Editorial Opinion
protocol for a randomized controlled trial. Trials. 2014;15(1):258. 11. Hosono S, Mugishima H, Fujita H, et al. Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeks’ gestation: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed. 2008;93(1):F14-F19. 12. Rabe H, Diaz-Rossello JL, Duley L, Dowswell T. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database Syst Rev. 2012;8:CD003248.
13. Ghavam S, Batra D, Mercer J, et al. Effects of placental transfusion in extremely low birthweight infants: meta-analysis of long- and short-term outcomes. Transfusion. 2014;54(4):1192-1198. 14. Backes CH, Rivera BK, Haque U, et al. Placental transfusion strategies in very preterm neonates: a systematic review and meta-analysis. Obstet Gynecol. 2014;124(1):47-56. 15. Schmidt B, Davis P, Moddemann D, et al; Trial of Indomethacin Prophylaxis in Preterms Investigators. Long-term effects of indomethacin prophylaxis in extremely-low-birth-weight infants. N Engl J Med. 2001;344(26):1966-1972.
16. Schmidt B, Roberts RS, Fanaroff A, et al; TIPP Investigators. Indomethacin prophylaxis, patent ductus arteriosus, and the risk of bronchopulmonary dysplasia: further analyses from the Trial of Indomethacin Prophylaxis in Preterms (TIPP). J Pediatr. 2006;148(6):730-734. 17. Tarnow-Mordi WO, Duley L, Field D, et al. Timing of cord clamping in very preterm infants: more evidence is needed. Am J Obstet Gynecol. 2014;211(2):118-123.
Ensuring Access to the Appropriate Health Care Professionals Regionalization and Centralization of Care in a New Era of Health Care Financing and Delivery Scott A. Lorch, MD, MSCE
Infants born prematurely continue to make up almost 11.5% of the more than 4 million deliveries in the United States, with 1.4% of these deliveries occurring at a gestational age of 28 weeks or less.1 The work of Kastenberg et al,2 published in this issue of JAMA Pediatrics, adds to the extensive literaRelated article page 26 ture showing that delivery at a high-volume/high-level neonatal intensive care unit is associated with lower mortality and morbidity linked with premature birth.3-5 Given the high cost of delivering care to these infants, estimated at around $26 billion annually,1 neonatal intensive care has been the focus of efforts to regionalize neonatal care, defined as the development of a structured system of care “to improve patient outcomes by directing patients to facilities with optimal capabilities for a given type of illness or injury.”6 Thus, efforts to improve access to these hospitals focus on improved antenatal access to prenatal care; improved identification and transfer of mothers at risk for preterm delivery; and state health policies, such as certificate of need programs, to reduce expansion of neonatal services without justification of community need.7 Changes in health care financing and delivery, highlighted by the Patient Protection and Affordable Care Act of 2010, introduce a surprising new challenge to the provision of services to high-risk, potentially chronically ill children, such as those born prematurely, but also other children with chronic medical conditions who, while making up a small percentage of patients, incur a large amount of health care cost and use.8 The Patient Protection and Affordable Care Act improves access to health care through a number of mechanisms, including the establishment of health exchanges, where patients purchase health insurance from a variety of health care insurance plans. These plans compete on price and coverage while providing an adequate network of care that is accessible without unreasonable delays. To balance cost and coverage while keeping premiums low, many plans limit which health care profes-
sionals patients may receive care from, justifying these limitations on the basis of cost, value, and quality of the care delivered by specific health care professionals. Thus, access to specific health care professionals may be restricted, especially to health care providers, such as children’s hospitals, that may be the primary, or only, source of subspecialty pediatric care but may be more costly than other care providers in a region. This issue is exemplified by the case of Seattle Children’s Hospital, which filed a lawsuit against the state of Washington’s Office of the Insurance Commissioner after its exclusion from several health exchange plans.9 Restrictions on the health care professionals available to an enrollee in a specific health insurance plan are not rare. In a survey of all 282 payers filing products on the 2014 health exchanges, which included 2366 unique individual exchange networks, 41% of all networks in the United States and 54% of the networks in the largest city of each US state were considered narrow or ultra-narrow, that is, they exclude between 30% and 69% of the largest 20 hospitals in a region (narrow) or more than 70% of