As healthcare in the United States—an enormous super-system not overly fond of abrupt turns&mdash;prepares for the 90-degree lurch that is healthcare reform, it has found an unlikely ally: behavioral health.

The healthcare market in the United States now comprises over $3 trillion per year—that is more than the gross domestic product of France. It is well accepted that, for all the resources we expend, our system doesn’t deliver the outcomes we would expect by almost all common measures: quality, safety, efficiency.

 In current parlance, our healthcare machinery doesn’t produce the value we need to keep our population and economy healthy and to make it worth that kind of investment. This is the basic principle driving healthcare reform: value; we need to transform from a volume-based system to a value- based one. In the value-based world, we use the “Triple Aim” as a guide: better care, better health of the population, and lower cost.

 As payments align evermore to the goal, what matters isn’t the number of diagnostic tests, surgeries, or outpatient visits you perform in a day, what matters is the response to this question: What value did those interventions produce, and at what cost? In this new world, where cost and population health matter just as much and, eventually, more than keeping hospital beds full, behavioral health has found itself on radar screens it never expected before.

In the volume world, behavioral health never added much to the bottom line given its labor-intense and time-dependent nature and its ever-shrinking reimbursement rates. In the value world, however, behavioral healthcare—when done well&mdash;is like gold. Why? Not because it generates revenue on its own side of the ledger, but because it reduces cost on the medical side, and does so significantly. This has been well known for decades. An extensive analysis by Milliman in 2014 confirmed it yet again, finding that a comorbid mental health condition doubles or triples the total cost of care, with most of that cost occurring in medical hospitalizations and emergency department (ED) visits.

 They suggest—conservatively, in my view&mdash;that integrating behavioral health and medical care would save $26 billion to $48 billion annually. Given that a modest investment in behavioral health infrastructure goes a long way (the positive side of its aforementioned nature as a system based on person-to-person time rather than procedures and equipment), and given that we have been spending significantly less on behavioral health as a percentage of overall healthcare over the last several decades,

 logic would suggest that now is the time to start investing in behavioral health if we want better health and lower cost.

My story would end there were it not for the fact that, over the last 3 years, I have had a front-row seat to watch what happens when a large health system makes exactly that decision. Carolinas HealthCare System (CHS) is a large, nonprofit, integrated delivery network with 39 hospitals and 900 care locations in the Carolinas, serving well over 2 million patients a year. Five or 6 years ago, CHS leaders began looking seriously into the subject of behavioral health and the value it could bring as healthcare transforms. Three years ago, they created a service line of behavioral health in order to have a corporate-level platform from which to assess the needs of the population and system, and from which to develop strategy in order to respond to these needs. I have been lucky to lead this service line, since its inception, in a dyad leadership pair with an administrative counterpart, Martha Whitecotton. What we have been able to achieve in 3 years is living proof of the value of behavioral health expansion within a large system. In just 3 years, our service line has driven 4 major projects.

The first, and most visible, was building a new state-of-the-art 66- bed psychiatric hospital. Although inpatient treatment is not the goal in behavioral health, it is a critical part of the continuum of care. The dearth of beds nationally has driven patients who are in crisis into medical EDs in record numbers. The number of state psychiatric beds in the United States has declined precipitously from over 550,000 in 1955 to less than 45,000 in 2010, leaving us with access to psychiatric beds per capita at comparable levels to what we had in 1850, as in before the Civil War.

 In North Carolina, with one of the lowest per-capita psychiatric bed ratios in the country, we have almost twice the national average of psychiatric patients stuck in medical EDs.

 The 66 new beds bring us to over 400 in our system are an important step in the right direction.

First Aid The second major initiative has been to promote Mental Health First Aid, an 8-hour course similar to CPR, which teaches the basics on how to recognize and manage a psychiatric crisis. We have trained over 5000 individuals in the community, including teachers, clergy, athletic trainers, and law enforcement officers. In addition to providing important tools, this is a public health literacy campaign that reduces the stigma associated with mental illness. The more stigma in a community, the fewer people access care and the more cases of untreated mental illness, which again results in driving down health and driving up suffering and cost.

The third initiative—the largest in scope&mdash;has been to integrate behavioral health into our 200 primary care offices, serving 800,000 patients, in order to intervene “upstream,” where the barriers and acuity are low, and before things have reached a crisis point. We based our model on the well-proven IMPACT model, which was created and based out of the University of Washington AIMS Center. 

 We knew, however, that scaling this co-located model across 200 offices would be a challenge, so we deconstructed and then reconstructed the model into a “virtual team,” which allowed our team to have more members, to be deployed across more primary care offices, and for each team member to be able to bring their full skill set to bear. They are located off-site and use the phone, video, and the electronic health record (EHR) to communicate with the primary care team and the patient. Whereas in the IMPACT model there is a somewhat generic, co-located “behavioral health provider” performing multiple tasks, such as assessment, diagnosis, navigation, communication, and registry-management, we were able to have distinct team members devoted to each of those functions. In almost 2 years, our team of 20—comprised of social workers, coaches, therapists, a pharmacist, and a psychiatrist&mdash;has treated 5000 patients in 50 primary care practices, and we have our first 6-month cut of data. It is a pre-/post cohort, and therefore not randomized or controlled, but we wanted an early look, and the results are encouraging. The mental health scores are improving significantly (for depression and anxiety), as are metrics like glycosylated hemoglobin and cholesterol&mdash; all with statistical significance. And, although 6 months is early to get a thorough assessment of utilization, this glimpse suggests that while outpatient visits are up modestly in this group, inpatient utilization is down, which is, of course, where most of the cost lies.

The fourth initiative of the behavioral health service line was a spinoff of this virtual primary care team that we deployed to help our medical EDs that are backed up with psychiatric patients. In North Carolina, the average length of stay for patients presenting to medical EDs needing psychiatric hospitalizations approaches 2 days; in our own system, it was nearing 40 hours. The boarding of psychiatric patients in EDs has become a national crisis according to many, including the Joint Commission.

 We took a smaller version of the virtual behavioral health team (ie, a nurse, bed manager, social worker, and psychiatrist) and deployed them to 20 of our Charlotte-area medical EDs. That team now feels ownership for the psychiatric patients presenting to the EDs, and gets involved as soon as possible in their care. The behavioral health team communicates with both the medical team and the patient, and uses tele-psychiatry if needed.

