BRIDGING THE GAP BETWEEN CONFUSION AND CLARITY IN HEALTHCARE

National Physician Advisor ConferenceNPAC2019

They’re Not Just Little Adults – How the Physician Advisor RoleIn Pediatrics Differs from the Role in Adult Medicine

Denise M. Goodman, MD, MS, FCCMMedical Director of Case Management and Care Coordination (Physician Advisor)Ann & Robert H. Lurie Children’s Hospital of ChicagoChicago, Illinois

3

• To understand some of the unique challenges pediatric physician advisors encounter

• To describe some of the underlying reasons for these challenges

• To review some of the literature regarding consequences of these challenges

Objectives

4

• Pediatric intensivist

• Physician advisor/Medical Director of Case Management and Care Coordination for 5 years

• Free-standing academic children’s hospital

• 270 360 beds

About me

5

• Patients

• Physiology

• Processes

What are some challenges for pediatric physician advisors?

6

• Many fewer children are hospitalized than adults• In 2016, 6% of children < 12 years had at least one overnight stay1

• In 2016, 16% of adults > 65 had at least one overnight stay1

• The rate of hospitalization was ~60/1000 for children < 12 and ~150/1000 for adults > 651 (2016 data)

• Children represent a small proportion of healthcare spending• In 2012, 11.7% of healthcare spending was for children 0-18 years old2

Patients

1 CDC, https://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2016_SHS_Table_P-10.pdf

2 CMS, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Age-and-Gender.html

7

Most care is for neonates and infants

https://www.hcup-us.ahrq.gov/reports/statbriefs/sb187-Hospital-Stays-Children-2012.pdf

8

And most spending is ambulatory after the first year of life

Bui AL, et al. JAMA Pediatr 2017;171:181-189

9

• Most common diagnoses for children have short LOS

• Children often get acutely ill very quickly but also turn around very quickly

• Physiology is dynamic through development

• Our population is often nonverbal which can complicate diagnosis

• Follow up depends on the integrity of family resources

Physiology and Practice

Morse RB, et al. J Pediatr. 2013 Oct;163(4):1034-1038.e.1. PMID: 23683748

10

• Many processes are hardwired for the volume and conditions typical of adult hospitalization, including Medicare payment structures, whereas pediatric care is driven by Medicaid

• In 2012 Medicaid covered 51.6% of non-neonatal stays for children compared to 26.4% for adults ages 18-441

• From 2000-2012 proportion of pediatric stays paid by Medicaid increased by 33%, private insurance decreased by 21%1

• Medicaid represents ~59% of inpatient days for children’s hospitals, but pays only ~80% of costs of care2

• The variability of state Medicaid practices makes it difficult to develop consistent pediatric processes across states

Processes

1 AHRQ, https://www.hcup-us.ahrq.gov/reports/statbriefs/sb187-Hospital-Stays-Children-2012.pdf

2 CHA, https://www.childrenshospitals.org/Issues-and-Advocacy/Medicaid/Fact-Sheets/2017/2017-State-Medicaid-Fact-Sheets

11

• Determining observation vs. inpatient status

• Network adequacy, resources, and fragmentation

• Evidence-based clinical care

• Culture of pediatric care

What sorts of challenges arise?

12

• It seems straightforward – severity of illness and intensity of service, but…

• Median LOS for common pediatric diagnoses (asthma, bronchiolitis, seizures, gastroenteritis, etc.) < 48 hours

• Payers want to default to observation

• Utilization of resources is similar between inpatient and observation patients1

• Reimbursement driven by administrative status with comparable resource utilization

