Maryland's Global Hospital Budgets: Impacts on Medicare Cost and Utilization for the First 3 Years.

BACKGROUND: Global budgets have been proposed as a way to control health care expenditures, but experience with them in the United States is limited. Global budgets for Maryland hospitals, the All-Payer Model, began in January 2014. OBJECTIVES: To evaluate the effect of hospital global budgets on health care utilization and expenditures. RESEARCH DESIGN: Quantitative analyses used a difference-in-differences design modified for nonparallel baseline trends, comparing trend changes from a 3-year baseline period to the first 3 years after All-Payer Model implementation for Maryland and a matched comparison group. SUBJECTS: Hospitals in Maryland and matched out-of-state comparison hospitals. Fee-for-service Medicare beneficiaries residing in Maryland and comparison hospital market areas. MEASURES: Medicare claims were used to measure total Medicare expenditures; utilization and expenditures for hospital and nonhospital services; admissions for avoidable conditions; hospital readmissions; and emergency department visits. Qualitative data on implementation were collected through interviews with senior hospital staff, state officials, provider organization representatives, and payers, as well as focus groups of physicians and nurses. RESULTS: Total Medicare and hospital service expenditures declined during the first 3 years, primarily because of reduced expenditures for outpatient hospital services. Nonhospital expenditures, including professional expenditures and postacute care expenditures, also declined. Inpatient admissions, including admissions for avoidable conditions, declined, but, there was no difference in the change in 30-day readmissions. Moreover, emergency department visits increased for Maryland relative to the comparison group. CONCLUSIONS: This study provides evidence that hospital global budgets as implemented in Maryland can reduce expenditures and unnecessary utilization without shifting costs to other parts of the health care system.

Behavioral Health Integration With Primary Care: Implementation Experience and Impacts From the State Innovation Model Round 1 States.

Policy Points Individuals with behavioral health (BH) conditions comprise a medically complex population with high costs and high health care needs. Considering national shortages of BH providers, primary care providers serve a critical role in identifying and treating BH conditions and making referrals to BH providers. States are increasingly seeking ways to address BH conditions among their residents. States funded by the Centers for Medicare and Medicaid Services under the first round of the State Innovation Models (SIM) Initiative all invested in BH integration. States found sharing data among providers, bridging professional divides, and overcoming BH provider shortages were key barriers. Nonetheless, states made significant strides in integrating BH care. Beyond payment models, a key catalyst for change was facilitating informal relationships between BH providers and primary care physicians. Infrastructure investments such as promoting data sharing by connecting BH providers to a health information exchange and providing tailored technical assistance for both BH and primary care providers were also important in improving integration of BH care. CONTEXT: Increasing numbers of states are looking for ways to address behavioral health (BH) conditions among their residents. The first round of the State Innovation Models (SIM) Initiative provided financial and technical support to six states since 2013 to test the ability of state governments to lead health care system transformation. All six SIM states invested in integration of BH and primary care services. This study summarizes states' progress, challenges, and lessons learned on BH integration. Additionally, the study reports impacts on expenditure, utilization, and quality-of-care outcomes for persons with BH conditions across four SIM states. METHODS: We use a mixed-methods design, drawing on focus groups and key informant interviews to reach conclusions on implementation and quantitative analysis using Medicaid claims data to assess impact. For three Medicaid accountable care organization (ACO) models funded under SIM, we used a difference-in-differences regression model to compare outcomes for model participants with BH conditions and an in-state comparison group before-and-after model implementation. For the behavioral health home (BHH) model in Maine, we used a pre-post design to assess how outcomes for model participants changed over time. FINDINGS: Informal relationship building, tailored technical assistance, and the promotion of data sharing were key factors in making progress. After three years of implementation, the growth in total expenditures was less than the comparison group by $128 (-$253, -$3; p < 0.10) and $62 (-$87, -$36; p < 0.001) per beneficiary per month for beneficiaries with BH conditions attributed to an ACO in Minnesota and Vermont, respectively. Likewise, there were reductions in emergency department use for ACO participants in all three states after two to four years of implementation. However, there was no improvement in BH-related quality metrics for ACO beneficiaries in all three states. Although participants in the BHH model had increased expenditures after two years of implementation, use of primary care and specialty care services increased by 3% and 8%, respectively, and antidepressant medication adherence also improved. CONCLUSIONS: The SIM Round 1 states made considerable progress in integrating BH and primary care services, and there were promising findings for all models. Taken together, there is some evidence that Medicaid payment models can improve patterns of care for beneficiaries with BH conditions.

