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A Well being System That Can't Look after Kids – jj

A Well being System That Can't Look after Kids


The field of pediatrics has made incredible strides over the past century in its ability
to care for critically ill children. The fields of pediatric critical care medicine
and pediatric emergency medicine have been board-certified subspecialties for over
30 years now and technical reports from the American Academy of Pediatrics have outlined
guidelines for pediatric care in the Emergency Department since 2001, with the most
recent report in 2018. Despite these advances, a recent trend threatens the well-being
of children–community hospital pediatric closures and consolidation at regional children’s

An important article by Michelson et. al (10.1542/peds.2019-2203) in Pediatrics adds to the prior reports from Franca and McManus1 and Khare and Rauch2 noting the recent trend of children not receiving definitive care in the community.
Using data from the Healthcare Utilization and Costs (HCUP) Nationwide Emergency Department
system (NEDS) database from 2008-2016, the authors demonstrated that in 8 years fewer
hospitals were able to care for children in inpatient settings and the number of transfers
for definitive care increased 28%. An accompanying commentary by Dr. Guache-Hill (10.1542/peds.2019-3372) highlights the “perfect storm” that’s occurring in the US–fewer hospitals are caring
for children with inpatient conditions and have to wait longer in emergency departments
that have gaps in their capability to care for them. The consolidation and regionalization
of care potentially could be successful, but not only would this take a coordinated
response, but also a payment structure that currently doesn’t exist in our country.

Given the pressure to reduce costs of hospital care, alternative payment models have
been implemented in many hospitals around the country. While most focus on the Medicare
population, these models have impacts on the delivery and payment of care to children
as well. Hospitals in value-based payment models such as global budgets, bundling,
or value-based care are incentivized to provide quality, reduce readmissions, and
keep ambulatory sensitive conditions out of the hospital setting. As general community
hospitals begin to focus on how to survive in this new environment, the focus turns
to the care of adults. Given the low payment for pediatric care in general, maintaining
a 24/7 unit staffed by pediatricians and pediatric trained nurses with low and variable
censuses creates a large financial deficit. Thus, the decision to close a “lost leader”
non-profitable, high-risk service as inpatient pediatrics becomes easier and more
common. Unless we follow Dr. Gauche-Hill’s recommendation to intentionally address
both the structural issues around regionalization of care and transport as well creating
adequate payment structures for pediatric care, we will continue to see a decline
in quality and access. Unfortunately, it will be the children who will pay the consequence
and the sickest won’t get the care they need in a timely manner.


  • França UL, McManus ML. Availability of Definitive Hospital Care for Children. JAMA Pediatr. 2017;171(9):e171096. doi:https://doi.org/10.1001/jamapediatrics.2017.1096
  • Trends in National Pediatric Bed Census. Manaswitha Khare, Daniel A. Rauch. Pediatrics. September 2017, VOLUME 140 / ISSUE 1 MeetingAbstract

Copyright © 2019 American Academy of Pediatrics

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