Dayton Children's affiliates, Anthem form value-based deal

Dayton Children’s Hospital has formed a network of affiliated pediatricians and struck a deal with Anthem that will give incentives to keep patients healthy and out of the ER and other expensive care when possible.

One of the challenges in the business of health care is that hospitals and doctors make more money from serving a sick population than they do from a healthier community that doesn’t need to pay for as many services. Providers, policy makers and insurers are trying to figure out how to change these misaligned financial incentives and develop new payment models that reward quality.

A new business contract could help push for more value-based care, formed by Dayton Children’s Hospital, Anthem Blue Cross and Blue Shield, and more than 50 Miami Valley pediatricians.

The Dayton Children’s Health Partners clinically integrated network is set up unique because the doctors aren’t directly employed by the hospital. Instead they have a business deal to join together to share health data to improve decision making as a group and to contract with Anthem on financial rewards for meeting certain quality measures.

“Population health has a lot to do with just having good data on your population. We’re able to identify who are those patients that are going to the ED (emergency department) and what could we do to help them not need to do that,” Lisa Henderson, executive director of Dayton Children’s Health Partners.

Kelly Owen, Anthem’s payment innovations market lead, said if a child has asthma, there’s more money to be made in ER visits than in preventative care or cheaper settings. But under the health partners model set up with the pediatricians or Dayton Children’s, there are changes in their reimbursement models to incentivize things like keeping schedules open for same day primary care appointments.

“Today our health care dollar pays for illness and what we are shifting to is we’re really paying providers to keep patients healthy,” Owen said.

This pay-for-value deal is part of a broader shift in health care to thinking about how to pay more for better quality health, said Greg Moody, director of the Office of Health Transformation, which has been pushing for value-based contracts.

“What we know is there are a lot of primary care practices already working hard to keep people well, but when they do the result is that practice gets paid less,” Moody said. “Because if you are keeping someone well and avoiding the services you are charging for, well that’s the only way the practice gets paid in the old fee-for-service model.”

“The incentive is to always provide more units of service at a higher price, which pushes things out of primary care up into an emphasis of specialty care when what people want is to prevent things from going wrong so they can prevent going into that higher cost care,” Moody said.

In Ohio, the state has data collection that lets primary care practices look at cost and quality data for specialists and have the information when referring patient to specialty care. It lets doctors make informed referrals.

“At the patient level a lot of this goes unseen, but you get a better version of primary care,” Moody said.

Pediatrician network

Nine Miami Valley pediatric practices will participate in the Anthem-Dayton Children’s collaboration.

• Child and Adolescent Specialty Care of Dayton

• Children’s Medical Center of Middletown

• Cornerstone Pediatrics

• Ohio Pediatrics

• Pediatric Associates of Dayton

• Shelby Pediatrics

• South Dayton Pediatrics

• Springboro Pediatrics

• Wilmington Medical Associates