Importantly, the ED physicians have agreed to allow our psychiatrists to enter orders remotely in the EHR, which saves time to initiate care. Additionally, we use a company that has expertise in safely transporting patients who need psychiatric hospitalization so that we don’t have to rely solely on law enforcement transport, which had been the case previously. We now do 300 transports a month with this private vendor, in addition to the 300 a month still done by law enforcement. We perform 900 tele-psychiatry encounters a month; the result being a 50% reduction in the length of stay for psychiatric patients in those 20 EDs and a savings of over $1 million in sitter costs alone. And, most importantly, the care and experience of care is much better for those patients who come to the ED in psychiatric crisis because they have no other place to go.

Challenges remain, of course, and we are still at the beginning of a larger journey. We struggle to scale these programs fast enough to meet the full demand across our geography. Nevertheless, after 3 years, our experience is living proof of the power of behavioral health to drive value in this new healthcare world. 

Carolinas HealthCare System, Charlotte, NC.

 The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content.

 John Santopietro, MD, DFAPA, Chief Clinical Officer, Behavioral Health, Carolinas HealthCare System, 720 East Morehead St, Ste 300, Charlotte, NC 28202. E-mail: john. santopietro@carolinashealthcare.org.

1. Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall, 2014 update: how the U.S. health care system compares internationally. The Commonwealth Fund website. http://www. commonwealthfund.org/publications/fund-reports/2014/jun/ mirror-mirror. Published June 16, 2014. Accessed May 2016.

2. Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769. doi: 10.1377/hlthaff.27.3.759.

3. Milliman report summary: economic impact of integrated medical- behavioral healthcare—implications for psychiatry. Milliman report summary. Alliance of Community Health Plans website. http://www.achp.org/wp-content/uploads/milliman-report-summary- 20141.pdf. Published April 2014. Accessed May 2016.

Better But Not Well: Mental Health Policy in the United States Since 1950

. Baltimore, MD: Johns Hopkins University Press; 2006.

5. Torrey EF, Fuller DA, Geller J, Jacobs C, Ragosta K. No room at the inn: trends and consequences of closing public psychiatric hospitals—2005-2010. Treatment Advocacy Center website. http:// www.tacreports.org/storage/documents/no_room_at_the_inn- 2012.pdf. Published July 19, 2012. Accessed May 2016.

6. Centers for Disease Control and Prevention. Emergency department visits by patients with mental health disorders—North Carolina, 2008-2010. 

7. IMPACT: Improving Mood—Promoting Access to Collaborative Treatment. AIMS Center website. http://aims.uw.edu/impact-improving- mood-promoting-access-collaborative-treatment/. Accessed May 2016.

8. Alleviating ED boarding of psychiatric patients. The Joint Commission website. https://www.jointcommission.org/assets/1/23/ Quick_Safety_Issue_19_Dec_20151.PDF. Published December 2015. Accessed May 2016. 

Articles

The American Journal of Accountable Care

Carolinas HealthCare System created a behavioral health service line to drive transformation in value-based healthcare. Four projects are described, which demonstrate that modest investment in behavioral health pays dividends in reduced cost and increased quality and experience.

The Hidden Value of Behavioral Health

The past 5 years have been a time of great uncertainty for health plan executives. Continued pressure on medical loss ratios, the migration to new payment methodologies, a rapidly consolidating competitive landscape, and sweeping uncertainties surrounding the individual market have combined to form a perfect storm, rendering the status quo untenable. In this frenzied environment of dwindling margins and regulatory confusion, managed care companies have begun to find new growth opportunities by experimenting with investment and innovation programs, or accelerators.

 this article provides a high-level evaluation of the universe of model options accessible to payers who are interested in launching such programs. It draws on the perspectives of a number of nationally renowned experts in the field from several organizations at the forefront of innovation. One such organization is Horizon Blue Cross Blue Shield (BCBS) of New Jersey. Minal Patel, senior vice president and chief strategy officer of Horizon, offers the following perspective: “Given the pace of innovation spurred by the Affordable Care Act and the flow of capital, Horizon recognized the need to work closely with entrepreneurs who are building capabilities required for us to continue to fulfill our mission which is to provide access to high quality, affordable healthcare with superior member experience (the triple aim). As such, we clearly defined those capabilities that we need to succeed and then began to socialize these needs with all entities that are in the ‘deal flow.’ Clearly articulating what these needs are must be a foundational task for any strategic investment arm so that we may efficiently source deals that fit our needs and more importantly, quickly decide upon which deals we will pass.”

Payers generally seek to achieve 4 principal goals when considering whether to undertake investment and innovation opportunities (

          1. Financial returns. Many organizations establish investment initiatives to drive financial returns. By taking equity stakes in early- and growth-stage companies and growing revenue through customer relationships, payers can generate new sources of income that are not subject to the reimbursement pressures affecting the core business of reimbursing medical care.

          2. Operations improvement. Innovation programs offer payers a means to identify a pipeline of promising companies that can help them upgrade operations, reduce medical costs, improve outcomes, and expand access to care.

          3. Brand enhancement. Investment programs can serve as vehicles to enhance brand integrity in an increasingly competitive landscape through differentiation and expansion of market reach.

          4. Foster innovation. Perhaps most significant, commercializing new ideas enables organizations to cultivate an innovation- focused culture. Rob Coppedge, president of Direct Health Solutions at Cambia, describes his organization’s multi-pronged objectives in operating a strategic investing program: “Cambia views strategic investing as a tactic to advance its corporate mission to create an economically sustainable healthcare system organized around the consumer. We are not investing to prop up the current, broken healthcare system…. So while financial return is expected from each investment, we also look closely at the impact our companies are having on the transformation of the healthcare experience for consumers.”

Models of Payer-Based Investment and Innovation Programs 

Depending on a given health plan’s risk appetite, resource commitment, and desired return, a variety of approaches are available (

• Accelerator investments. A number of third-party accelerators offer partner organizations access to, and a small equity stake in, a multitude of early-stage companies. In addition to providing interaction with other health plans and health systems that have made similar commitments, a well-publicized investment in an internal accelerator program may confer branding benefits.

• Innovation centers. Developing an in-house innovation center enables organizations to generate revenue from internal intellectual property (IP). Such a center may take the form of an internal accelerator, whereby new products are researched, developed, and launched using a health plan’s own resources. A successful center typically incorporates the following: a) mining mechanisms to identify ideas with commercial potential; b) screening processes to filter the most compelling concepts; and c) matching components to pair prospective entrepreneurs with the staffing, financial, and clinical resources needed to bring ideas to market.

• Warrant deals. Several organizations have developed warrant programs, in which the health plan picks up an equity percentage in a company in conjunction with signing a commercial agreement. This approach provides health plans with a low-risk means to share in the upside, while minimizing the downside financial risk.