States Encouraging Value-Based Payment: Lessons From CMS's State Innovation Models Initiative.

Policy Points Six states received $250 million under the federal State Innovation Models (SIM) Initiative Round 1 to increase the proportion of care delivered under value-based payment (VBP) models aligned across multiple payers. Multipayer alignment around a common VBP model occurred within the context of state regulatory and purchasing policies and in states with few commercial payers, not through engaging many stakeholders to act voluntarily. States that made targeted infrastructure investments in performance data and electronic hospital event notifications, and offered grants and technical assistance to providers, produced delivery system changes to enhance care coordination even where VBP models were not multipayer. CONTEXT: In 2013, six states (Arkansas, Massachusetts, Maine, Minnesota, Oregon, and Vermont) received $250 million in Round 1 State Innovation Models (SIM) awards to test how regulatory, policy, purchasing, and other levers available to state governments could transform their health care system by implementing value-based payment (VBP) models that shift away from fee-for-service toward payment based on quality and cost. METHODS: We gathered and analyzed qualitative data on states' implementation of their SIM Initiatives between 2014 and 2018, including interviews with state officials and other stakeholders; consumer and provider focus groups; and review of relevant state-produced documents. FINDINGS: State policymakers leveraged existing state law, new policy development, and federal SIM Initiative funds to implement new VBP models in Medicaid. States' investments promoted electronic health information going from hospitals to primary care providers and collaboration across care team members within practices to enhance care coordination. Multipayer alignment occurred where there were few commercial insurers in a state, or where a state law or state contracting compelled commercial insurer participation. Challenges to health system change included commercial payer reluctance to coordinate on VBP models, cost and policy barriers to establishing bidirectional data exchange among all providers, preexisting quality measurement requirements across payers that impede total alignment of measures, providers' perception of their limited ability to influence patients' behavior that puts them at financial risk, and consumer concerns with changes in care delivery. CONCLUSIONS: The SIM Initiative's test of the power of state governments to shape health care policy demonstrated that strong state regulatory and purchasing policy levers make a difference in multipayer alignment around VBP models. In contrast, targeted financial investments in health information technology, data analytics, technical assistance, and workforce development are more effective than policy alone in encouraging care delivery change beyond that which VBP model participation might manifest.

Maternal depressive symptoms and healthcare expenditures for publicly insured children with chronic health conditions.

This study estimated the prevalence of maternal depressive symptoms and tested associations between maternal depressive symptoms and healthcare utilization and expenditures among United States publicly insured children with chronic health conditions (CCHC). A total of 6,060 publicly insured CCHC from the 2004-2009 Medical Expenditure Panel Surveys were analyzed using negative binomial models to compare healthcare utilization for CCHC of mothers with and without depressive symptoms. Annual healthcare expenditures for both groups were compared using a two-part model with a logistic regression and generalized linear model. The prevalence of depressive symptoms among mothers with CCHC was 19 %. There were no differences in annual healthcare utilization for CCHC of mothers with and without depressive symptoms. Maternal depressive symptoms were associated with greater odds of ED expenditures [odds ratio (OR) 1.26; 95 % CI 1.03-1.54] and lesser odds of dental expenditures (OR 0.81; 95 % CI 0.66-0.98) and total expenditures (OR 0.71; 95 % CI 0.51-0.98). Children of symptomatic mothers had lower predicted outpatient expenditures and higher predicted expenditures for total health, prescription medications, dental care; and office based, inpatient and ED visits. Mothers with CCHC were more likely to report depressive symptoms than were mothers with children without chronic health conditions. There were few differences in annual healthcare utilization and expenditures between CCHC of mothers with and without depressive symptoms. However, having a mother with depressive symptoms was associated with higher ED expenditures and higher predicted healthcare expenditures in a population of children who comprise over three-fourths of the top decile of Medicaid spending.

Effects of early dental office visits on dental caries experience.