these hospitals (ultra-narrow). Narrow or ultranarrow programs make up 70% of the lowest-cost programs in the exchanges. Academic medical centers are absent from many narrow plans: 96% of the broad plans include academic centers compared with 73% of the narrow plans and 40% of the ultra-narrow plans.10 Similar changes are occurring in commercial plans, which are also implementing tiered payment programs that increase or decrease a patient’s copayment for care based on the health care provider’s cost and quality. These changes in health care financing highlight several issues with our understanding into the delivery of pediatric care, especially to high-risk patients. First, compared with adults, pediatric care has a lower prevalence of chronic disease and low to no illness severity for most children. As a result, many or most hospitals do not have access to subspecialists needed to manage high-risk, complex children. However, the need for such care, especially in acute situations high-
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Opinion Editorial
lighted by the article by Kastenberg et al,2 is frequently unknown for families choosing a health insurance plan. However, the wrong choice may place children in the situation of receiving care from health care professionals ill-equipped to manage their health care needs. A similar issue is seen in children requiring care from less-common subspecialists, such as pediatric rheumatologists, nephrologists, or neurologists, who in many states are concentrated in a few centers, which may not be included in all plans.11,12 The alternative—burdensome and costly out-of-network approvals for delayed treatment— may lead to patient dissatisfaction with the health care system. These changes also demonstrate the lack of accepted, validated quality metrics for pediatric care, especially for children with chronic medical conditions or children requiring subspecialty care. Finally, there is little to no research on how networks of care and regionalization actually operate in a given geographic area and how what patterns of care lead to improved outcomes of children. With other changes to health care delivery, such as accountable care organizations, increasing in pediatric care, understanding regional networks is important ARTICLE INFORMATION Author Affiliations: Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.
3. Lorch SA, Baiocchi M, Ahlberg CE, Small DS. The differential impact of delivery hospital on the outcomes of premature infants. Pediatrics. 2012; 130(2):270-278. 4. Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med. 2007; 356(21):2165-2175.
Corresponding Author: Scott A. Lorch, MD, MSCE, Children’s Hospital of Philadelphia, 3535 Market St, Ste 1029, Philadelphia, PA 19104 (lorch@email .chop.edu).
5. Rogowski JA, Horbar JD, Staiger DO, Kenny M, Carpenter J, Geppert J. Indirect vs direct hospital quality indicators for very low-birth-weight infants. JAMA. 2004;291(2):202-209.
Published Online: November 10, 2014. doi:10.1001/jamapediatrics.2014.2468.
6. Institute of Medicine. Committee on the Future of Emergency Care in the United States Health System: Board on Health Care Services: Emergency Medical Services at the Crossroads. Washington, DC: National Academies Press; 2007.
Conflict of Interest Disclosures: None reported. REFERENCES 1. March of Dimes Foundation. More than 450,000 babies are born too soon each year. www .marchofdimes.org/mission/prematurity -reportcard.aspx. Accessed September 18, 2014. 2. Kastenberg ZJ, Lee HC, Profit J, Gould JB, Sylvester KG. Effect of deregionalized care on mortality in very low-birth-weight infants with necrotizing enterocolitis [published online November 10, 2014]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2014.2085.
12
to ensure that patients receive timely and appropriate care for their health care needs. Given these changes, how can pediatricians and pediatric researchers respond? First, education of families is paramount. A survey found that 26% of all respondents who purchased insurance through a health exchange were unaware of the breadth of their plan.10 This is especially important for pregnant women, who are purchasing insurance for an as-yet undelivered infant, whose need for expensive care is not known. Second, there needs to be continued development and validation of quality measures, such as those sponsored by the Pediatric Quality Measures Program,13 to truly identify highvalue hospitals, where higher costs are outweighed by improved outcome metrics that are transparent to health care professionals, families, and insurers. Without this information and the proliferation of such narrow or ultra-narrow care networks, care to patients may be delayed or occur at sites illequipped to manage their health care needs, which is an unanticipated outcome to attempts to improve access to health care insurance.
