that participate in certain programs against each other and study successes that now have years of history. We're not there yet, but we're getting there.

Carol Vassar, podcast host/producer:

Is Medicaid the biggest insurer of children in the US?

Alex Koster, Nemours Children's Health:

I believe it is, particularly for newer born, but it is market-specific and community-specific. So we have areas that are 70, 80, 90% Medicaid within our organization. We have areas that are 20% Medicaid within our organization. It depends kind of on the community, the socioeconomic factors there, but we have seen a steady rise in Medicaid populations. With redetermination, it is not clear where we'll land in terms of our payer mix over the next year.

Carol Vassar, podcast host/producer:

What's redetermination?

Alex Koster, Nemours Children's Health:

The federal government had waived renewal requirements for families to qualify for Medicaid. They'd kind of frozen it because of COVID, and that is ending, and so families are now having to redetermine their eligibility. And so states are ending coverage. Different states have different models on how they're doing it, and then the families have to requalify, and it has resulted in a lot of families losing Medicaid coverage, many of which are struggling with the administrative burden of renewal. And so we have amazing folks at Nemours helping guide them through that process to make sure their children will continue to get coverage.

Carol Vassar, podcast host/producer:

So there's another barrier to access right there.

Alex Koster, Nemours Children's Health:

There is. There have been a lot of efforts to try and make it as well communicated as possible, but it is the same story we run into internally seven times, seven ways. You have to keep repeating the message and then, what does this actually mean for me? I thought I just renewed. Well, that's separate from redetermination or do you have access to the right documents, or... We have amazing teams that work with families and work with the state to help.

Carol Vassar, podcast host/producer:

How do you see your role in leadership as a value-based care expert connecting to the idea of well beyond medicine?

Alex Koster, Nemours Children's Health:

There's alignment between economic models that reduce health care cost, and models that actually improve health and well-being long-term. If you can improve a child's health, you're preparing them for success that has impact across a variety of sectors. As I mean, you can see, you can measure the impact. If we can take advantage of the opportunity where we're driving prevention and things that we've thought of historically as being relatively narrow and broaden them to what will make this child or enable them to achieve lifelong health, it's going to bring successes not only to them personally, but to communities, and overall it can really impact so many areas.

So, we think of this as not only working within the walls of our health system but also in schools. What can we be doing with school-based health partnerships with absenteeism interventions? What can we be doing with food to support children there? We are probably mitigating future healthcare problems as we're engaging in things that are happening actually outside of our walls. So, our future in this journey really lives outside of the walls of our facility for most kids. Whereas within the walls of our facilities, we're treating those who need it the most from a medical perspective. And so it's really about reassessing what it means to be promoters of health. And it's a different answer for different communities and different populations and different settings, but it's really shifting our eyes a little bit away from our feet and towards the windows and outside. And then figuring out what are the best levers that we can pull, whether it's through direct service activities, through investments, or through partnerships with communities, to meet needs? And if we do that, we'll find a lot of those things that cascade.

So you have economic burden on a family caused by a parent who can't hold a job because they're having to take off all the time to take care of a child. Or the sibling, this is one we've run into a lot in our school-based work, siblings are missing school because they have to take care of younger siblings because the parent cannot take off work. So, if we can help that younger sibling and then facilitate that older sibling to be able to stay in school and be academically successful, we have now created two points of success out of what was one point that was impacting a whole household with barriers.

And the opportunities are there, the key is can we craft the economic stories to create funding streams to support it? Can we craft the clinical, I'm going to call it the extension of a clinical pathway which happens inside of a setting of care, and translate into a population model where we hand off that child that just received the best treatment in an ER and say, and this is how we're going to help you be successful when you leave so you don't come back? So that's where we are. That's what I do with data and helping imagine possibilities with other leaders across the organization. It requires a lot of data. It requires a lot of integration of information that lives in silos.

Carol Vassar, podcast host/producer:

And a lot of good data.

Alex Koster, Nemours Children's Health:

It requires a lot of good data, which requires a lot of strong processes. We have to do things the same way so we can capture information.

