Consistent Primary Care for Children Cuts Hospital Use

Diana Phillips

December 15, 2015

Children in the Medicaid population who receive consistent primary care over the course of more than 2 years in an accountable care organization (ACO) are less likely to require inpatient care than those without continuous involvement in a primary care practice, according to results of a study published online December 14 in JAMA Pediatrics.

In addition, the annual costs are lower for those receiving consistent care.

"Consistent primary care among the pediatric Medicaid population is challenging, but these findings suggest substantial benefits if consistency can be improved," write Eric W. Christensen, PhD, and Nathaniel R. Payne, MD, from the Children's Hospitals and Clinics of Minnesota in Minneapolis.

To assess the association between the length of ACO attribution, a proxy for receiving consistent primary care, and the use and cost of healthcare resources in a pediatric Medicaid population, the investigators conducted a retrospective study of Medicaid claims data for nearly 29,000 patients who had been attributed to a pediatric ACO for at least 1 month, from September 1, 2013, to May 31, 2015.

In the overall population, length of attribution of at least 2 years was associated with a 40.6% decrease in the number of inpatient days, whereas office visits, emergency department visits, and use of pharmaceuticals increased in this population by 23.3%, 5.8%, and 15.3%, respectively.

"[T]he increased use of outpatient resources may be explained by patients' having easier access to care that had previously been relatively inaccessible," the study authors write.

Attribution to the ACO appeared most effective at lowering inpatient use among patients with chronic conditions, they report. "The presence of at least 3 body systems with a chronic condition was associated with a greater decrease in inpatient use of resources compared with the presence of 0 to 2 chronic conditions."

With respect to cost, continuous involvement with a primary care practice for 2 years reduced costs by 15.7% (95% confidence interval, 6.6% - 24.8%) in the study population. "These cost reductions were largest 13 to 18 months after attribution and diminished with longer attribution," the study authors explain.

The most significant cost reduction was observed among patients with three body systems with a chronic condition. In these patients, costs decreased by 32.5% (95% confidence interval, 15.1% - 49.8%). In contrast, no significant cost reduction was associated with duration of attribution among patients with from zero to two body systems with a chronic condition, they report.

Together with the observed association between duration of attribution and decreased resource use, the cost finding "suggests that pediatric Medicaid ACOs may be substituting less expensive outpatient care for more expensive inpatient care and exerting their greatest effect in the first year of a patient's attribution," the authors write. They note that ACOs seemed most effective at reducing costs and resource use among patients with multiple chronic conditions.

Although policies that would increase the length of attribution to the ACO might increase cost savings, such initiatives "might also be challenging to implement because these patients often have social determinants that influence when and where they seek care," the authors hypothesize.

For example, in the current study, only 30% of the ACO population remained attributed for 2 years. Compared with the 15.7% cost reduction associated with attribution of at least 2 years, the cost reduction among the overall population was 9.8%, which is a decrease that "would be substantial at the population level if applied to most pediatric Medicaid patients," the authors state.

The benefits associated with primary care consistency in this patient population "will need to be replicated in other populations," the authors conclude.

The authors have disclosed no relevant financial relationships.

JAMA Pediatr. Published online December 14, 2015. Full text

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