7. Lorch SA, Maheshwari P, Even-Shoshan O. The impact of certificate of need programs on neonatal intensive care units. J Perinatol. 2012;32(1):39-44. 8. Berry JG, Hall DE, Kuo DZ, et al. Hospital utilization and characteristics of patients experiencing recurrent readmissions within children’s hospitals. JAMA. 2011;305(7):682-690.
-hospital-sues-state-over-exclusion-from -exchange-plan-networks/. Accessed September 18, 2014. 10. Bauman N, Coe E, Ogden J, Parikh A. Hospital networks: updated national view of configurations on the exchanges. http://healthcare.mckinsey .com/hospital-networks-updated-national-view -configurations-exchanges. Accessed September 18, 2014. 11. National Association of Children's Hospitals and Related Institutions. Pediatric subspecialist physician shortages affect access to care. http: //www.childrenshospitals.net/AM/Template.cfm ?Section=Home3&Template=/CM/ContentDisplay .cfm&ContentID=49841. Accessed September 18, 2014. 12. Ray KN, Bogen DL, Bertolet M, Forrest CB, Mehrotra A. Supply and utilization of pediatric subspecialists in the United States. Pediatrics. 2014; 133(6):1061-1069. 13. Agency for Healthcare Research and Quality. Pediatric Quality Measures Program (PQMP) Centers of Excellence grant awards. http://www .ahrq.gov/policymakers/chipra/pubs/pqmpfact .html. Accessed September 18, 2014.
9. Landa AS. Children’s Hospital sues state over exclusion from exchange plan networks. The Seattle Times. October 4, 2013. http://blogs.seattletimes .com/healthcarecheckup/2013/10/04/childrens
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Copyright 2015 American Medical Association. All rights reserved.
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protocol for a randomized controlled trial. Trials. 2014;15(1):258. 11. Hosono S, Mugishima H, Fujita H, et al. Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeks’ gestation: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed. 2008;93(1):F14-F19. 12. Rabe H, Diaz-Rossello JL, Duley L, Dowswell T. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database Syst Rev. 2012;8:CD003248.
13. Ghavam S, Batra D, Mercer J, et al. Effects of placental transfusion in extremely low birthweight infants: meta-analysis of long- and short-term outcomes. Transfusion. 2014;54(4):1192-1198. 14. Backes CH, Rivera BK, Haque U, et al. Placental transfusion strategies in very preterm neonates: a systematic review and meta-analysis. Obstet Gynecol. 2014;124(1):47-56. 15. Schmidt B, Davis P, Moddemann D, et al; Trial of Indomethacin Prophylaxis in Preterms Investigators. Long-term effects of indomethacin prophylaxis in extremely-low-birth-weight infants. N Engl J Med. 2001;344(26):1966-1972.
16. Schmidt B, Roberts RS, Fanaroff A, et al; TIPP Investigators. Indomethacin prophylaxis, patent ductus arteriosus, and the risk of bronchopulmonary dysplasia: further analyses from the Trial of Indomethacin Prophylaxis in Preterms (TIPP). J Pediatr. 2006;148(6):730-734. 17. Tarnow-Mordi WO, Duley L, Field D, et al. Timing of cord clamping in very preterm infants: more evidence is needed. Am J Obstet Gynecol. 2014;211(2):118-123.
