Breaking New Ground in Health Services Research: Effect of Attribution Length in a Pediatric Medicaid Accountable Care Organization

In the current accountable care organization (ACO) environment, pediatric health systems and hospitals are striving toward better population health management and cost control as they begin to assume the risk for the use of health care resources and spending. In this issue of JAMA Pediatrics, Christensen and Payne1 have elevated the conversation on the impact of pediatric ACOs to a higher level of sophistication by exploring the relationship among attribution, resource use, and cost within a pediatric Medicaid population. The authors demonstrated promising findings within a Medicaid ACO involving Children’s Hospitals and Clinics of Minnesota and the State ofMinnesota Department of Human Services. Specifically, thestudy foundthatACOattributionwas correlated with decreases in the use of inpatient care resources and spending, particularly among childrenwithmultiple chronic conditions. The authors acknowledged, however, that the total ACOcohort hadbeen reducedby 50%after 12 months and by 70% after 24months. Given that the study did not control for social determinants, the authors asked the following question: If the proportion of patientswho became unattributed represent thosewhose social circumstanceshave a negative influence on their health, would successful efforts tomaintainengagementhave resulted ina reduction in theuse of resources and cost in this group? In the context of social determinants for theMedicaidpopulation, a corollary issuearises with the assumption that continued attribution is a useful proxy for consistent primary care. These observations raise 2 critical questions for hospitals andhealth systems involved inpediatricMedicaidACOs.First, what levelof responsibility shouldweassume insustainingpatient engagement in the primary caremedical home? Second, what types of efforts tomaintainACOattributionwould yield a solid return on investment in a shared risk and shared savings environment? Clearly, ifpediatrichealthsystemsandhospitalsassumethat maintenanceofattribution isour role, thesolutionwill becomplex and the pathwill be nonlinear. To identifywhich types of populationhealth interventionsmightbemosteffective inkeepingpatientsattributed, in improvingtheirhealthoutcomes,and inreducingtheircostsofcare,wemust firstdeterminewhat factorsdrivedisengagementfromprimarycare.Datacollectedfrom screeningACOmembers for social determinantswouldpermit organizations to risk stratify for disengagement and use predictive analytics to target appropriate engagement maintenanceefforts.Thesedatacouldalsodriveanorganization’splanningandimplementationofthepopulationhealthinterventions, which could enhance the ACO’s effects on attributed members’ health outcomes, resource use, and spending. In considering the implementation of interventions designed to address social determinants, ACOs must balance the likelihood of an intervention’s efficacy with its anticipated value for a given population, often without the ability to rely on randomized clinical trials or rigorous cost-benefit analyses. Investing in interventions that lack a substantial evidence base feels risky to organizations, even when powerful, individual anecdotal evidence supports their implementation. For example, medical-legal partnerships (MLPs) integrate civil legal services in health settings to help lowincome patients and their families meet basic needs toward improved health. A pediatric patient attributed to an ACO whose family is wrongfully evicted from their home may disengage from their primary care medical home and become unattributed when the family is forced to move. Given that MLPs provide “preventive” legal care, this patient’s family may have been able to engage with the attorney member of their health care team at the initial eviction notice, preventing their eviction in the first place. In fact, as observational pilot studies have shown, MLPs have improved patients’ and families’ adherence to treatment plans2 and have reduced emergency department visits and readmission rates among adults with high rates of resource use.3 Unfortunately, a dearth of empirical evidence to date undermines the ability to bring the MLP model to scale.4 Furthermore, at a health system level, whether the MLP intervention and its subsequent stabilizing effects for families produce downstream health outcomes and value might feel too uncertain to justify a significant contribution of scarce resources. To be sure, the efficacy and value of attribution maintenance efforts will increase exponentially if they are implemented with an eye toward the families’ quality of experience in accessing those services. That is, focusing on the quality of attribution is as important as focusing on the length of attribution. Pediatric settings could address social determinants more systematically with a family-based orientation, providing a range of services to caregivers and to patients. As pediatric health systems increasingly engage payers around value-based or accountable care contracts, opportunities emerge to improve outcomes and value in pediatric care through more direct engagement with parents. This engagement could take the form of communitybased partnerships with infant-home visitation programs, standardized screening for psychosocial or mental health risk within families (including subsequent referrals and treatment), or provision of direct services within the pediatric system to support parents (eg, voluntary, integrated reproductive health services to adolescent and young mothers). Related article page 148 Opinion Editorial