• Fund investments. This option offers the opportunity to invest in a portfolio of companies while not being tied to the fate of any single business. It also allows organizations to benefit from the due diligence and investment management resources of a fund, rather than assuming this burden themselves.

• Direct investments. Increasingly, health plans are making direct equity investments in healthcare information technology (IT) and service firms to leverage commercial relationships with these vendors. Although they represent the biggest possible financial return, direct investments also carry the greatest amount of risk because financial returns are linked to a single company.

Of course, these models are not mutually exclusive. Sophisticated organizations will typically apply a multi-pronged strategy in operating an investment and innovation program—featuring, for example, internal IP commercialization alongside external investment activity. Minal Patel of Horizon describes his program’s hybrid investment approach as follows: “We distinguish our direct investments from our indirect investments through funds in 1 very important way. We will only invest directly once we have decided to work with the business as a client and where the company gives us some authority to help provide input into the business. We may or may not do business with a company within the portfolio of any of our investment funds.”

The evolving landscape of innovation and investment programs has a number of implications for healthcare leaders.

A new paradigm of health plans working with early-stage companies has emerged. Although the features of innovation and investment programs vary widely across organizations, all mandate a new mode of working with early-stage companies. The prohibitively long sales cycles these businesses customarily face when selling in a healthcare setting represent a major deterrent for entrepreneurs attempting to penetrate this segment. In many ways, the barriers to sales represent barriers to innovation. Breaking down these obstacles will require a systematic method of screening companies against organizational objectives and identifying the appropriate business unit champions to help them reach decision makers. This relationship needs to work both ways, however: health plans should be rewarded for the effort and risk associated with supporting early-stage businesses. Thomas Hawes, managing director of Sandbox Industries, elaborates on his organization’s method of working with prospective companies: 

The key goal of the BCBS Venture Partners (BCBSVP) program is to find or create companies that address the strategic priorities of our LPs. This has been done by creating a 2-sided network, mapping the many active BCBS executives who are looking to collaborate with the network of entrepreneurs that come through the BCBSVP platform.

An Internal Resource Commitment Is Essential 

Undertaking an investment and innovation program in earnest requires both executive sponsorship and a dedicated financial and personnel commitment. If the intention is to transform a health plan’s core business model for the future, then executives would be well served to treat the program as a priority. Maureen O’Connor, president of Mosaic Health Solutions, offers the following description of her organization’s commitment: “Mosaic Health Solutions is focused on achieving the dual goal of driving top-tier financial performance while also accelerating innovation within BCBS of North Carolina and the broader healthcare ecosystem. We strive to be a highly engaged strategic investor that adds value to our portfolio companies through deep industry knowledge, potential commercial relationships with our parent company, and a broad national network of other Blues Plans. We seek both control and minority investment positions where we can influence the future direction of the company.”

Considerations in Launching Investment and Innovation Programs

Innovation program structure depends on goals and risk appetite. With a multitude of available options, healthcare leaders must prioritize and decide which investments are most appropriate for their organization’s risk appetite and return goals. Structuring warrant deals with companies or investing in an external accelerator presents a reasonably low risk of losing capital, but these approaches do not offer substantial upside potential. Conversely, making direct investments in companies or rolling out an internal IP commercialization effort comes with higher levels of both financial risk and return. 

 outlines a number of factors executives should consider in launching their programs.

Revenue diversification is the name of the game. In many ways, the rise of health plan investment and innovation programs has paralleled the rollout of risk-based payment models. Healthcare reform has galvanized executives to think more critically about margin enhancement strategies. Although some payers have been laser focused on doing anything they can to maximize profitability under the fee-for-service system, others understand that surviving in a new world—one in which hospitals are assuming significant financial risk for a patient’s treatment&mdash;will require new ideas, products, and sources of revenue.

A market scan shows widespread agreement among leaders that innovation is no longer optional for health plans. The question thus becomes how to develop and implement an investment and innovation strategy that meets an organization’s distinctive financial, strategic, and marketing goals, while staying within internal resource constraints. Although few organizations have “cracked the code” on strategic investing and innovation, studying the best practices of those that have done so is an important exercise for any health plan leader who stands on the precipice of launching an internal investment and innovation program. Equipped with the insights of the experts in this article, we can identify a set of implications for other healthcare executives. 

Health Enterprise Partners, LP, New York, NY; Columbia University, New York, NY.

: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Ezra Mehlman, MBA, Health Enterprise Partners, LP, 565 Fifth Ave, 26th Fl, New York, NY 10017. E-mail: emehlman@hepfund.com.

1. Matthews AW. Insurers under pressure to improve margins on health plans. 

 website. http://www.wsj.com/ articles/insurers-under-pressure-to-improve-margins-on-healthplans- 1455154838. Published February 10, 2016. Accessed May 24, 2016.

2. Mehlman, E. Rise of the accelerators: the growth of health system- based investment and innovation programs. In: Society for Healthcare Strategy & Market Development, American College of Healthcare Executives. 

. Chicago, IL: Health Administration Press; 2016.

Spurred by the migration to new payment methodologies and a rapidly evolving competitive landscape, many managed care companies have
launched venture and innovation programs. This article provides a high-level evaluation of the universe of model options accessible to payers who are interested in such programs.

Launching a Payer Venture and Innovation Group: Options and Trade-Offs

Finding the right way to address a patient’s condition before it worsens will ultimately lower the cost of healthcare—and it seems like the healthcare industry is now getting on board with that notion. “You do the right thing, at the right time, at the right dose with the right patient … and the total cost of care goes down, not up,” said Leonard M. Fromer, MD, FAAFP, from Group Practice Forum. “Even if the cost of the treatment might be a lot of money.” Over the course of 2 days, attendees at the spring live meeting of the ACO & Emerging Healthcare Delivery Coalition, presented by 

, not only heard case studies, panel discussions, and presentations that highlighted how better integration and more coordinated care can improve quality of care while lowering costs, but also shared their own best practices.

With ACOs accountable for both the health and the cost of the population they serve, integrating the behavioral and medical components of health is a necessity. “Unless you address both the medical and behavioral, you’ll have poor outcomes,” said Roger G. Kathol, MD, CPE, of Cartesian Solutions, Inc, and the University of Minnesota. Only 25% of people with behavioral health problems are seen in the behavioral health sector, which means that 75% never have access to evidence-based care. The vast majority of patients seen in the primary care setting receive either no treatment or ineffective treatment, he explained, which provides a tremendous opportunity to better address the needs of those with behavioral health issues seen in the medical setting.