OBJECTIVES: We determined the association between timing of a first dentist office visit before age 5 years and dental disease in kindergarten. METHODS: We used North Carolina Medicaid claims (1999-2006) linked to state oral health surveillance data to compare caries experience for kindergarten students (2005-2006) who had a visit before age 60 months (n=11,394) to derive overall exposure effects from a zero-inflated negative binomial regression model. We repeated the analysis separately for children who had preventive and tertiary visits. RESULTS: Children who had a visit at age 37 to 48 and 49 to 60 months had significantly less disease than children with a visit by age 24 months (incidence rate ratio [IRR]=0.88; 95% confidence interval [CI]=0.81, 0.95; IRR=0.75; 95% CI=0.69, 0.82, respectively). Disease status did not differ between children who had a tertiary visit by age 24 months and other children. CONCLUSIONS: Medicaid-enrolled children in our study followed an urgent care type of utilization, and access to dental care was limited. Children at high risk for dental disease should be given priority for a preventive dental visit before age 3 years.

Cost-effectiveness of alternative treatments for depression in low-income women.

BACKGROUND: Low-income mothers are more likely to experience depressive symptoms than their higher income counterparts, but they are less likely to receive treatment. One way to overcome common barriers to care for low-income women is to do therapy in the mother's home. AIMS OF THE STUDY: The objective of this study was to compare the cost-effectiveness of in-home interpersonal therapy (IPT) to two standard therapies for depression treatment: office based cognitive behavioral therapy (CBT) and psychotropic medication. METHODS: This cost utility analysis used a Markov model with a 3-year time horizon to compare the cost-effectiveness of the alternate therapies from the public payer perspective. We followed a hypothetical cohort of 1,000 women age 19 to 35 years with depressive symptoms who had an income level at or below 200% of the federal poverty level. Costs were based on the number of women who completed the therapy. We used data from published literature on clinical trials with low-income minority women to determine the completion rates, duration, and effectiveness of each type of therapy. Additionally, costs for in-home IPT were calculated from unpublished trial data. Costs were determined using 2011 North Carolina Medicaid reimbursement rates; utility weights were taken from published literature. The endpoint was the total outpatient medical cost (therapy and outpatient medical visits). The study outcomes were depression free days (DFD), which were translated into quality of adjusted life years (QALY). We calculated the incremental cost-effectiveness ratio (ICER) of each therapy based on the number of QALYs gained. We conducted deterministic and probabilistic sensitivity analyses to determine how robust the results were to uncertainty in the parameters. RESULTS: Treating patients with IPT resulted in an ICER of USD 13,479/QALY and USD 29,309/QALY as compared to CBT and medications, respectively. The results were most sensitive to the efficacy of IPT. Simulations showed that, with a threshold of USD 50,000/QALY, IPT was cost-effective 95% and 78% of the time as compared to CBT and medications, respectively. If policy makers were willing to pay USD 50,000 per QALY, IPT had a 0.586 probability of being the cost-effective option relative to medication and in-office CBT. DISCUSSION: Due to higher completion rates, in-home IPT cost more but resulted in more QALYs gained than the other therapies. Our results indicated that in-home IPT was cost-effective as compared to office-based CBT and at least as cost-effective as medication therapy. The analysis was based on limited data because there have been few randomized, controlled studies on treatments for depression in low-income women, however; additional studies are needed to improve the accuracy of the model. IMPLICATIONS FOR HEALTH POLICY: In coming years, the number of low-income women covered by public insurance should increase due to the Affordable Care Act. Given the high prevalence of depression in this population, it will be important to consider the value of potential resources spent on depression treatments. This study found that both in-home IPT and medication could be cost-effective treatments for depression. The results of this study support public payers reimbursing for in-home services.

Health Care Impacts Of Resource Navigation For Health-Related Social Needs In The Accountable Health Communities Model.

Social determinants of health can adversely affect health and therefore lead to poor health care outcomes. When it launched in 2017, the Accountable Health Communities (AHC) Model was at the forefront of US health policy initiatives seeking to address social determinants of health. The AHC Model, sponsored by the Centers for Medicare and Medicaid Services, screened Medicare and Medicaid beneficiaries for health-related social needs and offered eligible beneficiaries assistance in connecting with community services. This study used data from the period 2015-21 to test whether the model had impacts on health care spending and use. Findings show statistically significant reductions in emergency department visits for both Medicaid and fee-for-service Medicare beneficiaries. Impacts on other outcomes were not statistically significant, but low statistical power may have limited our ability to detect model effects. Interviews with AHC Model participants who were offered navigation services to help them find community-based resources suggested that navigation services could have directly affected the way in which beneficiaries engage with the health care system, leading them to be more proactive in seeking appropriate care. Collectively, findings provide mixed evidence that engaging with beneficiaries who have health-related social needs can affect health care outcomes.