Ensuring Access to the Appropriate Health Care Professionals Regionalization and Centralization of Care in a New Era of Health Care Financing and Delivery Scott A. Lorch, MD, MSCE
Infants born prematurely continue to make up almost 11.5% of the more than 4 million deliveries in the United States, with 1.4% of these deliveries occurring at a gestational age of 28 weeks or less.1 The work of Kastenberg et al,2 published in this issue of JAMA Pediatrics, adds to the extensive literaRelated article page 26 ture showing that delivery at a high-volume/high-level neonatal intensive care unit is associated with lower mortality and morbidity linked with premature birth.3-5 Given the high cost of delivering care to these infants, estimated at around $26 billion annually,1 neonatal intensive care has been the focus of efforts to regionalize neonatal care, defined as the development of a structured system of care “to improve patient outcomes by directing patients to facilities with optimal capabilities for a given type of illness or injury.”6 Thus, efforts to improve access to these hospitals focus on improved antenatal access to prenatal care; improved identification and transfer of mothers at risk for preterm delivery; and state health policies, such as certificate of need programs, to reduce expansion of neonatal services without justification of community need.7 Changes in health care financing and delivery, highlighted by the Patient Protection and Affordable Care Act of 2010, introduce a surprising new challenge to the provision of services to high-risk, potentially chronically ill children, such as those born prematurely, but also other children with chronic medical conditions who, while making up a small percentage of patients, incur a large amount of health care cost and use.8 The Patient Protection and Affordable Care Act improves access to health care through a number of mechanisms, including the establishment of health exchanges, where patients purchase health insurance from a variety of health care insurance plans. These plans compete on price and coverage while providing an adequate network of care that is accessible without unreasonable delays. To balance cost and coverage while keeping premiums low, many plans limit which health care profes-
sionals patients may receive care from, justifying these limitations on the basis of cost, value, and quality of the care delivered by specific health care professionals. Thus, access to specific health care professionals may be restricted, especially to health care providers, such as children’s hospitals, that may be the primary, or only, source of subspecialty pediatric care but may be more costly than other care providers in a region. This issue is exemplified by the case of Seattle Children’s Hospital, which filed a lawsuit against the state of Washington’s Office of the Insurance Commissioner after its exclusion from several health exchange plans.9 Restrictions on the health care professionals available to an enrollee in a specific health insurance plan are not rare. In a survey of all 282 payers filing products on the 2014 health exchanges, which included 2366 unique individual exchange networks, 41% of all networks in the United States and 54% of the networks in the largest city of each US state were considered narrow or ultra-narrow, that is, they exclude between 30% and 69% of the largest 20 hospitals in a region (narrow) or more than 70% of these hospitals (ultra-narrow). Narrow or ultranarrow programs make up 70% of the lowest-cost programs in the exchanges. Academic medical centers are absent from many narrow plans: 96% of the broad plans include academic centers compared with 73% of the narrow plans and 40% of the ultra-narrow plans.10 Similar changes are occurring in commercial plans, which are also implementing tiered payment programs that increase or decrease a patient’s copayment for care based on the health care provider’s cost and quality. These changes in health care financing highlight several issues with our understanding into the delivery of pediatric care, especially to high-risk patients. First, compared with adults, pediatric care has a lower prevalence of chronic disease and low to no illness severity for most children. As a result, many or most hospitals do not have access to subspecialists needed to manage high-risk, complex children. However, the need for such care, especially in acute situations high-
jamapediatrics.com
JAMA Pediatrics January 2015 Volume 169, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Georgia User on 06/08/2015
11
Opinion Editorial
lighted by the article by Kastenberg et al,2 is frequently unknown for families choosing a health insurance plan. However, the wrong choice may place children in the situation of receiving care from health care professionals ill-equipped to manage their health care needs. A similar issue is seen in children requiring care from less-common subspecialists, such as pediatric rheumatologists, nephrologists, or neurologists, who in many states are concentrated in a few centers, which may not be included in all plans.11,12 The alternative—burdensome and costly out-of-network approvals for delayed treatment— may lead to patient dissatisfaction with the health care system. These changes also demonstrate the lack of accepted, validated quality metrics for pediatric care, especially for children with chronic medical conditions or children requiring subspecialty care. Finally, there is little to no research on how networks of care and regionalization actually operate in a given geographic area and how what patterns of care lead to improved outcomes of children. With other changes to health care delivery, such as accountable care organizations, increasing in pediatric care, understanding regional networks is important ARTICLE INFORMATION Author Affiliations: Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.