For ACOs, there are a few options for how to handle behavioral health: do nothing and eat the cost when patients have poor outcomes, buy traditional services that people are proven to not use, or build behavioral health services inside the ACO. In his workshop, John Santopietro, MD, outlined the virtual care model being used by Carolinas HealthCare System. Instead of co-locating 1 social worker in each practice, the system adapted the model by deconstructing what the provider does and recreating that as a virtual team of providers that includes the call center clinician, a care manager, a behavioral health coach, a pharmacist, a therapist, and a psychiatrist. “If you do it that way, you can deploy [the team] much more effectively,” Dr Santopietro said.

The early results from the program have found a decrease in depression and anxiety scores, and a decrease in glycated hemoglobin, total cholesterol, and low-density lipoprotein cholesterol. The biggest hurdle to getting the program off the ground was not hesitation on the part of the patient, but that from psychiatrists.

“But we’re getting out of the world where psychiatrists were concerned and didn’t want to do it,” Dr Santopietro said. “More and more, they are getting trained in telepsychiatry.”

During his keynote presentation, Dr Fromer explained that precision medicine is a fundamental piece of the accountable care movement. The benefit of precision medicine is that caring for patients LAURA JOSZT, MA Coverage from the 2016 Spring Live Meeting of the ACO & Emerging Healthcare Delivery Coalition™ held April 28-29, 2016, in Scottsdale, Arizona. ajmc.com 6.16 / 63 becomes less expensive when healthcare zooms into classes of patients, he said. Medications may be more expensive, but “the big picture cost” plummets only by improving the health of the individual and keeping them well.

Oncology is the biggest and earliest adapter, and stakeholders in that space have begun to create nomograms that use an alpha-numeric code to describe something unique about the patient: genetic makeup, tumor makeup, comorbidities, social environment, etc. “To know which drug will work best first, and not hunt and peck, that’s where you save money—a lot of money,” Dr Fromer said.

Where this all ties into ACOs is through the idea of being proactive with the population being cared for. Dr Fromer added that he expects to begin seeing quality measures move precision medicine forward. “Precision medicine quality measures—they’re coming,” he said. “It will follow, not lead. It will be there because it will be a natural output from aligning the payment model in general.”

Clifford Goodman, PhD, of The Lewin Group, moderated a panel discussion between Michael E. Chernew, PhD, of Harvard Medical School; Patricia Salber, MD, MBA, of The Doctor Weighs In; and Bruce Sherman, MD, FCCP, FACOEM, of Buck Consultants, A Xerox Company. They discussed the future of healthcare in the United States, including the sustainability of the Affordable Care Act (ACA), the impact of the presidential election on healthcare delivery, employer coverage, and maintaining cost of care in the era of innovation.

The panel kicked off with a discussion on Medicaid expansion. Dr Salber noted that it is difficult to separate the decision to expand the program from the politics and she added that since the implementation of the ACA, resistance to expanding the program has begun to deteriorate. She also expects to see more and more states agree to expand Medicaid. Dr Chernew echoed this sentiment, explaining that the ACA was designed to have very strong incentives for states to agree to expand.

“I think that if the election moves in a direction that it looks like the ACA will not be repealed at the federal level, you will see a lot of states move to [expand Medicaid],” he said. “If it looks like it’s really here to stay, you’ll see more states expanding.”

According to Dr Sherman, from an employer standpoint, expanding Medicaid has been a good thing. After all, if people have the money to pay for healthcare, the employer stands to benefit. Expanding Medicaid potentially helps to mitigate some of the disproportionate share of costs that employers cover because of charity care, he added. One of the biggest challenges to the ACA may not even be the politics and the threat of a Republican president repealing the law. Healthcare spending continues to grow, and if the United States cannot get the healthcare delivery system working in a more sustainable way, then the ACA may collapse under its own weight when the country can no longer afford the level of subsidies included in the law, explained Dr Chernew.

Dr Salber then shifted the conversation over to drug pricing. Although there has been development of life-saving, life-altering therapies, they come with huge price tags that the health system hasn’t figured out how to deal with just yet. She expects to continue to see innovative drugs and the pharmaceutical industry continuing to increase the cost of those treatments. Nevertheless, how those drugs are handled in the insurance benefit design could have huge ramifications, she added.

“If all of those things end up fourth tier with huge coinsurance or huge deductibles, there will be a situation where if you have money you can survive, but if you don’t, you will get chemotherapy instead of targeted therapy,” Dr Salber said. “In that part of healthcare we could see a widening disparity.”

Dr Chernew pointed out that regardless of the public sentiment around drug pricing, it has been well established that there is a relationship between profitability and innovation. And while it can be debated whether that relationship 

be there, it is. “I think that the fundamental challenge that healthcare faces is that innovation is universally considered good, but it’s something we continue to struggle to finance,” Dr Chernew said.

In Oregon, there are some unique innovations taking place regarding healthcare delivery. The state is home to coordinated care organizations (CCOs), which are essentially ACOs, but specifically for Medicaid. These CCOs are charged with the responsibility of ensuring that healthcare delivery change is driven by providers and to improve quality of care. In order to do so, Health Share of Oregon has invested in Project ECHO, a telementoring program that connects specialists with primary care providers.

The basic idea of Project ECHO is to “demonopolize the specialist’s knowledge,” explained Mark Lovgren, director of telehealth services at Oregon Health & Science University. The program runs for 40 weeks and includes 15- to 20-minute didactic presentations delivered by specialists and real-time case-based presentations from primary care providers who are struggling with specific situations. The expert team of specialists are able to provide recommendations to the primary care provider who is struggling with how to care for a specific patient.

“The idea is that through repeated exposure to these difficult cases, everyone participating will feel more comfortable with them,” Lovgren explained.

It does take a few weeks for providers to feel comfortable when participating in the program to open up and share a case, he added. After all, when a provider shares a case, he or she is asking for help, which isn’t always easy for them to do.

“The secret sauce is your facilitator and team,” explained Christine Bernsten, senior manager of delivery system transformation for Health Share of Oregon. “You can get the cookbook to implement [Project ECHO], but you need the facilitators who are good teachers and they are kind and supportive of the providers participating in [the program].”

Although ACOs are by no means new, few so far have sought accreditation in the way that patient-centered medical homes have. Michael Massey, MD, chief medical officer at BSWHA, related why Baylor Scott & White Quality Alliance (BSWHA) decided to become one of just a handful of ACOs that are accredited.

The main reason for seeking accreditation is to evaluate an organization’s ability to delivery coordinated, patient-centered care; improve clinical quality; enhance patient experience; and reduce costs, Dr Massey explained. In addition, accreditation, although voluntary, identifies which ACOs are likely to be good partners.