And then we have to teach other sectors. So, one of the things we are able to provide when we partner with school districts the most is data expertise. As much as we have healthcare expertise about children, we also have data expertise that they don't necessarily have on, this is how we might measure the impact of some of these programs. How we might relate the presence of a wellness center at a school to improved academic performance for children that were at risk. The impact of integrated behavioral health on missed days. We already have data that shows the impact of missed days on academic performance. What happens if we're making an investment in behavioral health? Can we correlate that to that reduction in missed days to that improved academic performance? So those are some of the areas we're looking at. There's many, many others, and we're lucky at Nemours, we have experts in just all kinds of different areas who come together to figure out what we can do.

Carol Vassar, podcast host/producer:

It's all in the data, isn't it?

Alex Koster, Nemours Children's Health:

It's in the data, but it's also in the imagination. I think we cannot downplay the impact that being imaginative with models and creative with services and finding those levers beyond, again, our own feet, our own two walls. Where is it that we can impact and make that big difference? And listen to the communities we serve because they may only answer, they may have the answer, and if we listen with humility, we can be taught where we can be most impactful. And then we can apply our resources towards success, and success builds on success. You end up creating and infusing the whole health system with energy when you bring those success stories back, it kind of creates catalysts for additional creative thinking and energy in the care teams. It's wonderful to see what happens when you bring back success stories.

Carol Vassar, podcast host/producer:

Do you have any success stories that you can share?

Alex Koster, Nemours Children's Health:

I know we have a care coordinator who supports our school-based health programs in Delaware. His name is Dwayne. He has been able to reach out to families whose children are missing a lot of school. Based on new programs we have where we're getting alerts for absences, and he's been able to connect families who are running into transportation problems getting their kids to school with services. He's been able to connect families with behavioral health support for their children who are missing school because of some behavioral health concern, anxiety, or stress, or depression that the child simply needed support with. He's been able to connect people with community resources that might help them with a social need that was really the reason for the attendance decline. Even when we thought we were looking for traditional healthcare issues, what we found is social needs are such an overwhelming part of the barriers that families are facing and he's been able to help broker support.

And so I would say he is, and that model is a success story. He is the bringer of the success stories individually, and to be able to tell of his successes is what energizes others, that these models can be applied elsewhere and bring benefit. And so an individual family we're impacting, but we're able to harness that across a variety of different opportunities to see if we could scale this type of program elsewhere and help even more children.

Carol Vassar, podcast host/producer:

So it's that creativity combined with that data and that information-

Alex Koster, Nemours Children's Health:

Exactly.

Carol Vassar, podcast host/producer:

... that you spoke about.

Alex Koster, Nemours Children's Health:

There it is, and you have to be willing to fail and sometimes say, this didn't work.

Carol Vassar, podcast host/producer:

Right, and reassess and maybe-

Alex Koster, Nemours Children's Health:

And move on.

Carol Vassar, podcast host/producer:

... rejigger and move on.

Alex Koster, Nemours Children's Health:

There you go.

Carol Vassar, podcast host/producer:

I'm going to ask you three questions. It might be repetitive from what you've already spoken about, but there's a method to my madness. So, what barriers have you seen firsthand among patients and their families that prevent them from obtaining the full potential of their children in terms of health and wellbeing?

Alex Koster, Nemours Children's Health:

A lot of it comes down to the impact that poverty has on household stability. So children benefit from stability, and when you don't know where you're going to sleep, or the act of trying to survive economically requires a lot of nighttime hours and interruption to sleep patterns, or a lot of instability, that creates uncertainty and stress in that child. It creates a compounding effect of a physiological impact of that stress, combined with the psychological impact of the uncertainty on children, and that has a burden. It translates into medical conditions that we can track and monitor. So if we can support families and kind of alleviate some of those external pressures, it will have an effect on the health and wellbeing of the children.

Carol Vassar, podcast host/producer:

Second question. How do the teams that you lead demonstrate going well beyond medicine to create the healthiest generations of children?

