Principles of Financing the Medical Home for Children.

A well-implemented and adequately funded medical home not only is the best approach to optimize the health of the individual patient but also can function as an effective instrument for improving population health. Key financing elements to providing quality, effective, comprehensive care in the pediatric medical home include the following: (1) first dollar coverage without deductibles, copays, or other cost-sharing for necessary preventive care services as recommended by Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents; (2) adoption of a uniform definition of medical necessity across payers that embraces services that promote optimal growth and development and prevent, diagnose, and treat the full range of pediatric physical, mental, behavioral, and developmental conditions, in accord with evidence-based science or evidence-informed expert opinion; (3) payment models that promote appropriate use of pediatric primary care and pediatric specialty services and discourage inappropriate, inefficient, or excessive use of medical services; and (4) payment models that strengthen the patient- and family-physician relationship and do not impose additional administrative burdens that will only erode the effectiveness of the medical home. These goals can be met by designing payment models that provide adequate funding of the cost of medical encounters, care coordination, population health services, and quality improvement activities; provide incentives for quality and effectiveness of care; and ease administrative burdens.

A Conceptual Model of Financial Toxicity in Pediatric Oncology.

The purpose of this article is to explicate a conceptual framework for financial toxicity in pediatric oncology to guide nursing practice and research. The framework is based on one for financial outcomes of severe illness attributed to Scott Ramsey and adapted by the National Cancer Institute to describe relationships between preexisting factors, a cancer diagnosis, financial distress, and health outcomes for adult cancer patients and survivors. The adaption for pediatric oncology was informed by the results of a systematic scoping review to identify advances and gaps in the recent literature about the personal costs of illness to parents in the pediatric oncology context. The conceptual model for pediatric oncology indicates that existing and dynamic parent and family factors, other risk and protective factors, the child's diagnosis and treatment, and treatment-related financial costs can affect parent financial coping behaviors and parent health and family financial outcomes, all of which may affect child outcomes. Additionally, nursing's historic emphasis on holistic care, quality of life, and health determinants justify attention to financial toxicity as a nursing role. Therefore, pediatric oncology nurses must be sensitive to financial toxicity and related risk factors, become comfortable communicating about treatment-related financial costs and financial distress with parents and other health professionals, and collaborate in efforts that draw on the expertise of multiple stakeholders to identify potential or actual financial toxicity in parents and mitigate its impact on childhood cancer health outcomes through direct care, referral, research, quality improvement, and health advocacy.

The My Child Matters programme: effect of public-private partnerships on paediatric cancer care in low-income and middle-income countries.

In low-income and middle-income countries, an excess in treatment failure for children with cancer usually results from misdiagnosis, inadequate access to treatment, death from toxicity, treatment abandonment, and relapse. The My Child Matters programme of the Sanofi Espoir Foundation has funded 55 paediatric cancer projects in low-income and middle-income countries over 10 years. We assessed the impact of the projects in these regions by using baseline assessments that were done in 2006. Based on these data, estimated 5-year survival in 2016 increased by a median of 5·1%, ranging from -1·5% in Venezuela to 17·5% in Ukraine. Of the 26 861 children per year who develop cancer in the ten index countries with My Child Matters projects that were evaluated in 2006, an estimated additional 1343 children can now expect an increase in survival outcome. For example, in Paraguay, a network of paediatric oncology satellite clinics was established and scaled up to a national level and has managed 884 patients since initiation in 2006. Additionally, the African Retinoblastoma Network was scaled up from a demonstration project in Mali to a network of retinoblastoma referral centres in five sub-Saharan African countries, and the African School of Paediatric Oncology has trained 42 physicians and 100 nurses from 16 countries. The My Child Matters programme has catalysed improvements in cancer care and has complemented the efforts of government, civil society, and the private sector to sustain and scale improvements in health care to a national level. Key elements of successful interventions include strong and sustained local leadership, community engagement, international engagement, and capacity building and support from government.

Pediatric Specialty Care Model for Management of Chronic Respiratory Failure: Cost and Savings Implications and Misalignment With Payment Models.

