Clinicians involved in children’s health care can drive changes in payment models to improve the quality, cost-effectiveness, and the degree to which care is child-focused according to a viewpoint article published in JAMA Pediatrics.

Payment system reform should reflect the unique needs of children and adolescents. Children differ from adults epidemiologically, evolving over time from infants to adolescents, and requiring different approaches as they grow and develop. Currently, Medicaid and the Children’s Health Insurance Program (CHIP) insure more than 50% of children in the United States, allowing these programs to hold tremendous influence on payment structures.

Charlene A. Wong, MD, MSHP, of the department of pediatrics, Margolis Center for Health Policy, Duke Clinical Research Institute at Duke University, Durham, North Carolina, and colleagues argue for the inclusion of children’s health care providers in value-based payment reform efforts. They presented 4 different payment models.

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The first of these is the fee for service (FFS) model, which is currently the predominant health care payment system in the United States. However, the investigators contend that FFS does not effectively support many valuable child health care services, such as family-centered care coordination and screening for and tackling high-risk social situations and school problems. The second system is the FFS linked to quality and value. Although this type of system retains an FFS payment structure, it includes payments for infrastructure development and rewards for good performance on quality measures. 

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The third and fourth systems are alternative payment models (APMs) that introduce the concept of payment based on accountability for patients and populations. These models are part of a spectrum that is based on the degree of accountability for patients and populations involved and range from an APM model built on an FFS architecture to population-based payments linked to full accountability for quality and spending.

The researchers cite Partners for Kids at Nationwide Children’s Hospital as a full-risk, population-based model that receives a Medicaid per-member, per-month, age- and sex-adjusted payment that has lowered costs but with mixed results on quality measures. They also note that some APMs coordinate between health care organizations and payers such as Medicaid or CHIP, and health-related services such as Early Heard Start, child welfare, and juvenile justice programs, which may aid in addressing the kind of social adversity in childhood that affects long-term health. 

The investigators concluded by calling for value-based payment approaches and care models that increase quality and cost-effectiveness and hold promise for increased overall financial support for child health.


Wong CA, Perrin JM, McClellan M. Making the case for value-based payment reform in children’s health care [published online April 9, 2018]. JAMA Pediatrics.   doi:10.1001/jamapediatrics.2018.0129.