3. Lorch SA, Baiocchi M, Ahlberg CE, Small DS. The differential impact of delivery hospital on the outcomes of premature infants. Pediatrics. 2012; 130(2):270-278. 4. Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med. 2007; 356(21):2165-2175.
Corresponding Author: Scott A. Lorch, MD, MSCE, Children’s Hospital of Philadelphia, 3535 Market St, Ste 1029, Philadelphia, PA 19104 (lorch@email .chop.edu).
5. Rogowski JA, Horbar JD, Staiger DO, Kenny M, Carpenter J, Geppert J. Indirect vs direct hospital quality indicators for very low-birth-weight infants. JAMA. 2004;291(2):202-209.
Published Online: November 10, 2014. doi:10.1001/jamapediatrics.2014.2468.
6. Institute of Medicine. Committee on the Future of Emergency Care in the United States Health System: Board on Health Care Services: Emergency Medical Services at the Crossroads. Washington, DC: National Academies Press; 2007.
Conflict of Interest Disclosures: None reported. REFERENCES 1. March of Dimes Foundation. More than 450,000 babies are born too soon each year. www .marchofdimes.org/mission/prematurity -reportcard.aspx. Accessed September 18, 2014. 2. Kastenberg ZJ, Lee HC, Profit J, Gould JB, Sylvester KG. Effect of deregionalized care on mortality in very low-birth-weight infants with necrotizing enterocolitis [published online November 10, 2014]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2014.2085.
12
to ensure that patients receive timely and appropriate care for their health care needs. Given these changes, how can pediatricians and pediatric researchers respond? First, education of families is paramount. A survey found that 26% of all respondents who purchased insurance through a health exchange were unaware of the breadth of their plan.10 This is especially important for pregnant women, who are purchasing insurance for an as-yet undelivered infant, whose need for expensive care is not known. Second, there needs to be continued development and validation of quality measures, such as those sponsored by the Pediatric Quality Measures Program,13 to truly identify highvalue hospitals, where higher costs are outweighed by improved outcome metrics that are transparent to health care professionals, families, and insurers. Without this information and the proliferation of such narrow or ultra-narrow care networks, care to patients may be delayed or occur at sites illequipped to manage their health care needs, which is an unanticipated outcome to attempts to improve access to health care insurance.
7. Lorch SA, Maheshwari P, Even-Shoshan O. The impact of certificate of need programs on neonatal intensive care units. J Perinatol. 2012;32(1):39-44. 8. Berry JG, Hall DE, Kuo DZ, et al. Hospital utilization and characteristics of patients experiencing recurrent readmissions within children’s hospitals. JAMA. 2011;305(7):682-690.
-hospital-sues-state-over-exclusion-from -exchange-plan-networks/. Accessed September 18, 2014. 10. Bauman N, Coe E, Ogden J, Parikh A. Hospital networks: updated national view of configurations on the exchanges. http://healthcare.mckinsey .com/hospital-networks-updated-national-view -configurations-exchanges. Accessed September 18, 2014. 11. National Association of Children's Hospitals and Related Institutions. Pediatric subspecialist physician shortages affect access to care. http: //www.childrenshospitals.net/AM/Template.cfm ?Section=Home3&Template=/CM/ContentDisplay .cfm&ContentID=49841. Accessed September 18, 2014. 12. Ray KN, Bogen DL, Bertolet M, Forrest CB, Mehrotra A. Supply and utilization of pediatric subspecialists in the United States. Pediatrics. 2014; 133(6):1061-1069. 13. Agency for Healthcare Research and Quality. Pediatric Quality Measures Program (PQMP) Centers of Excellence grant awards. http://www .ahrq.gov/policymakers/chipra/pubs/pqmpfact .html. Accessed September 18, 2014.
9. Landa AS. Children’s Hospital sues state over exclusion from exchange plan networks. The Seattle Times. October 4, 2013. http://blogs.seattletimes .com/healthcarecheckup/2013/10/04/childrens
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