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1 News Articles, Private Payer Advocacy, Administration/Practice Management, Billing & Coding Chapter leaders offer advice on how to help shape new payment models by Jonathan Price M.D., FAAP Payments to physicians increasingly are shifting from fee-for-service (volume-based) toward value-based and other alternative models. The AAP encourages pediatricians to be involved in the design of these models and their evaluation and improvement. One way pediatricians can speak with one voice is through their chapters and pediatric councils, which engage with state Medicaid plans and commercial payers on coverage and payment issues. In the following Q&A, Ohio Chapter President Michael A. Gittelman, M.D., FAAP, and CEO Melissa Arnold share their experiences in engaging payers on coverage for pediatric services, alternative payment models, quality improvement (QI) and value. Q: About 18 states involve commercial insurance payers and Medicaid plans in alternative payment models involving nearly 3,000 primary care practices via Comprehensive Primary Care Plus (CPC+). This model pays for case management and quality and uses flat payments to improve services. How did the Ohio Chapter get involved with your state at the beginning of the design process to represent pediatric concerns about potential problems and unintended consequences of CPC+? Arnold: We are fortunate that Ohio Medicaid Medical Director Mary Applegate, M.D., FAAP, is a med-peds specialist. It was actually the state that approached us for input. Q: What advice would you give a chapter that isn't so connected with its state's Medicaid leadership? Arnold: A chapter should make contact every time there is a new Medicaid director and create a relationship with that person. Over time, you have to work to establish your relationships and credibility. The AAP also can be a resource to help you, both in approaching the state and in learning from other states. Q: Can you give an example of a credibility-building measure you used with your state government? Arnold: Our state has several Medicaid managed care organizations (MCOs). If we have issues with only one of them, we communicate through our Pediatric Care Council. The state Medicaid director knew we would only contact her if we have a problem with several MCOs. Also, we told the state we are interested in evidence-based quality care. That saves money, but it also requires investing money in QI programs that we were already running. The state invested in us via grants for QI in mental health and vaccines. It could have invented programs from scratch on these important subjects, but it saw that would have been duplicated effort. A payer also has to invest in incentivizing practices. A group practice that includes some of our members received $48,000 per provider in enhanced payments from a payer because of practice improvements that came from Maintenance of Certification (MOC) programs we had developed. Q: Which came first, the payer's pay-for-performance program or the MOC programs? Arnold: The MOC programs. Payers saw how much was spent on asthma and ED visits, so they paid to help us expand the QI program because they saw savings. Q: How can smaller chapters put themselves forward as QI providers if they don't run QI programs themselves? Copyright © 2019 American Academy of Pediatrics

2 News Articles, Private Payer Advocacy, Administration/Practice Management, Billing & Coding Arnold: They can quote national data about the value of these programs. It might even persuade payers to help them get QI programs up and running. Dr. Gittelman: It can be expensive to start a new program but easy to implement a program that already exists. They can use AAP programs (see resource) and those of larger chapters. Q: Can pediatricians or AAP chapters have influence beyond simply pointing out the opportunity for short-term savings? Arnold: Pediatricians can shine a light on the value of focusing on certain populations. The designers of payment models initially thought of savings in dollars and cents. We brought the directors of the state Department of Medicaid and of the state association of health plans to our annual meeting, where our members drove home the value of reaching out to our high-risk populations. At that moment, we didn't have data on that value, but we had the relationships with the directors that made them open to hearing our thoughts. Q: Did that result in any emphasis on prevention, which is the heart of primary care pediatrics? Arnold: What sold payers on prevention was our state's high infant mortality rate. They were interested in our safe sleep initiative, though we didn't have data yet. They also do a pretty good job covering developmental screening because of our relationships and their willingness to look beyond the short term. Dr. Gittelman: There might be programs that will show results in five years, but their initial commitment might be only for two years, so you can't promise too much. It's baby steps at first, but QI programs should start gathering outcome data from the beginning. Q: Your state has taken care in how it bundles payments for some "episodes of care." For otitis media, for example, it excludes cases where co-existing conditions likely complicate the care. How involved were pediatricians in designing this alternative payment arrangement? Arnold: There were 10-15 physicians on every panel, mostly subspecialists. I would recommend chapters advocate to have a balance of primary care pediatricians and medical and surgical pediatric specialists on these panels, since all may have to live with the results and to be aware of any unintended consequences impacting primary care and specialty pediatrics. Q: Does the chapter have input in the state's applications for Medicaid waivers and other proposals that address social determinants of health, such as assisting with housing or transportation to medical visits? Arnold: Yes, we argued those items could reduce infant mortality. We're working on that now and feel it's the chapter's responsibility to be a voice for children. Pregnancy already is a condition recognized for presumptive Medicaid eligibility, saving a long application process. Dr. Price is a member of the AAP Payer Advocacy Advisory Committee and chair of the Committee on Child Health Financing. Resources l The AAP Chapter Quality Network (CQN) is an example of a program in which smaller chapters can participate. CQN aims to build chapter capacity to lead improvement efforts with member practices that Copyright © 2019 American Academy of Pediatrics

3 News Articles, Private Payer Advocacy, Administration/Practice Management, Billing & Coding result in improved care and outcomes at a population level. l Additional Private Payer Advocacy columns Copyright © 2019 American Academy of Pediatrics

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