BSWHA sought its accreditation through the National Committee for Quality Assurance, which assesses organizations on 65 elements across 7 categories: ACO structure and operations, access to needed providers, patient-centered primary care, care management, care coordination and transition, patient rights and responsibilities, and performance reporting and quality reporting.

In a panel discussion following his presentation, Dr Massey said that seeking accreditation allowed BSWHA to see where it had gaps and what it had to work on to become better. The organization went through the same issue when it sought accreditation for its patient-centered medical home.

“We thought we had it all covered and then we found we had a huge problem with access,” he said.

Dennis Scanlon, PhD, professor of health policy and administration and director of the Center for Health Care and Policy at the Pennsylvania State University, explained that accreditation programs are good for the sake of providing an internal assessment. However, he was skeptical about the idea that getting accredited could be a differentiator among ACOs.

Lysette Cournoyer, a consultant, said that ACO accreditation is likely to follow the precedent set by patient-centered medical homes, which started with just a few getting accredited and grew.

“For providers, it helps them start with something,” she said. “It gives them guidance. A lot of times you go into systems that are burdened by their own data and this helps them know where to start.”

With 18% of patients readmitted within 30 days of hospital discharge and 50% of those readmissions being preventable, transitional care management can save billions of dollars each year. Further, providers are being incentivized to follow best practices that reduce unnecessary readmissions.

Megan Hunt, MD, PGY3, and Luke Peterson, DO, PGY3, both from Banner University Medical Center, discussed how their program formalized a protocol and utilized 2 specific reimbursement codes in order to decrease hospital readmission rates, decrease emergency department visits, and increase clinic revenue.

The 2 new codes—99495 and 99496&mdash;significantly increased reimbursement compared with the older, comparable codes from $223 to $356 and from $300 to $501, respectively. Dr Peterson explained that they built the protocol for patients when they leave the hospital based on those 2 codes with the hope to exchange an expensive hospital with a reimbursed clinic visit.

The transitional care protocol requires that when a patient is discharged that an inpatient team member makes an appointment within 2 weeks. The lead medical assistant calls the patient to confirm the appointment, review discharge instructions and medication and if there are nay questions, an inpatient team member calls the patient or if it is a difficult case, then a case manager follows up. And even if the lead medical assistant calls but is unable to make contact with the patient, they need to document that 2 attempts were made in the chart.

In the small pilot study that they ran, Drs Hunt and Peterson’s group found significant reductions in readmissions and emergency department visits. In addition, they saved almost $200,000 from their inpatient service and increased revenue by $25,000 by billing with the new codes. “This additional revenue pays for the [medical assistant]’s salary that is making all the calls,” Dr Peterson explained.

Coverage from the 2016 Spring Live Meeting of the ACO & Emerging Healthcare Delivery Coalition on April 28-29, 2016, in Scottsdale, Arizona.

Better Integration to Improve Care Outcomes Highlighted at AJMC's ACO Coalition

 Accountable care organizations (ACOs) have rapidly become one of the preferred approaches to providing more efficient healthcare to the Medicare population. The ingredients of a successful ACO have not been well described in the literature, however. We present the descriptive epidemiology of our ACO to illustrate the elements in our organization that are critical to its success. We explain how we gained cost savings and show the quality measures that were monitored, which are essential to whether savings are received or not.

Medicare provided expenditure data through claims files collected for the HackensackAlliance ACO. Quality data on 33 measures were collected from 3 sources: the Medicare claims files, a chart review of physician notes in patient charts, and a Medicare patient experience survey of a sample of ACO beneficiaries.

The ACO submitted 9 Claim and Claim Line Feeds (CCLFs) to Verisk Health for analysis. Premier Inc reviewed the analysis and discussed the results with the principals of the HackensackAlliance ACO.

 As a whole, the ACO had fewer hospital admissions, readmissions, and emergency department visits compared with a group of ACOs—these were the major factors that reduced our expenses, as we focused on maintaining a high level of quality. The number of patient office visits far exceeded those found in the comparable ACO group, resulting in better healthcare for all&mdash;especially for those with chronic disease, such as diabetes and heart failure. The complex process for calculating savings or losses is also carefully described. The HackensackAlliance ACO saved expenses in 2 successive years, which is an uncommon feat.

 One reason our ACO succeeded in having savings in 2 successive years is the initial requirement that physician practices be certified as patient- centered medical homes by the National Committee on Quality Assurance. These doctors understood and accepted what would be required in the current evolution of medicine care. Also critical, was instituting nurse care coordination of high-risk patients from the beginning of the ACO contract. These 2 factors helped eliminate waste in the system and changed physician behavior, not physician practice.The accountable care organization (ACO) model has captured the imagination of more than 700 healthcare sites in the United States. However, there is little in the academic literature describing how the model works, and most of the reports in the medical literature are editorials on whether ACOs will succeed, whether the philosophy for their creation is reasonable, and whether progress has occurred in the 5 years since they were created.

 Within the ACO model, there are multiple choices based on whether the organization agrees to assume downside risk and whether the federal government or a private enterprise supports them. The federal government, under the auspices of CMS, created most of the ACOs as either Pioneer ACOs or Medicare Shared Savings Programs (MSSPs). CMS also created other payment models, including Bundled Payments for Care Improvement (BPCI), Value-Based Payment for Physicians, and Comprehensive Primary Care Initiative (CPCI).

 This article will focus on the descriptive epidemiology of the MSSP model, how it assesses the ability to save expenses, and how it evaluates compliance with the 33 quality measures.

Most MSSPs are in Track 1, which aims for upside savings when costs are reduced, and does not assume downside risk when there are losses. Accepting both upside gains and assuming downside risk is referred to as Track 2, Track 3, or Next Generation

—each of the latter 3 has other features that distinguish them from one another. We will focus on Track 1, as that is the model selected by most ACOs.

An important point to emphasize is that the current approach to ACOs and other alternative payment models is different from the managed care programs of the 1990s. At that time, saving money was the sole goal. Now, under the ACO approach for MSSPs, it is important to achieve a high level of quality in the care of the patient in order to be eligible for sharing any significant savings generated. The ultimate goal for the ACO is to achieve the “Triple Aim”: namely, better care for the individual, better health for the population, and lower growth of expenditures.

Each quarter, we receive the claims files from Medicare—referred to as Claim and Claim Line Feeds (CCLFs). They detail claims Medicare receives from each physician, hospital, and other healthcare service providers, such as skilled nursing facilities. We send the CCLFs to a data analytics firm, Verisk Health, for further analysis, and their findings are forwarded to Premier&mdash;a healthcare performance improvement alliance of 3000 hospitals&mdash;to be digested and to cull out important clinical findings. These findings are then reviewed by our data analyst (author ME) and clinician (author PG) to select the key clinical findings for presentation to our physicians&mdash;mainly, our primary care providers (PCPs).

