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The business case for pediatric asthma quality improvement in low-income populations: examining a provider-based
Kristin L Reiter1, Kristin Andrews Lemos2, Charlotte E Williams3
1Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7411, USA.
Insights
A pediatric asthma pay-for-reporting intervention by a Medicaid plan showed a negative return on investment (ROI). High costs and no reduction in emergency or hospital use meant the program was not financially viable.
Area of Science:
- Health economics
- Pediatric healthcare management
- Quality improvement initiatives
Background:
- Medicaid managed care plans seek cost-effective interventions for chronic pediatric conditions like asthma.
- Pay-for-reporting models incentivize healthcare providers to improve care quality through performance measurement.
Purpose of the Study:
- To evaluate the financial return on investment (ROI) of a pediatric asthma pay-for-reporting intervention.
- To determine the economic viability of a chart audit and incentive program for asthma care in a Medicaid population.
Main Methods:
- A practice-level, randomized prospective evaluation was conducted with 25 primary care practices.
- 11 treatment practices received monthly incentives for conducting bi-annual chart audits and reporting adherence to asthma guidelines.
- Control practices (12) received usual care; ROI was calculated using net present value analysis.
Main Results:
- The intervention resulted in a negative ROI for the Medicaid managed care plan.
- High intervention costs and a lack of significant reductions in emergency department and hospital utilization were key factors.
- No financial benefit was observed in the treatment group compared to the control group.
Conclusions:
- A pay-for-reporting intervention using chart audits is unlikely to yield a positive financial ROI within a 2.5-year timeframe.
- Significant reductions in high-cost healthcare utilization are necessary for such interventions to become financially sustainable.
- Alternative strategies may be needed to improve pediatric asthma care quality and control costs effectively.
Objective:
To measure the return on investment (ROI) for a pediatric asthma pay-for-reporting intervention initiated by a Medicaid managed care plan in New York State.
Design:
Practice-level, randomized prospective evaluation.
Setting:
Twenty-five primary care practices providing care to children enrolled in the Monroe Plan for Medical Care (the Monroe Plan).
Participants:
Practices were randomized to either treatment (13 practices, 11 participated) or control (12 practices).
Intervention:
For each of its eligible members assigned to a treatment group practice, the Monroe plan paid a low monthly incentive fee to the practice. To receive the incentive, treatment group practices were required to conduct, and report to the Monroe Plan, the results of chart audits on eligible members. Chart audits were conducted by practices every 6 months. After each chart audit, the Monroe Plan provided performance feedback to each practice comparing its adherence to asthma care guidelines with averages from all other treatment group practices. Control practices continued with usual care.
Main Outcome Measures:
Intervention implementation and operating costs and per member, per month claims costs. ROI was measured by net present value (discounted cash flow analysis).
Results:
The ROI to the Monroe Plan was negative, primarily due to high intervention costs and lack of reductions in spending on emergency department and hospital utilization for children in treatment relative to control practices.
Conclusions:
A pay-for-reporting, chart audit intervention is unlikely to achieve the meaningful reductions in utilization of high-cost services that would be necessary to produce a financial ROI in 2.5 years.