Effect of early preventive dental visits on subsequent dental treatment and expenditures.

OBJECTIVE: Professional organizations recommend a preventive dental visit by 1 year of age. This study compared dental treatment and expenditures for Medicaid children who have a preventive visit before the age of 18 months with those who have a visit at age 18-42 months. METHODS: This retrospective cohort study used reimbursement claims for 19,888 children enrolled in North Carolina Medicaid (1999-2006). We compared the number of dental treatment procedures at age 43-72 months for children who had a visit by age 18 months with children who had a visit at ages 18-24, 25-30, 31-36, and 37-42 months using a zero-inflated negative binomial model. The likelihood and amount of expenditures at age 43-72 months were compared by group using a logit and ordinary least squares regression. RESULTS: Children who had a primary or secondary preventive visit by age 18 months had no difference in subsequent dental outcomes compared with children in older age categories. Among children with existing disease, those who had a tertiary preventive visit by age 18 months had lower rates of subsequent treatment [18-24 mo incidence density ratio (IDR): 1.19, 95% confidence interval (CI), 1.03-1.38; 25-30 mo IDR: 1.21, 95% CI, 1.06-1.39; 37-42 mo IDR: 1.39, 95% CI, 1.22-1.59] and lower treatment expenditures compared with children in older age categories. CONCLUSIONS: In this sample of preventive dental users in Medicaid, we found that children at highest risk of dental disease benefited from a visit before the age of 18 months, but most children could delay their first visit until the age of 3 years without an effect on subsequent dental outcomes.

Pediatricians' assessments of caries risk and need for a dental evaluation in preschool aged children.

BACKGROUND: Risk-based prioritization of dental referrals during well-child visits might improve dental access for infants and toddlers. This study identifies pediatrician-assessed risk factors for early childhood caries (ECC) and their association with the need for a dentist's evaluation. METHODS: A priority oral health risk assessment and referral tool (PORRT) for children < 36 months was developed collaboratively by physicians and dentists and used by 10 pediatricians during well-child visits. PORRT documented behavioral, clinical, and child health risks for ECC. Pediatricians also assessed overall ECC risk on an 11-point scale and determined the need for a dental evaluation. Logistic regression models calculated the odds for evaluation need for each risk factor and according to a 3-level risk classification. RESULTS: In total 1,288 PORRT forms were completed; 6.8% of children were identified as needing a dentist evaluation. Behavioral risk factors were prevalent but not strong predictors of the need for an evaluation. The child's overall caries risk was the strongest predictor of the need for an evaluation. Cavitated (OR = 17.5; 95% CI = 8.08, 37.97) and non-cavitated (OR = 6.9; 95% CI = 4.47, 10.82) lesions were the strongest predictors when the caries risk scale was excluded from the analysis. Few patients (6.3%) were classified as high risk, but their probability of needing an evaluation was only 0.36. CONCLUSIONS: Low referral rates for children with disease and prior to disease onset but at elevated risk, indicate interventions are needed to help improve the dental referral rates of physicians.

Effects of Global Budget Payments on Vulnerable Medicare Subpopulations in Maryland.

There is little evidence regarding population equity in alternative payment models (APMs). We aimed to determine whether one such APM, the Maryland All-Payer Model (MDAPM), had differential effects on subpopulations of vulnerable Medicare beneficiaries. We utilized Medicare fee-for-service claims for beneficiaries living in Maryland and 48 comparison hospital market areas between 2011 and 2018. We used doubly robust difference-in-difference-in-differences regression models to estimate the differential effects of MDAPM on Medicare beneficiaries by dual eligibility for Medicare and Medicaid, disability as original reason for Medicare entitlement, presence of multiple chronic conditions (MCC), race, and rural residency status. Dual, disabled, and beneficiaries with MCC had greater reductions in expenditures and utilization than their counterparts. Hospitals may have prioritized high-cost, high-need patients as they changed their care delivery practices. The percentage of hospital discharges with 14-day follow-up was significantly lower for disadvantaged subpopulations, including duals, disabled, and non-White.

Impacts of Maryland's Global Budgets on Medicare and Commercial Spending and Utilization.