It should be noted that claims may not be available for all patients, as patients have the opportunity to opt out of sharing their information with their physician. This occurred in less than 3% of our patients, however.

The types of information sent to the PCPs include basic demographics and information on clinical areas that have a significant impact on expenses, such as hospital admissions, readmissions, and emergency department (ED) visits. For example, 

 shows that the largest individual practices—namely practices A, B, and C&mdash;are cost-efficient and have fewer admissions, readmissions, and ED visits than the ACO norm, as well as many more office visits than the ACO norm.

The clinical quality provided by the PCPs is based on the 33 measures required by Medicare (

). These measures cover 4 major areas: patient/caregiver experience; care coordination/patient safety; preventive health; and at-risk populations for diabetes, vascular disease, hypertension, heart failure, and coronary artery disease. A full score is achieved when the measure compliance achieves the 90th percentile level.

The savings achieved by the ACO are determined by an elaborate risk-based formula (

 The following presentation describes our experience in the second year (January-December 2014) of the CMS contract. In the first year, our total savings was $10,747,669 and our savings share came to $5,266,358. It should be noted that the “first year” was 21 months long (April 2012-December 2013) and the quality was measured on reporting, not on compliance. In both contract years, current expenses were compared with a 3-year historical expense benchmark. To eliminate the possibility of random variation being responsible for a savings or a loss, Medicare sets a minimum savings rate (MSR) that has to be exceeded on the upside to be considered a true savings, and a minimum loss rate (MLR) that has to be exceeded on the downside to be considered a true loss.

 The size of the minimum rates is dependent on the number of Medicare beneficiaries at the individual ACO—the larger the ACO, the smaller the minimum rate.

We will review the major steps leading up to identifying whether the ACO achieves cost savings or not in the second year (2014).

If a beneficiary has at least 1 primary care service from a physician in the ACO, the beneficiary will be assigned to the ACO after they complete a 2-step process.

 First, the beneficiary receives the plurality of their primary care services from a primary care physician in the ACO. PCP is defined as a physician specializing in internal medicine, general practice, family practice, or geriatric medicine. Second, if step 1 did not occur, a beneficiary could still be assigned to the ACO if the beneficiary receives the plurality of their primary care services from other non—primary care professionals within the ACO, including physician specialists, nurse practitioners, clinical nurse specialist, and physician assistants.

Let’s consider the method for determining shared savings (Table 3).

 First, we have to identify the number of beneficiaries assigned by CMS to our ACO and, more accurately, the person-years (#2 in Table 3). Next, the per-capita historical benchmark expenditures (#3 in Table 3) and the actual per-capita expenditures (#4 in Table 3) are identified. The total benchmark expenditures and actual expenditures are calculated as shown in Table 3. The total savings is the difference between the two. The minimum savings rate percentage is selected from a table (not shown) that illustrates how the rate varies inversely with the population size. In our case, the minimum savings rate in dollars is less than the total savings

; therefore, our ACO has the opportunity to share in the savings with Medicare. Potential net savings for the ACO are 50% of the total savings, and Medicare keeps the other 50%. How the ACO performs on the 33 quality measures from CMS is critical to receiving all or part of the savings.

 As our final quality score is 89%, we are able to keep 89% of 50%, or 44.7%, of the potential net savings. Then, from that number, a portion is taken out for the sequester adjustment (#15 in Table 3) when the federal government was shut down in 2014. The final net earned savings performance payment becomes $2,832,988.

There are some finer points that are considered in the calculation. Knowing the distribution of the population is also relevant. There are 4 enrollment groups that CMS reports: 1) patients with end-stage renal disease (ESRD), 2) patients who are disabled, 3) aged and dual- eligible patients who have both Medicare and Medicaid coverage, and 4) aged but non—dual-eligible patients who have only Medicare coverage. The patients with ESRD are the most expensive, but make up only 0.6% of our total patient population; consequently, focusing on the expenses generated by patients with ESRD, while important, is not an initial priority. The aged/non–dual eligible patients are the largest percentage of our population (86.5%). Even though they are the least expensive, they receive our immediate attention because this group incurs the largest overall expense. Fee-for-service expenses are then analyzed for each of the 4 enrollment types, annualized, truncated, and a payment completion factor is added in. Indirect Medical Education (IME) payments and Disproportionate Share Hospital (DSH) payments, as well as uncompensated care payments, are not included.

Next, using a complicated process, we identify the historical benchmark for per-capita expenditures in the previous 3 calendar years. The first benchmark year is 2009, and it is weighted 10%; the second is 2010 with a 30% weight, and the third is 2011 with a 60% weight. In addition, the federal Office of the Actuary (OACT) updates the benchmark to account for changes in beneficiary characteristics and the absolute amount of growth in per-capita expenditures. The historical benchmark is updated for subsequent years.

Beneficiary risk scoring uses the CMS-Hierarchical Condition Categories (HCCs) retrospective risk-adjustment model to adjust the benchmark years when updating the historical benchmark in subsequent years. Each year, the historical benchmark is updated for changes in health status and demographic factors that occur in the originally assigned beneficiaries. Consequently, the risk scores could go up or down depending on the diagnostic codes gathered by CMS claims. In the Verisk Health application, the DxCG risk scores for Models 125— a risk score that indicates how much the individual is predicted to cost (includes age, gender, eligible months, diagnostic codes, selected utilization, and prior cost) by multiplying the risk score by the plan average cost per person per year&mdash;were developed in concert with the HCCs.

Distribution of Net Savings Within the ACO 

There are many different approaches to dividing up the shared savings. In our case, this amount is divided into 2 parts. One part goes to Hackensack University Medical Center to repay part of their initial investment in the ACO—the balance goes to the primary care practices. The practices then divide up the amount among their physicians. The actual amount each practice or tax identification number (TIN) receives is based on the number of beneficiaries cared for by the TIN.

The story on the ability of MSSP to reduce costs is mixed. In performance year 1, which was 21 months long, 53 of 220 ACOs (24.1%) earned shared savings.

 In performance year 2, 97 of 353 ACOs (27.5%) earned shared savings.

 Behind the numbers is the fact that approximately half of the ACOs saved money in each of the performance years, but only the numbers shown exceeded the minimum savings rate to allow those few MSSPs to earn savings. For the 2 performance years, only 38 of 353 ACOs (10.8%) generated savings (according to a memo from Holly Wittenberg, Avalere Health, February 2016). The key factors that we believe most likely made a difference and permitted us to generate shared savings are as follows.