OBJECTIVE: To describe program design, costs, and savings implications of a critical care-based care coordination model for medically complex children with chronic respiratory failure. DESIGN: All program activities and resultant clinical outcomes were tracked over 4 years using an adapted version of the Care Coordination Measurement Tool. Patient characteristics, program activity, and acute care resource utilization were prospectively documented in the adapted version of the Care Coordination Measurement Tool and retrospectively cross-validated with hospital billing data. Impact on total costs of care was then estimated based on program outcomes and nationally representative administrative data. SETTING: Tertiary children's hospital. SUBJECTS: Critical Care, Anesthesia, Perioperative Extension and Home Ventilation Program enrollees. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The program provided care for 346 patients and families over the study period. Median age at enrollment was 6 years with more than half deriving secondary respiratory failure from a primary neuromuscular disease. There were 11,960 encounters over the study period, including 1,202 home visits, 673 clinic visits, and 4,970 telephone or telemedicine encounters. Half (n = 5,853) of all encounters involved a physician and 45% included at least one care coordination activity. Overall, we estimated that program interventions were responsible for averting 556 emergency department visits and 107 hospitalizations. Conservative monetization of these alone accounted for annual savings of $1.2-2 million or $407/pt/mo net of program costs. CONCLUSIONS: Innovative models, such as extension of critical care services, for high-risk, high-cost patients can result in immediate cost savings. Evaluation of financial implications of comprehensive care for high-risk patients is necessary to complement clinical and patient-centered outcomes for alternative care models. When year-to-year cost variability is high and cost persistence is low, these savings can be estimated from documentation within care coordination management tools. Means of financial sustainability, scalability, and equal access of such care models need to be established.

Financial Analysis of Behavioral Health Services in a Pediatric Endocrinology Clinic.

OBJECTIVE: This article addresses a current need in psychological practice by describing a financially feasible model that moves toward integrated care of behavioral health services in a pediatric endocrinology clinic. METHODS: Financial information (costs and revenue associated with behavioral health services) for the clinic, over an 18-month period (July 2012 to December 2013), was obtained through the hospital's financial department. The clinic meets one half day per week. RESULTS: Over the 18-month period, the behavioral health services generated a net gain of $3661.45 in the favor of the clinic. We determined that the psychologist and clinical psychology residents needed to see a total of four patients per half-day clinic for the clinic to "break-even." CONCLUSIONS: We describe one financially feasible way of integrating behavioral health services into a pediatric endocrinology clinic in the hope that this will be generalizable to other medical settings.

The diagnostic pathway in complex paediatric neurology: a cost analysis.

BACKGROUND: The diagnostic trajectory of complex paediatric neurology may be long, burdensome, and expensive while its diagnostic yield is frequently modest. Improvement in this trajectory is desirable and might be achieved by innovations such as whole exome sequencing. In order to explore the consequences of implementing them, it is important to map the current pathway. To that end, this study assessed the healthcare resource use and associated costs in this diagnostic trajectory in the Netherlands. METHODS: Fifty patients presenting with complex paediatric neurological disorders of a suspected genetic origin were included between September 2011 and March 2012. Data on their healthcare resource utilization were collected from the hospital medical charts. Unit prices were obtained from the Dutch Healthcare Authority, the Dutch Healthcare Insurance Board, and the financial administration of the hospital. Bootstrap simulations were performed to determine mean quantities and costs. RESULTS: The mean duration of the diagnostic trajectory was 40 months. A diagnosis was established in 6% of the patients. On average, patients made 16 physician visits, underwent four imaging and two neurophysiologic tests, and had eight genetic and 16 other tests. Mean bootstrapped costs per patient amounted to €12,475, of which 43% was for genetic tests (€5,321) and 25% for hospital visits (€3,112). CONCLUSION: Currently, the diagnostic trajectories of paediatric patients who have complex neurological disease with a strong suspected genetic component are lengthy, resource-intensive, and low-yield. The data from this study provide a backdrop against which the introduction of novel techniques such as whole exome sequencing should be evaluated.

[The importance of ultrasound in the pediatric practice in Switzerland]. / Ein Stiefblümchen: Sonographie in der pädiatrischen Praxis.

For various reasons, sonography is best suited for the use in children. In pediatric practice and emergency departments, it turns out to be just as valuable for many indications, as in pediatric hospitals. As a clinical method of imaging, ultrasound is very profitable in the hands of pediatricians. Examples from daily practice illustrate this fact. Still, against this background, it is surprising, that in Switzerland - in contrast to neighbouring countries - pediatric sonography is largely given over to radiologists.

Medicinal systems of complementary and alternative medicine: a cross-sectional survey at a pediatric emergency department.