In 2014, Maryland incorporated global budgets into its long-running all-payer rate-setting model for hospitals in order to improve health, increase health care quality, and reduce spending. We used difference-in-differences models to estimate changes in Medicare and commercial insurance utilization and spending in Maryland relative to a hospital-based comparison group. We found slower growth in Medicare hospital spending in Maryland than in the comparison group 4.5 years after model implementation and for commercial plan members after 4 years. We identified reductions in Maryland Medicare admissions but no changes for commercial plan members, although their inpatient spending declined. Relative declines in emergency department and other hospital outpatient spending in Maryland drove slower Medicare hospital spending growth, saving $796 million. Our findings suggest global budgets reduce hospital spending and utilization but aligning incentives between hospital and nonhospital providers may be necessary to further reduce utilization and total spending.

Early impact of the implementation of Medicaid episode-based payment reforms in Arkansas.

OBJECTIVE: To evaluate episode-based payments for upper respiratory tract infections (URI) and perinatal care in Arkansas's Medicaid population. STUDY SETTING: Upper respiratory infection and perinatal episodes among Medicaid-covered individuals in Arkansas and comparison states from fiscal year (FY) 2011 to 2014. STUDY DESIGN: Cross-sectional observational analysis using a difference-in-difference design to examine outcomes associated with URI and perinatal episodes of care (EOC) from 2011 to 2014. Key dependent variables include antibiotic use, emergency department visits, physician visits, hospitalizations, readmission, and preventive screenings. DATA COLLECTION: Claims data from the Medicaid Analytic Extract for Arkansas, Mississippi, and Missouri from 2010 to 2014 with supplemental county-level data from the Area Health Resource File (AHRF). PRINCIPAL FINDINGS: The URI EOC reduced the probability of antibiotic use (marginal effect [ME] = -1.8, 90% CI: -2.2, -1.4), physician visits (ME = 0.6, 90% CI: -0.8, -0.4), improved the probability of strep tests for children diagnosed with pharyngitis (ME = 9.4, 90% CI: 8.5, 10.3), but also increased the probability of an emergency department (ED) visit (ME = 0.1, 90% CI: 0.1, 0.2), relative to the comparison group. For perinatal EOCs, we found a reduced probability of an ED visit during pregnancy (ME = 0.1, 90% CI: -0.2, -0.0), an increased probability of screening for HIV (ME = 6.2, 90% CI: 4.0, 8.5), chlamydia (ME = 9.5, 90% CI: 7.2, 11.8), and group B strep-test (ME = 2.6, 90% CI: 0.5, 4.6), relative to the comparison group. Predelivery and postpartum hospitalizations also increased (ME = 1.2, 90% CI: 0.4, 2.0; ME = 0.4, 90% CI: 0.0, 0.8, respectively), relative to the comparison group. CONCLUSION: Upper respiratory infection and perinatal EOCs for Arkansas Medicaid beneficiaries produced mixed results. Aligning shared savings with quality metrics and cost-thresholds may help achieve quality targets and disincentivize over utilization within the EOC, but may also have unintended consequences.

Accuracy of record linkage software in merging dental administrative data sets.

OBJECTIVE: To determine the accuracy of record matching using "Link King" software that uses an ordinal score for the certainty that linked records are valid matches. METHODS: We linked records in North Carolina Medicaid files to public health surveillance files using Link King matching software. We selected a stratified random sample of 230 of 45,295 linked records and 50 of 35,119 non-linked surveillance records, then manually reviewed the records. Sensitivity (Sn) and Specificity (Sp) were calculated based on each cut point of the Link King score, using manual review as the gold standard. RESULTS: The Sn increased from 0.837 (95% CI: 0.785, 0.892) to 0.935 (0.879, 0.994) and Sp decreased from 0.893 (0.816, 0.976) to 0.865 (0.790, 0.947) as cut points were varied to widen the scope of declared matches. With a goal of both Sn and Sp being large, accuracy was best when linked record pairs from the top three levels of certainty were included in the match. CONCLUSIONS: This study found that a publicly available software program accurately merged Medicaid and surveillance data. The Link King could be useful to researchers in merging administrative databases.

Primary health care providers' advice for a dental checkup and dental use in children.

