Wise health care spending for children with medical complexity

Spending on children with medical complexityJay Berry, MD, MPH, is a pediatrician and hospitalist in the Complex Care Service at Boston Children’s Hospital.

Growing up, my parents repeatedly reminded me that “money doesn’t grow on trees.” They pleaded with me to spend it wisely. I’ve recently been thinking a lot about my parents and how their advice might apply to health care spending for my patients.

As a general pediatrician with the Complex Care Service at Boston Children’s Hospital, I care for “medically complex” children. These children—numbering an estimated 500,000 in the U.S.— have serious chronic health problems such as severe cerebral palsy and Pompe disease. Many of them rely on medical technology, like feeding and breathing tubes, to help maintain their health.

These children are expensive to take care of. They make frequent health care visits and tend be high utilizers of medications and equipment. Some use the emergency department and the hospital so often that they’ve been dubbed frequent flyers. This hefty use of health services can be extremely taxing for the children, their families and the health system.

Many clinicians, policymakers and parents believe that health care spending for children with medical complexity isn’t as wise as it could be. They think that spending is too high for emergency department and hospital care, and that it is too low for primary care and other forms of outpatient care.

Children with medical complexity
Modest reductions in spending for hospital care could be used to fund better outpatient care for medically complex children.

What if we spent more on primary and outpatient care for these children? Maybe the kids would receive better care, be healthier and wouldn’t have to use the emergency department or the hospital so much.

The problem with this speculation, though, is that no one fully understands how much and where money is spent on health care for children with medical complexity. So, my colleagues and I decided to document health care spending for these children and conduct a business case analysis.

Since about two thirds of children with medical complexity are on Medicaid, we tapped Medicaid data from multiple states. We set a budget for spending on hospital and emergency department visits and determined how much extra money might be available if we could manage children’s care in the community to avoid these visits. We then described how that extra money could be spent on primary and outpatient care.

This exercise greatly increased our understanding of health care spending for children with medical complexity. We found that modest reductions in spending for hospital care could, in turn, be used to fund better outpatient care for many of the children.

Our findings were released yesterday in the December issue of Health Affairs—a peer-reviewed journal that bridges health care research to politics—as part of a larger special issue on children’s health. The findings are timely because of the current bipartisan bill encouraging states to innovate and improve models of care for children with medical complexity. With time and robust data, I hope we’ll figure out the wisest way to invest in the health care that will benefit children with medical complexity and their families the most.

Read more on the Health Affairs blog and on The Advancing Care for Exceptional Kids Act (ACE Kids Act; H.R. 4930).