In the initial design for our ACO, the selection of the membership was critical. We decided to select practices that were already certified as patient-centered medical homes (PCMHs). A PCMH is defined as “a way of organizing primary care that emphasizes care coordination and communication to transform primary care into ‘what patients want it to be.’ Medical homes can lead to higher quality and lower costs, and can improve patients’ and providers’ experience of care.”

 The National Committee for Quality Assurance grants the certification. For those physicians who want to join the ACO but are not certified as PCMHs, we insist that they acquire the software to practice with an electric health record and become certified as a PCMH within 1 year. We agree to provide, free-of-charge, a trainer to facilitate their acquisition of PCMH certification.

The other major commitment we made initially was to provide a nurse care coordinator for the larger practices. Their goal is to identify the high-risk patients, get to know them well, and assure those patients relate to them whenever they felt ill to avoid the knee-jerk response of going to the ED immediately.

To minimize waste and avoid unnecessary hospitalizations, the combination of physician and nurse coordinator working in concert enabled the identification of areas of wasteful spending, creation of work plans, and provision of timely appointments to see the PCP team.

The physicians and nurses were informed of the 33 quality measures required by CMS. It was made clear that compliance with these measures determines whether savings generated by more efficient care will accrue to the ACO.

The next part was not so easy. We knew that information would be the key to success for this project. Consequently, we had to identify a data analytics firm to help determine which practices were and were not doing well. This information came from CMS in several reports—namely, the CCLFs and Financial Reconciliation Reports.

 We identified 3 companies—Health Endeavors, Verisk Health, and Milliman&mdash;that are helping us with various parts of our data analysis. The data from Verisk Health and Milliman go through a second filter at Premier Inc, which helps us identify key areas of required attention and areas where more investigation is needed.

Using these data analytics firms, we found from the Verisk Health analysis that our risk score for our population was higher (24.34) than many ACOs (17.17). This factor, in turn, meant that CMS determined that our historical expenses should be relatively high.

Although there is some evidence that ACOs with higher initial benchmark expenditures are more likely to be able to reduce expenditures, 

 this factor did not guarantee a reduction in expenditures for all high-cost ACOs. Regional differences need to be examined more closely to fully understand this phenomenon.

There are many areas where CMS and the ACOs themselves need to improve their programs, but time does not permit serious consideration of all these areas. For CMS, some of the areas, for example, include revision of the retrospective attribution of beneficiaries, reducing the complexity of determining cost savings, reexamining the “normal variation” in savings and losses, considering regional effects on cost, the role of merit-based incentive payment system, and competition from other alternative payment models such as bundled payments and the comprehensive primary care initiative. ACOs, themselves, need to deal with leakage of beneficiaries to other ACOs, performing annual wellness visits on all assigned beneficiaries, interconnectivity of numerous EHRs, choosing other areas to reduce waste such as skilled nursing facilities and other post-acute care options, and selecting appropriate data analytic software.

The MSSP’s ACOs appear to offer ample opportunity to improve the quality of care for the patient while at the same time, reduce the cost of care. Initial factors that should facilitate these changes are having physicians certified as patient-centered medical homes by NCQA and providing financial support for increased care coordination. In this setting, high-risk patients are likely to be seen more often in the office in order to prevent deterioration and to better manage their chronic conditions. PCMHs and care coordinators will provide the greatest opportunity to impact a large segment of medical care costs by decreasing hospital admissions, readmissions, and ED visits, while maintaining a higher quality of healthcare.

We should emphasize that we do not change physician practice, we change physician behavior. By creating the appropriate interventions, we eliminate waste in our bloated healthcare system. We learn to address patient needs better. Although we are still good at disease management, we learn how to perform health management better from the PCMH model.

The authors appreciate the editorial assistance provided by Regina G. Gross, MA.

Hackensack Physician-Hospital Alliance Accountable Care Organization, LLC (dba HackensackAlliance ACO) (PAG, ME, MM, EG, IS, RCG, RLG), Hackensack, NJ; Hackensack University Medical Center (PAG, ME, MM, EG, IS, RCG, RLG), Hackensack, NJ; Rutgers New Jersey Medical School (PAG, IH), Newark, NJ; Premier Inc (EP, VC), Charlotte, NC; Verisk Health Inc (JH), Salt Lake City, UT.

 The Hackensack University Medical Center supplied the startup and continuation funds.

 Dr Sawczuk is an employee of Hackensack University Medical Center CMO. MS Hart is an employee of Verisk Health. Mr Garrett is a member of the Hospital and Network Board of Hackensack and is the CEO of Hackensack University Health Network. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (PAG, EG, MM, VC, IS, RCG, RLG); acquisition of data (PAG, EG, ME, EP, VC); analysis and interpretation of data (PAG, EG, ME, MM, EP, VC, JH); drafting of the manuscript (PAG, MM, JH); critical revision of the manuscript for important intellectual content (PAG, ME, MM, JH); statistical analysis (PAG, ME, EP, VC); provision of study materials or patients (PAG, EG); obtaining funding (PAG, IS, RCG, RLG); administrative, technical, or logistic support (PAG, EG, ME, EP, VC, IS, RCG, RLG); and supervision (PAG, EG, MM, IS, RCG, RLG).

 Peter A. Gross, MD, Chair, ACO Board of Managers, 30 Prospect Ave, Hackensack, NJ 07601. E-mail: pgross@hackensackumc.org.

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3. Howell BL, Conway PH, Rajkumar R. Guiding principles for Center for Medicare & Medicaid Innovation model evaluations. 

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4. Ryan AM, Press MJ. Value-based payment for physicians in Medicare: small step or giant leap? 

. 2014;160(8):565-566. doi: 10.7326/M13-1715.

For 2 successive years, the Hackensack Alliance Accountable Care Organization achieved cost savings and maintained quality by using physicians with patient-centered medical homes and nurse care coordinators focused on high-risk patients.

The Ingredients of Success in a Medicare Accountable Care Organization

 To identify characteristics of effective, evidence-based pediatric medical home models using a primary care patient segmentation approach.

A systematic literature review of literature using the Medline database focusing on improving pediatric primary care and original studies of the pediatric medical home model was conducted. The primary care patient segmentation approach to organizing original studies resulted in 5 patient population segments used to further categorize and present findings.

 We searched the MEDLINE Ovid database with the keywords [“pediatric primary care”] and [“pediatric medical home”]. Inclusion criteria included data specific to pediatric primary care and data specific to the pediatric medical home. We excluded nonempirical data, non—peer-reviewed articles, medical case studies, articles not in the English language, and published abstracts.