OBJECTIVE: In this study we estimated factors associated with children being advised to see the dentist by a doctor or other health provider; tested for an association between the advisement on the likelihood that the child would visit the dentist; and estimated the effect of the advisement on dental costs. METHODS: We identified a sample of 5268 children aged 2 to 11 years in the 2004 Medical Expenditures Panel Survey. A cross-sectional analysis with logistic regression models was conducted to estimate the likelihood of the child receiving a recommendation for a dental checkup, and to determine its effect on the likelihood of having a dental visit. Differences in cost for children who received a recommendation were assessed by using a linear regression model. All analyses were conducted separately on children aged 2 to 5 (n = 2031) and aged 6 to 11 (n = 3237) years. RESULTS: Forty-seven percent of 2- to 5-year-olds and 37% of 6- to 11-year-olds had been advised to see the dentist. Children aged 2 to 5 who received a recommendation were more likely to have a dental visit (odds ratio: 2.89 [95% confidence interval: 2.16-3.87]), but no difference was observed among older children. Advice had no effect on dental costs in either age group. CONCLUSIONS: Health providers' recommendation that pediatric patients visit the dentist was associated with an increase in dental visits among young children. Providers have the potential to play an important role in establishing a dental home for children at an early age. Future research should examine potential interventions to increase effective dental referrals by health providers.

Dental care utilization and expenditures in children with special health care needs.

BACKGROUND: The authors compared children with special health care needs (CSHCN) and children without special health care needs (SHCN) with respect to the odds, amount and determinants of having any dental care and dental care expenditures. METHODS: The authors assessed data from the 2004 Medical Expenditures Panel Survey, Agency for Healthcare Research and Quality, to identify a sample of 8,518 children aged 2 to 17 years. The authors used logistic regression to determine the effect of having SHCN on the probability of having any dental care expenditure, for total dental care expenditures and procedure-specific expenditures. They tested the modifying effect between CSHCN and other variables on the probability of having any dental care expenditure. RESULTS: Compared with children without SHCN, CSHCN did not differ in the probability (odds ratio = 0.91, 95 percent confidence interval [CI] = 0.76 to 1.09) or amount (beta = 30.17, 95 percent CI = -162.93 to 223.27) of total dental care expenditures. Likewise, CSHCN did not differ in their likelihood of having undergone a preventive, restorative, diagnostic or other procedure. Known determinants of dental care utilization did not modify the relationships between having SCHN and any dental care expenditure. CONCLUSIONS: Despite the reported difficulty in CSHCN's accessing dental care, the authors found that CSHCN had dental care utilization and expenditures that were comparable with those of children without SHCN. Furthermore, the association of CSHCN status and any dental care expenditure was not modified by known determinants of dental care utilization. Future research should focus on characterizing risk for dental disease among CSHCN more accurately and identifying factors that affect dental care utilization in CSHCN, including provider and parent characteristics. PRACTICE IMPLICATIONS: The study results highlight low rates of dental care utilization among all young children, including CSHCN. Efforts to increase dental care utilization among children are warranted and need to include broad-based provider and parent initiatives.

Distance to care and relative supply among pediatric surgical subspecialties.

BACKGROUND/PURPOSE: The aim of this study is to describe geographic proximity to and quantify relative supply of 7 pediatric surgical specialties in the United States. METHODS: Data from the 2005 American Medical Association Physician Masterfile and the Claritas Pop-Facts Database were used to calculate subspecialty-specific, population-weighted, straight-line distances between each zip code centroid and the nearest provider. These same data sources were used to calculate the percentage of hospital referral regions with a provider, the percentage of the younger than 18 years population living within selected distances of providers, and provider-to-population ratios for each of the pediatric surgical subspecialties. Further, we calculated the correlation between practice locations and children's hospitals offering pediatric surgical services. RESULTS: Across pediatric surgical specialties, average distances to the nearest provider ranged from 27.1 miles for pediatric surgery to 100.9 miles for pediatric cardiothoracic surgery. The average population-weighted distance to a provider was less than 30 miles for pediatric surgery and pediatric ophthalmology only. For 5 of the 7 pediatric surgical specialties studied, approximately one quarter of the younger than 18 years population lives more than 1-hour drive from a provider. Provider-to-younger than 18 years population ratios range across hospital referral region from 0.04 per 100,000 for pediatric cardiothoracic surgery to 0.97 per 100,000 for pediatric surgery. The correlation between pediatric surgeons and children's hospitals offering services was 0.72. CONCLUSIONS: Although the practice locations of pediatric surgical subspecialties parallel the geographic distribution of children in the United States, large percentages of the younger than 18 years population must travel long distance to receive care from these providers. Large coefficients of variation reveal substantial maldistribution. These findings lay the groundwork for workforce assessments of the pediatric surgical subspecialties and underscore the need for future studies that assess access barriers for children in need of surgical care.