91´óÉñ

October 2026

By: Jeff Steller, MSc, Manager of Quality Network Operations, Aetna OhioRISE

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This post dives into the perspective of (Resilience through Integrated Systems and Excellence), a specialized Medicaid managed care plan administered by Aetna Better Health of Ohio that offers wraparound care management and additional services for youth up to age 21 with complex behavioral health and multisystem needs.

What shared goals can payers and providers pursue when they work together to advance pediatric pay for health models?

Together, payers and providers can pursue the ultimate goal: delivering the right care, in the right place, at the right time, in a way that supports the whole family. As we advance pay for health models, our collective focus must expand beyond utilization of healthcare services. Now we can also ask whether the child is safer, more stable, less likely to need the emergency department, and better supported at home, school, and in the community.

For payers and providers, this expanded vision of health care creates a strong common purpose. Providers bring deep knowledge of children and families. Payers can help align benefits, care coordination, data, and incentives. When those pieces work together, the healthcare system can stop reacting to crises and start preventing them. The best pay for health models allow payers and providers to take on problems together that once felt impossible to overcome.

Describe a pay for health model in which Aetna OhioRISE participates. Who are the key stakeholders, and what are some of the key goals and metrics?

One of the pay for health models we use is our Pay for Quality (P4Q) plan. Care Management Entities (CMEs) are eligible to participate. CMEs are community-based organizations delegated to provide wraparound care coordination for OhioRISE members. The program consists of two parts: a shared savings pool and a fixed dollar allocation.

To receive savings from the shared savings pool, the CME must achieve certain performance measures focused on the quality-of-care coordination services and reduction in inpatient readmissions. The CMEs often reinvest the funds in workforce development; they hire additional staff, offer additional trainings and, in several instances, hire staff focused on improving outcomes.

The second part of the P4Q program is the fixed dollar allocation. This allocation is tied to Aetna Better Health of Ohio’s participation in the , the quality improvement structure connected to the Ohio Department of Medicaid’s Quality Withhold Program. When Aetna meets its quality performance standards through OAK, a portion of the payout is passed on to CMEs. Each CME is eligible for these funds by meeting targets for 7-day follow-up after a behavioral health or substance use-related emergency department (ED) visit.

What was the process for designing and implementing this model?

OhioRISE’s value-based contracting approach was intentionally designed through a collaborative process that engaged the CMEs responsible for delivering services and supporting youth and families across the state. Aetna met individually and collectively with CMEs to discuss program goals, identify operational realities, review performance opportunities, and shape a value-based model that balances accountability with the resources needed to succeed. These conversations helped ensure that performance measures reflected meaningful outcomes for youth and families while remaining practical for implementation across diverse regions. The OhioRISE Provider Agreement also reinforces the expectation that payers develop key value-based measures for CMEs in partnership with system stakeholders and aligned with statewide standards.

While at the same time, Aetna worked closely with the Ohio Children’s Alliance, behavioral health providers, and the Ohio Department of Medicaid to refine measures, incentives, and implementation strategies. Through ongoing feedback sessions, workgroups, and regulatory collaboration, the model evolved into a shared accountability framework focused on improving care coordination, increasing access to community-based services, strengthening quality outcomes, and advancing OhioRISE’s broader vision of a more coordinated system of care for children and families.

What lessons or advice would you have for others looking to advance similar work?

First, do not underestimate the challenge of implementation. A good model on paper is not the same as a working system for families. Families often tell me they experience the system as one, not as separate organizations, funding streams, or provider networks.

Second, measure what matters, but keep the measure set focused. ED visits, inpatient stays, length of stay, timely follow-up, and access to community-based care are meaningful because they show whether children are getting help before they reach crisis. They can also be useful indicators of future health outcomes, which makes them especially valuable in this work.

Third, build the model around local relationships. Statewide infrastructure is important, but local care teams know the providers, schools, agencies, and family supports that determine whether a care plan is realistic.

Finally, be honest about what is hard. Cross-system work is slow. Even when data is available, it is often imperfect. When partnerships are extended outside of healthcare settings, the complications multiply and make the work much more challenging. Incentives can help, but they do not replace trust, accountability, and day-to-day problem solving.

Do you have any recommendations to policymakers about how best to incentivize payers and providers to participate in pediatric pay for health models?

In his blog post, President and CEO of 91´óÉñ Children’s Health, R. Lawrence Moss, MD, FACS, FAAP, articulated many of the recommendations I find necessary to incentivize payers and providers to move towards pay for health models. If we want better outcomes for children, we need payment models that look beyond health care alone. States need room to test cross-sector approaches that address housing, food security, schools, and family stability. We must stop expecting immediate results and measure impact over years, not months. Failing to do so disincentivizes ambitious, long-term thinking for fear of losing out on future funding or affecting operating margins. This short-term thinking also risks us cutting off promising models before their results are fully visible.

Creating policies that facilitate cross-sector data sharing is imperative. If we reduce the costs associated with data sharing (e.g., legal negotiations, data engineering, and cross-system interoperability efforts), systems can redirect that money towards interventions and other system work.

Ideally, policymakers should start looking at lifetime savings and allow for payment models that reward payers and providers for moving care upstream. If we prioritize outcomes like these across the full continuum of factors that shape child health, we can build systems that help more children reach their full potential.