 We identified 94 studies that met all inclusion criteria. Of these studies, 6 were identified and described as evidence-based models that targeted 5 patient population segments. We found that studies that report statistically significant results are directed toward even more targeted sub-segments than the original primary care patient segmentation framework used for this study and so used specialized care teams targeted toward these segments.

 The developed pediatric primary care patient segmentation framework developed in this study can be applied to improve implementation and operationalization of pediatric medical homes. This study demonstrates the importance of specialized sub-segments within pediatric population segments beyond the original primary care patient segmentation framework.A pediatric medical home is comprised of a coordinated system of care encompassing a team of health and social providers who are focused on supporting the medical and nonmedical needs of the child and its family.

 In light of the 2010 Affordable Care Act (ACA), medical homes have been implemented as a method to improve health outcomes, as well as reduce rising healthcare expenditures.

The American Academy of Pediatrics (AAP) developed the medical home model with the aim of delivering better primary care to children and adolescents with special health needs in the late 1960s.

It is purposed to facilitate an integrated healthcare system with an interdisciplinary team of patients and families, primary care physicians, specialists, subspecialists, hospitals and healthcare facilities, public health officials and the community.

 Interest in the patient-centered medical home (PCMH) model has grown exponentially across many spectrums of the healthcare system since 2010.

 It is important to note that the literature on PCMH has supplied primary care providers and policy makers with limited evidence and mixed results about the effectiveness of this patient care model, which calls for a systematic review of PCMH outcomes and effectiveness using a patient segmentation framework approach that can shed some light on the mixed messages in today’s literature. In using a primary care patient segmentation framework approach for this study, we were able to identify evidence-based models of PCMH practice and refine the patient segmentation model for pediatric primary care.

The Primary Care Patient Segmentation Framework 

As a way to better individualize and reduce discontinuity in healthcare delivery, Porter and colleagues propose in their study that improving primary care should be approached through organizing subgroups of patients with similar needs as a way to better individualize and reduce discontinuity in healthcare delivery.

 They note that value is often improved by multidisciplinary teams of clinicians that act as integrated provider units and collaborate to meet the major needs of the patients.8

Moreover, Porter et al recommend that patients’ outcomes and true costs should be measured by subgroups, and payment should be customized to bundle reimbursement for each subgroup to successively reward any improvement in care.

 By dividing the population into subgroups of patients with similar needs and conditions, progress can be made toward measuring outcomes and costs in regard to integrating primary care with specialty care.

 Additionally, collaboration and integration of care has the potential to improve and to increase by integrating primary care patient subgroup teams with relevant specialty care teams.

In this current study, we propose that for pediatric practices, children can be segmented similarly into analogous groups. By grouping children according to similarities in chronic diseases, special needs, and health status, many pediatric practices have developed multiple “needs-based” delivery systems explicitly designed to measure and improve value for specific segments of pediatric patients and families.

An exhaustive computer-assisted search was conducted in the Ovid interface to MEDLINE databases to identify relevant published articles. The search terms: [“pediatric primary care”] and [“pediatric medical home”] were used in the MEDLINE Ovid database. An additional search was also conducted in Google Scholar to identify any missing literature. Manual searches of references from relevant articles were performed to identify studies that were missed by the computer-assisted search. This study was approved by the Texas A&M University Institutional Review Board.

Two investigators (DT and BK) reviewed all publication titles of citations identified by the search strategy and confirmed the selected articles presented in this study. Study populations were then organized into the primary care patient segmentation framework by the second investigator (BK) and further reviewed and confirmed by both investigators (DT and BK). Potentially relevant studies were retrieved and articles were independently checked for inclusion. Inclusion criteria included data specific to pediatric primary care and data specific to the pediatric medical home. We excluded nonempirical data, non—peer-reviewed articles, medical case studies, articles not in the English language, and published abstracts.

One investigator (DT) independently extracted required information from eligible studies using a standardized form adapted from Porter et al.

 The second investigator (BK) reviewed and confirmed all data extracted. Data was also collected on study design, date of the study, outcomes and impact of the study, and information related to the respective pediatric patient segmentation. These population segmentation groups were separated into 5 ordinal health categories: 1) Healthy, 2) Healthy With A Complex Acute Illness, 3) At Risk, 4) Chronically Ill, and 5) Complex; modeled after Porter and colleagues’ framework.

 Frequencies of emergent themes in relation to pediatric primary care were also recorded.

This patient segmentation model served as the framework of analysis; the primary care patient segmentation strategy is therefore applied to pediatric primary care. This conceptual model is presented in 

The computer-assisted search yielded 200 potentially relevant citations. After the initial review, 174 titles were considered appropriate, and these abstracts were reviewed. Of these articles, 31 did not meet inclusion criteria, and, subsequently, 143 articles underwent full-text review. Of these articles, 49 were excluded, as they did not have relevant information or evidence-based data specific to pediatric primary care or the pediatric primary care home. This left a total of 94 studies that met all inclusion criteria.

Of the remaining 94 studies, 6 were chosen and those evidence- based models were categorized into the framework of the aforementioned 5 population segments (Healthy, Healthy With a Complex Acute Illness, At Risk, Chronically Ill, and Complex). We found that a more sub-segmented approach was needed to serve pediatric populations with special needs because the primary care patient segmentation framework was too general for these populations. Sub-segments for various socioeconomic statuses, geography, and payer mix should also be considered when developing evidence- based programs of pediatric primary care. A summary table of the evidence-based pediatric primary home results is presented (

), and includes selected studies that also provided guidance and information on how to operationalize the evidence-based model of care.

Applying this primary care patient segmentation framework to the results of the systematic literature review, we find that studies that report statistically significant results are directed toward very targeted sub-segments. A detailed analysis of these evidence-based pediatric primary care models and correlated segment populations and subsequent sub-segments are presented next.

The medical home model has the potential to foster high-quality care and reduce disparities in treatment, especially among vulnerable populations.

 In an effective medical home, a family’s cultural background—including beliefs, rituals, and customs&mdash;are recognized, valued, respected, and incorporated into the care plan. Pediatric primary care physicians should make an effort to improve their knowledge, skills, and attitudes in working and communicating with diverse children and families.

A qualitative study by DeCamp and colleagues assessed the views and experiences of Latina mothers with regard to expectations for pediatric primary care to inform medical home implementation in practices serving large limited English proficiency (LEP) populations.

 DeCamp and colleagues found that children with mothers with limited English proficiency were not receiving high-quality pediatric care.

These mothers suggested methods to improve this, which included a composition of certain members of the patient care team.

This study presents practice relevant information and actionable results that can help to operationalize evidence-based patient-centered medical home models in pediatric clinics.

June 2016

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