Alex Koster, Nemours Children's Health:

We are a support function, so my teams deliver data, they deliver Epic configuration, they deliver template optimization, and things like that. It's their willingness to support where the need is. And so where we collaborate and partner and share resources with the idea team to work on equity and disparities and to help understand where there might be gaps that could be addressed with more partnerships with communities and with different populations. Again, that's outside of medication dosing and it's outside of diagnostic validation and things like that. We're really trying to understand our communities better because that is beyond the medicine side.

We are looking at projects to help enable all of our families to take advantage of digital healthcare. What would happen if we could empower everyone to take advantage of patient portals, of telehealth, of remote monitoring by meeting their need in a care management context to be digitally ready to take advantage of these other tools? So in a way, it's applying kind of a medical care management model, but actually to digital readiness. So we're assessing not just, do you have allergens in the home that are triggering asthma? We're assessing, do you have internet access that would allow you to take advantage of telehealth at the same time? So we actually have, one of my teams is actually working on that, and it's a partnership between multiple departments at Nemours to see what could we do.

It's even a partnership where we learned a lot from our cell phone vendor at Nemours that configures our cell phones. We got on a call with them, and they taught us an enormous amount that we didn't know that we can apply, being imaginative towards care for patients and families so they can take advantage not only of digital healthcare but also of home education opportunities. If you don't have internet for a telehealth visit, you don't have internet to do schooling from home. Let's say you are bound to home. So, we're exploring that as well.

Carol Vassar, podcast host/producer:

One more question. When it comes to the social determinants of health, what do you see as the biggest barriers and the biggest opportunities?

Alex Koster, Nemours Children's Health:

The workflow development and resourcing of effective social determinants screening and intervention is a large task, and it is a task you don't get right the first time. And so we have implemented screening in primary care in the Delaware Valley. We just did, I think, 55,000 children screened this year in primary care in the Delaware Valley. It is live in the hospitalist program in Orlando. They have fascinating findings in Orlando from that program. But scaling it is complicated because it does require new workflows, it requires new job roles, it requires new tools. And so applying scale is a barrier.

Broader than that, we know that us intervening, we're trying, again, applying a medical model, we're trying to fix what's broken, and ultimately the path to true transformation, to true well beyond medicine is, don't have things break. And so we have to make sure that as we gather information about what is not working for families or where their barriers are, we take advantage of that not only on the individual member intervention where we're helping someone, again, something that's not working well, but also holistically and say, this is what we've learned from the population, from the everyone, and therefore, this is what we think could be done whether it's on our own through investments or through partnerships, through advocacy, through lobbying through legislation. This is where we think the most effective system intervention would be to prevent the breaking. And so that's part of designing models to do that where you can back up with evidence, the recommendations and the proposals and the plans so that they get funded or they get the resourcing they need. It's very deliberate. It is not something you're just going to do.

And I think Nemours has expertise that positions us well in that area, and we're already applying lessons learned at a variety of levels, but it's not simple. And unfortunately, a lot of the entities that show all of the barriers, they don't collaborate between each other. So state agencies between education and health, and criminal justice and education and health, and the welfare system, criminal justice education, all of them one part of the data and part of the picture of what's happening as barriers. Or, even when we're beyond the socioeconomic realm, when we're looking at populations that maybe don't have the same economic barriers, but we're only looking at the health system, the fragmentation still stands in the way of optimal care.

Carol Vassar, podcast host/producer:

Alex Koster is Nemours’ Associate Vice President of Value Transformation.

Music:

Well Beyond Medicine.

Carol Vassar, podcast host/producer:

Thanks to Alex for joining us on this episode, and thanks to you for listening.

From policy to patient stories, we cover it all. Is there something you'd like to hear more about in an upcoming podcast episode? Let us know by visiting nemourswellbeyond.org and leaving us a voicemail. While you're there, please be sure to subscribe to the podcast and leave a review. That's nemourswellbeyond.org.

Our production team for this episode includes Cheryl Munn, Susan Masucci, Lauren Teta, and Steve Savino. Join us next time as we talk about health equity and what it looks like from the point of view of a healthcare system in Chicago. I'm Carol Vassar. Until then, remember, we can change children's health for good, Well Beyond Medicine.

Music:

Let's go, oh, oh. Well Beyond Medicine.