Chronically ill children with private insurance less likely to be admitted to specialty-care center: Study

Chronically ill children with private insurance are much less likely than those with public insurance, such as Medi-Cal, to be admitted to a California hospital offering specialized pediatric care, according to a new study by researchers at Lucile Packard Children's Hospital and the Stanford University School of Medicine.

The study also shows that the likelihood of a chronically ill child being admitted to a specialty-care center varies wildly across the state. For example, chronically ill children in San Francisco and San Mateo counties were far more likely to be hospitalized at a pediatric specialty-care center than their counterparts just across the bay in Sonoma and Napa.

These findings and several others in the study suggest that decisions about whether to refer a chronically ill child to a pediatric specialty-care hospital are in many cases driven by factors other than medical need. The study appears in the June issue of Pediatrics, which is also available online at http://pediatrics.aappublications.org.

In examining hospital-discharge data from 1999 to 2007, the researchers concluded that the state's health leaders urgently need to review the policies and practices that determine where chronically ill kids are hospitalized. "There does not appear to be a coordinated and coherent system," said Paul Wise, MD, MPH, the study's senior author. "We were expecting some variation, but not this much."

Pediatric specialty-care centers offer high levels of intensive care and a variety of clinical subspecialties. There are about 20 of these centers in California, including Santa Barbara Cottage Hospital and Riverside County Regional. Eight of these centers offer the most comprehensive range of services and are accredited as children's hospitals, among them Packard Children's.

In 2007, pediatric beds at specialty-care centers were occupied 67 percent of the time by children with public insurance but only 32 percent of the time by privately insured children, the study reported.

The reasons for the discrepancy are likely complex, the researchers said. But Wise, the Richard E. Behrman Professor of Child Health and Society at the School of Medicine and a pediatrician at Packard Children's, said he and his colleagues were planning to conduct a follow-up study to determine whether health maintenance organizations and other private insurers contributed to this disparity. It's possible, he said, that doctors are less likely to refer chronically ill kids with private insurance to pediatric specialty-care centers, whose services generally cost more than those of regular hospitals.

The study also suggests that the state has been successful in helping low-income children with chronic illnesses get access to specialty-care services. However, the fact that public insurance is paying for the majority of these services makes the pediatric specialty-care centers, not to mention the children who depend on them, especially vulnerable to the state's current financial problems, said the lead author Lisa Chamberlain, MD, MPH, a pediatrician at Packard Children's and assistant professor of pediatrics at the medical school.

"The specialty centers that see these patients are very dependent on the public financing of care," Chamberlain said. "With the unprecedented state budget crisis, Sacramento may look to balance the books by changing reimbursement patterns."

How far chronically ill children lived from specialty-care centers also played a role in determining whether they would be hospitalized at one, but geography wasn't the only important factor, the researchers said, pointing to several counterintuitive findings. One is that chronically ill children in central California - the counties of Mariposa, Madera, Fresno and Kings, which are among the poorest in the state - were among the most frequent users of specialty-care centers statewide: 72 to 91 percent of these patients were discharged from such a center, even though there is only one, Children's Hospital Central California in Madera, serving the entire region.

Chronically ill children in this area may have been going to a specialty-care center at higher rates because they were covered by public insurance and because of the relative paucity of nearby hospitals with inpatient services, Wise said.

But in densely populated Los Angeles County, only 60 percent of chronically ill children were admitted to pediatric specialty-care centers, even though the county had by far the greatest concentration of such centers - seven - statewide.

This relatively low admission rate may stem from a lack of pediatric beds at the specialty-care centers, but it could also have been the result of an abundance of nearby hospitals that offer inpatient care, the researchers said. In addition to the seven specialty-care centers, there were 97 other inpatient hospitals that care for children in the county.

"I'm not sure that parents driving past a community hospital in L.A. would necessarily know that it doesn't provide the same kind of services that a children's specialty-care center would for their chronically sick child," Chamberlain said. Once their child is admitted to such a community hospital, the doctor may take into account factors unrelated to the patient's clinical condition, such as payer type and geography, in deciding whether to refer that patient to a specialty-care center, she said.

The researchers noted that among children who had chronic illnesses and who died, one in six stayed for longer than two days in a non-specialty-care center - a trend they called "worrisome."

David Alexander, the president and CEO of the Lucile Packard Foundation for Children's Health and an adjunct clinical professor at the medical school, noted that one in eight U.S. children reside in California, making the issue one of national concern. "A greater number of hospital days are being filled by kids with chronic conditions," he said. "We need to find a way to provide these specialty care services to all children who need them."