By Suzanne Brundage, originally posted on www.uhfnyc.org

Most people in the child health community—and almost assuredly all readers of “Say Ahhh!”—are aware of the ways in which children’s health and their use of health care services differ from those of the adult population. Key differences include the prominence of prevention efforts in children’s health, the relatively small proportion of children with high health care spending; and the way in which health care needs differ across childhood developmental stages.

Each of these differences has important implications for measuring the quality of health care, which in turn has ramifications for the structuring of value-based payment arrangements. The transition to value-based payment is at the core of many current health reform discussions, including those focused on improving the Medicaid program in New York, where my work with the United Hospital Fund is focused. Of special note, most discussions to date of value-based payment have focused on managing high-cost conditions that occur most commonly among adults, and far less attention has been paid to how value-based payment arrangements can best meet the needs of children. As I explore in greater detail in the new United Hospital Fund report, You Get What You Pay For: Measuring Quality in Value-Based Payment for Children’s Health Care, this gap should concern us all.

As Tricia Brooks, Senior Fellow at the Center for Children and Families, has noted during our discussions that informed the report, a major challenge for measuring the value of children’s health care is capturing the long-term and multi-system outcomes that result from delivering high-quality care. The most prevalent health challenges for children are often developmental and behavioral in nature. Prevention can have significant health and societal payoffs but can take many years to observe, and the benefits often accrue to sectors outside the health care system, such as education or juvenile justice. How do we begin to measure these outcomes and reward the providers who contributed to them?

While it seems no one has the full answer, there is much we can learn from the innovative payers and providers that already have child-focused value-based payment arrangements underway. The report presents three case studies, from Oregon, Ohio, and Colorado. I’ll offer you one tantalizing detail: Oregon is currently assessing whether Medicaid-serving pediatric primary care providers can and should be held partially accountable for a child’s “kindergarten readiness.”

The takeaways from You Get What You Pay For are focused on things that New York policymakers and stakeholders designing value-based payment arrangements for kids should keep in mind. But they are also applicable to these payment arrangements nationwide.

1. Government and public programs, particularly Medicaid, have historically led in the development and use of children’s health quality measures and have good reasons to continue to do so. New York’s Medicaid program, in particular, has a unique opportunity to ensure that value-based payment arrangements are supportive of long-term health and development in children.
2. New York’s current child health measures, which draw heavily from the Medicaid and CHIP core measure set, are a solid start for thinking about what incentives value-based payment arrangements should include. But high-value care for children goes beyond what is currently measured in the core set. Policymakers and health care leaders should consider establishing a process for adopting more ambitious measures that match its long-term goals for child health and well-being. New York’s Medicaid program can simultaneously encourage the use of quality measures to achieve near-term goals for children’s health, such as reducing unnecessary asthma hospitalizations, and plan to pursue more aspirational goals for children’s health care services, like improving the overall health trajectory of children.
3. Ensuring that children with special needs receive high-quality care amid cost reductions incentivized by value-based payment is critically important—and potentially complex. With regard to value-based payment for vulnerable subpopulations of children, New York’s Medicaid program will need to think through several challenging issues, including sorting through the methodological challenges that may arise when holding providers accountable for outcomes among small subpopulations of children.
4. Given frequent primary care use by children, value-based payment measures could encourage primary care providers to integrate (or actively coordinate) oral health services, behavioral health services, and interventions for addressing social determinants of health. While primary care providers should not be held accountable for problems they cannot fix, such as shortages of specialists, thought should be given to rewarding providers (through incentive measures) for using tested but innovative means to increase access to oral and behavioral health prevention and treatment services.

Certainly, other factors will come to the fore as discussions proceed. But as I argued in a prior 2016 report, Seizing the Moment: Strengthening Children’s Primary Care in New York, we have a momentous opportunity to improve the health and well-being of children through a renewed focus on early childhood development in primary care. In my new report, I point to the potential of value-based payment to be one of the most important ways to embrace this opportunity.

Read You Get What You Pay For: Measuring Quality in Value-Based Payment for Children’s Health Care.