OBJECTIVE: The purpose of this study was to find out which experiences adults are making while treating children with complementary and alternative medicine (CAM) therapies in German-speaking Switzerland. DESIGN AND SUBJECTS: A cross-sectional survey was performed on adults accompanying the children presenting to an urban, tertiary pediatric emergency department in Zurich; 71% of the distributed questionnaires (1143 of 1600) could be used for data analysis. The respondents were asked about their experiences while treating the child with CAM and--for comparison reasons--with conventional medicine (CM). RESULTS: The respondents perceived the effectiveness of CAM therapies in general to be inferior to that of CM, although 49% of all respondents stated that CAM therapies were more effective than CM in certain cases/against certain diseases and 13% that CAM therapies were as effective as CM. Higher frequency of use and lower compliance were observed in the case of CAM, relatively to CM. Respondents described the direct costs for the patient of both types of medicine to be comparable. Ninety-three percent (93%) of the respondents experienced no side-effects with CAM therapies, whereas only 52% of the respondents stated the same about CM therapies; the observed side-effects of CAM were weaker than those of CM. Homeopathy was the most frequently used form of CAM (77% of all CAM users), followed by herbal medicine (64%), anthroposophic medicine (24%), Traditional Chinese Medicine (13%), Ayurveda (5%), and others (34%). CONCLUSIONS: From the respondents' point of view, the most marked difference between CAM- and CM therapies concerns the frequency and intensity of side-effects, which were markedly higher in the latter case. The respondents made use of a wide variety of CAM therapies.

Diners, rendibilitat social i consciència pediàtrica / No disponible

No disponible

[Development of pediatric surgery in the next 20 years]. / Entwicklung der Kinderchirurgie in den nächsten 20 Jahren.

Pediatric surgery focuses not on an anatomic region or organ system, but on the development of a growing human being according to age. Recently, a tendency to reduce and to downgrade pediatric surgery could be observed which is due to economic reasons and an alarming lack of trained surgeons. Just as 60 years ago, general surgeons continue to operate on infants and children. However, this is a step backwards and an anachronism. Children are not small adults and pediatric surgery can be distinguished from adult surgery in many aspects, such as the spectrum of surgical diseases, the congenital malformations and frequently the indications and techniques of surgery. Pediatric surgeons, however, by themselves should specialize in centers which are focused on rare and complex diseases. Pediatric surgery should not be separated in the hospital, but integrated in a network with general surgery, traumatology, pediatrics, neonatology and specialists of the other surgical disciplines. Strict patient age limitations are not compatible with the individuality of adolescents and should be avoided. A well-equipped clinic for pediatric surgery is expensive, but a mandatory investment in the future!

Hypoallergenic formula prescribing practices in Australia.

AIM: To gain insight into the use of hypoallergenic formula in Australia by analysis of prescribing statistics. METHODS: Statistics on supply of amino acid and extensively hydrolyzed formula were obtained from the Health Insurance Commission web site. The number of prescriptions supplied in 2003 and 2004 per 1000 children aged 4 years and younger were calculated for each State and Territory. This was related to the numbers of paediatric physicians and paediatric allergists in each State. RESULTS: There was a marked rise in the use of amino acid formula (AAF) commencing in 2001. The Australian Capital Territory, New South Wales and Victoria had 6-7 times more AAF items per 1000 children prescribed than Western Australia. This did not appear to relate to the numbers of paediatricians or paediatric allergists in each State. In all States and Territories the prescribing of extensively hydrolyzed formula was less than that of AAF. CONCLUSIONS: There are significant regional differences which do not appear to be related to the prevalence of allergic disease. In some States and Territories AAF may be frequently prescribed as a first line treatment for cows milk allergy and for prevention of allergic disease in contradistinction to current recommendations of the Pharmaceutical Benefits Scheme and authoritative statements and position papers. Re-examination of both the Pharmaceutical Benefit Scheme guidelines and the knowledge and perceptions of the prescribing community is indicated.

Cost-effectiveness analysis and emergency medical services for children: issues and applications.

Studies to assess the cost-effectiveness of alternative treatment or prevention strategies for children are far fewer than those for adults. This article highlights specific issues relevant to the conduct of cost-effectiveness analysis (CEA) in pediatric populations following the recommendations of the US Panel on Cost-effectiveness in Health and Medicine and discusses CEA applications relevant to emergency medical services for children. The article addresses whether patient time should be included in measures of costs, whether caregiver time costs are included and measured properly, and most importantly, whether the study can use quality adjusted life years (QALYs) as an outcome measure. Pediatric researchers may be unable to follow the panel's recommendations for including QALYs as an outcome measure in CEA studies involving young children. Developing preference weights applicable to young children may be a productive field for pediatric researchers. Without such efforts, the field of child health services research in general and the field of emergency medical services for children in particular will continue to lag behind adult fields in assessing the costs and outcomes of the services they provide.

