Health Network by Cincinnati Children’s is putting a new spin on an old idea – capitation – and using it to better serve high-risk pediatric patients in southern Ohio.
The recently launched community-based network (HNCC) of physicians, health providers, and social service providers focuses on specialized case management for low-income children. Nonphysician members at the accountable care organization include nurses, social workers, mental and behavioral health care specialists, and community health workers.
Lawrence Rosser
Dr. Colleen Kraft is medical director of the Health Network by Cincinnati Children's, an accountable care organization for at-risk children in Ohio.
"We can make those staff available to anyone that our physicians or providers see as somebody who needs some sort of help, whether it’s medical or social," Dr. Colleen Kraft, HNCC medical director, said in an interview. "The real success of the network is in the connection and relationship with families to get them to resources that help their child and prevent high-cost care."
HNCC, which started in July 2013, serves Medicaid families in eight Ohio counties and has nearly 35,000 members, 150 of whom are enrolled in high-risk case management. The network contracts with two Ohio Medicaid insurers, Paramount and Molina Healthcare – also called managed care organizations (MCOs) – to provide case management for complex patients. Any practice that accepts Paramount or Molina has access to the network’s services, whether it is a Cincinnati Children’s hospital practice, a private practice, or a federally qualified health center.
The network receives a global, capitated fee for each child in the MCO plan to spend on medical management. While a capitated payment model is nothing new, the way in which the network uses the dollars is unique, Dr. Kraft said. Traditionally, MCOs provide capitated payments to physicians for face-to-face patient care. HNCC concentrates its funds on medical management. Paramount and Molina Healthcare contract separately with physicians for payments.
"The biggest difference with this model is we are not responsible for physician payment," Dr. Kraft said. "We’ve contracted for those medical management dollars, and we’re doing our own care management for these families and building of [care] teams. There’s a lot of interaction between our vulnerable families and our care managers, and we’re able to help them navigate the health care system."
The network’s relationship with primary care providers plays a central role in the system’s success. It’s no secret that doctors are often frustrated with Medicaid’s low payments and the red tape and hassles the system brings, Dr. Kraft said. For physicians, network advantages include more feedback about cases, broader coverage of treatments, and the potential for bonuses.
HCNN uses part of its funding to provide bonuses for physician practices that see a high number of Medicaid patients. The network provides $2 per member, per month in incentive payments for all health network patients in a practice, well over what Medicaid pays, Dr. Kraft said. In addition, physician administrators and case managers regularly contact and discuss cases with physicians, said Dr. Camille Graham, HCNN’s executive community physician liaison and a Cincinnati-based pediatrician in private practice. “From the outset, the network was determined to partner with primary care physicians in a meaningful way,” she said. “With most insurance companies, the primary care physician doesn’t receive any feedback about case management other than: The case was closed, there was no response, or we’re continuing (management). With the network, there’s more of a dialogue about what’s working and what’s not working with this family.”*
HCNN has the ability to pay for services that traditionally would not be covered by Medicaid, Dr. Kraft said. Administrators conduct utilization management reviews for referrals in which they evaluate the need of items such as durable medical equipment and high-cost testing. In a recent case, family members requested an additional gastrostomy tube for their child in case the current tube became unattached. Medicaid would not pay for a second tube, although it would have paid for an emergency department visit if the original tube were to detach, she said. In another case, Medicaid refused to pay for an out-of-network provider to administer an approved medication to a pregnant teenager.
"We can pay for an extra G-tube and save an ED visit for that family," Dr. Kraft said. "We can pay for an out-of-network nurse to give a high-cost medication to a high-risk teenager to prevent a premature delivery. Because we take full risk for the patient, we have the freedom to make decisions that make sense rather than follow strict Medicaid guidelines."
In the event that a requested treatment or test cannot be authorized, administrators search for other services that can support or assist the patient, said Dr. Melodie Blacklidge, HNCC associate medical director. Dr. Blacklidge is charged with evaluating physicians’ requests for tests and procedures that don’t easily fit within Medicaid guidelines.