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. 2023 Aug 1;6(8):e2327264.
doi: 10.1001/jamanetworkopen.2023.27264.

Analysis of North Carolina Medicaid Claims Data to Simulate a Pediatric Accountable Care Organization

Rushina Cholera  1   2   3 , David M Anderson  1   3 , Richard Chung  2 , Jessica Genova  1 , Peter Shrader  3 , William K Bleser  1 , Robert S Saunders  1 , Charlene A Wong  1   2
Affiliations

Analysis of North Carolina Medicaid Claims Data to Simulate a Pediatric Accountable Care Organization

Rushina Cholera et al. JAMA Netw Open. .

Abstract

Importance: Despite momentum for pediatric value-based payment models, little is known about tailoring design elements to account for the unique needs and utilization patterns of children and young adults.

Objective: To simulate attribution to a hypothetical pediatric accountable care organization (ACO) and describe baseline demographic characteristics, expenditures, and utilization patterns over the subsequent year.

Design, setting, and participants: This retrospective cohort study used Medicaid claims data for children and young adults aged 1 to 20 years enrolled in North Carolina Medicaid at any time during 2017. Children and young adults receiving at least 50% of their primary care at a large academic medical center (AMC) in 2017 were attributed to the ACO. Data were analyzed from April 2020 to March 2021.

Main outcomes and measures: Primary outcomes were total cost of care and care utilization during the 2018 performance year.

Results: Among 930 266 children and young adults (377 233 children [40.6%] aged 6-12 years; 470 612 [50.6%] female) enrolled in Medicare in North Carolina in 2017, 27 290 children and young adults were attributed to the ACO. A total of 12 306 Black non-Hispanic children and young adults (45.1%), 6308 Hispanic or Latinx children and young adults (23.1%), and 6531 White non-Hispanic children and young adults (23.9%) were included. Most attributed individuals (23 133 individuals [84.7%]) had at least 1 claim in the performance year. The median (IQR) total cost of care in 2018 was $347 ($107-$1123); 272 individuals (1.0%) accounted for nearly half of total costs. Compared with children and young adults in the lowest-cost quartile, those in the highest-cost quartile were more likely to have complex medical conditions (399 individuals [6.9%] vs 3442 individuals [59.5%]) and to live farther from the AMC (median [IQR distance, 6.0 [4.6-20.3] miles vs 13.9 [4.6-30.9] miles). Total cost of care was accrued in home (43%), outpatient specialty (19%), inpatient (14%) and primary (8%) care. More than half of attributed children and young adults received care outside of the ACO; the median (IQR) cost for leaked care was $349 ($130-$1326). The costliest leaked encounters included inpatient, ancillary, and home health care, while the most frequently leaked encounters included behavioral health, emergency, and primary care.

Conclusions and relevance: This cohort study found that while most children attributed to the hypothetical Medicaid pediatric ACO lived locally with few health care encounters, a small group of children with medical complexity traveled long distances for care and used frequent and costly home-based and outpatient specialty care. Leaked care was substantial for all attributed children, with the cost of leaked care being higher than the total cost of care. These pediatric-specific clinical and utilization profiles have implications for future pediatric ACO design choices related to attribution, accounting for children with high costs, and strategies to address leaked care.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Anderson reported receiving personal fees from Alliant Health Plans, EvenSun and SilverSpread Consulting outside the submitted work. Dr Chung reported receiving personal fees from Ambetter of North Carolina outside the submitted work. Dr Bleser reported receiving personal fees from StollenWerks, BioMedical Insights, Gerson Lehrman Group, Robert Wood Johnson Foundation, and West Virginia Primary Care Association outside the submitted work. Dr Saunders reported receiving personal fees from Yale–New Haven Health System outside the submitted work. Dr Wong reported serving as the Assistant Secretary for Children and Families at the North Carolina Department of Health and Human Services. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Simulation of Prospective Attribution to the Hypothetical Medicaid Accountable Care Organization (ACO) Based on Prior Year Primary Care Usage
AMC indicates academic medical center. aDefined as at least 50% but less than 100%.
Figure 2.
Figure 2.. Health Care Utilization Patterns in the Accountable Care Organization Performance Year Among Attributed Children and Young Adults in Lowest and Highest Cost Quartiles
Figure 3.
Figure 3.. Type of Care Sought Outside the Accountable Care Organization (Leaked Care) During the Performance Year by Frequency and Cost
See this image and copyright information in PMC

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