A new paradigm in academic health centers: productivity-based physician compensation.

This article describes the challenge of designing an incentive-based compensation program for a large group of academic pediatricians in the Division of General Pediatrics at the University of Michigan Health System. The program is based on an incentive system that measures performance in clinical care, education and research. Faculty members' salaries arise from five components: base, clinical incentive, academic supplement, administrative differential and teaching credit.

Pediatric system uses contracts with providers, plans to shape its role in managed Medicaid.

CASE STUDY: A pediatric provider system seeks control in managed Medicaid. By creating its own provider network, and making some unusual contracting arrangements, Cook Children's Health Care System in Fort Worth, TX, has lowered utilization and even paid bonuses to physicians under its first full-risk contracts with three Medicaid plans. See how this system's providers set themselves up to succeed.

Upstairs downstairs: vertical integration of a pediatric service.

BACKGROUND: The combined effects of recent changes in health care financing and training priorities have compelled academic medical centers to develop innovative structures to maintain service commitments yet conform to health care marketplace demands. In 1992, a municipal hospital in the Bronx, New York, affiliated with a major academic medical center reorganized its pediatric service into a vertically integrated system of four interdependent practice teams that provided comprehensive care in the ambulatory as well as inpatient settings. One of the goals of the new system was to conserve inpatient resources. OBJECTIVE: To describe the development of a new vertically integrated pediatric service at an inner-city municipal hospital and to test whether its adoption was associated with the use of fewer inpatient resources. DESIGN: A descriptive analysis of the rationale, goals, implementation strategies, and structure of the vertically integrated pediatric service combined with a before-and-after comparison of in-hospital resource consumption. METHODS: A before-and-after comparison was conducted for two periods: the period before vertical integration, from January 1989 to December 1991, and the period after the adoption of vertical integration, from July 1992 to December 1994. Four measures of inpatient resource use were compared after adjustment for case mix index: mean certified length of stay per case, mean number of radiologic tests per case, mean number of ancillary tests per case, and mean number of laboratory tests per case. Difference-in-differences-in-differences estimators were used to control for institution-wide trends throughout the time period and regional trends in inpatient pediatric practice occurring across institutions. Results. In 1992, the Department of Pediatrics at the Albert Einstein College of Medicine reorganized the pediatric service at Jacobi Medical Center, one of its principal municipal hospital affiliates, into a vertically integrated pediatric service that combines ambulatory and inpatient activities into four interdependent practice teams composed of attending pediatricians, allied health professionals, house officers, and social workers. The new vertically integrated service was designed to improve continuity of care for patients, provide a model of practice for professional trainees, conserve scarce resources, and create a clinical research infrastructure. The vertically integrated pediatric service augmented the role of attending pediatricians, extended the use of allied health professionals from the ambulatory to the inpatient sites, established interdisciplinary practice teams that unified the care of pediatric patients and their families, and used less inpatient resources. Controlling for trends within the study institution and trends in the practice of pediatrics across institutions throughout the time period, the vertical integration was associated with a decline in 0.6 days per case, the use of 0.62 fewer radiologic tests per case, 0.21 fewer ancillary tests per case, and 2.68 fewer laboratory tests per case. CONCLUSIONS: We conclude that vertical integration of a pediatric service at an inner-city municipal hospital is achievable; conveys advantages of improved continuity of care, enhanced opportunities for primary care training, and increased participation of senior clinicians; and has the potential to conserve significant amounts of inpatient resources.

The changing health care environment: implications for residency training.

Throughout the United States, the growth of managed care is forcing pediatric providers (physicians and hospitals) to reconstruct and integrate the health care delivery system with a focus away from the academic center and toward the community. Managed care also is forcing new financing approaches geared toward the assumption of economic risk for patient management and utilization of services. Radical changes in pediatric training programs will be necessary to accommodate the strategic and operational changes being pursued in response to these evolving market forces. These changes, while disruptive, will strengthen the breadth and diversity of graduate medical education and will better prepare trainees for the new delivery system in which they will practice. In this article, we examine how the evolution of managed care is redefining the basic financial and organizational framework for pediatric care and the implications of this redefinition for children's hospitals and academic medical center-based pediatric programs. We draw on our experience in the greater Philadelphia market to illustrate the impact of these changes and discuss one pediatric system's response. Finally, we review the educational opportunities provided by these changes.