Observation vs. Inpatient

1Fieldston ES, et al. Pediatrics 2013;131:1050-1058

13

There is substantial overlap in observation and inpatient costs

1Fieldston ES, et al. Pediatrics 2013;131:1050-1058

14

Admission Criteria – Hypertension, Pediatrics vs Adults

• Pediatric Admission Criteria• No acute care criteria for

Hypertension

• CV diagnoses listed under larger “General Medicine” umbrella

• Adult Admission Criteria• Listed as condition specific-

options, greater criteria versatility• Acute Coronary Syndrome

• Arrhythmia

• DVT

• Heart Failure

• Hypertension

• Pulmonary Embolus

• TIA

• Stroke

15

• Many pediatric diagnoses don’t fit into criteria points• Intussusception

• Aspiration requiring enteral feeding initiation

• Ketogenic diet initiation

• Cyclic vomiting syndrome

• Juvenile Idiopathic Arthritis (and other rheumatologic conditions)

• Maple Syrup Urine Disease (and other inborn errors of metabolism)

Common Diagnoses

16

• Other subsets don’t take into account medical complexities of children with multiple comorbid conditions• 2 yo male with Lennox-Gastaut syndrome*, seizures, scoliosis, severe

developmental impairment, s/p trach with laryngo-tracheal separation, s/p gastrostomy presents with fever and irritability.

Common Diagnoses

*A severe form of epilepsy with cognitive impairment

17

• Medicaid enrollees not required to pay deductibles or copayments (so possibly cost neutral to patients)

• Large administrative and compliance costs shifted to hospitals and payers• Estimated $65.10/admitted patient1

• Cost shifting to families with commercial insurance

Consequences of Observation/Inpatient determinations

1Tejedor-Sojo, J. Hosp Pediatr 2014;4:321-323

18

• A 6 yo with cerebral palsy, colonic dysmotility, non-verbal, failed multiple attempts at outpatient clean-out for a manometry study, has encopresis from the impaction, now comes in for NG/IV clean-out, which takes 52 hours to complete• Inpatient or observation?

• What do the criteria say? (MCG or IQ?)

• What does the payer say?

• Even with daily concurrent review, hospitals and payers don’t always agree

A practical example

19

• Admitted for clean-out/constipation – denied for inpatient status

• Child is 3 yo with functional short gut from ACTG2-related visceral myopathy with neurogenic bladder, cecal volvulus, prior surgeries, ostomy, G-J tube

A case from our denials meeting

20

• Determining observation vs. inpatient status

• Network adequacy, resources, and fragmentation

• Evidence-based clinical care

• Culture of pediatric care

What sorts of challenges arise?

21

• Once a child no longer needs acute care, what happens• Fewer options for lower level of care (transitional or long-term)

• Fewer options for home nursing agencies

• Fewer DME, specialty pharmacy, and other providers

Network Adequacy, Resources, and Fragmentation

22

• Asked our case managers to look at real payer lists for home care provision:• Illinois MCO #1, home health agency for skilled nursing visits = 68

providers listed, 5 take pediatric patients

• Illinois MCO #2, home infusion need = 7 providers listed, 1 takes pediatric patients

• Commercial payer, DME needed = 61 providers listed, 3 take pediatric patients

Payer restrictions – real life examples from Illinois

23

• Intermittent skilled nursing and private duty nursing• Coverage varies among commercial insurers

• Comprehensive home health benefits are provided in Medicaid, but…

• Few agencies will take pediatric patients, and payments may not cover costs

• If children need these services (teaching around injections, catheter changes, wound care, etc.) not to mention more intense needs (tracheostomy, home ventilation) there may be few alternatives to continued hospitalization

Home Nursing

24

• “States are required to provide any additional health care services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct or reduce illnesses and conditions…regardless of whether the service is covered in a state’s Medicaid plan. It is the responsibility of states to determine medical necessity on a case-by-case basis.”

• Inconsistent state-specific variability in program implementation and interpretation of the federal law

Early and Periodic Screening, Diagnostic, and Treatment - EPSDT

https://www.medicaid.gov/medicaid/benefits/epsdt/index.html

25

• A 6 yo with leukemia required an antineoplastic through a central venous catheter• Of perhaps 30 agencies in a network, only 2-3 took pediatric cases• At the time one agency had only a few nurses certified in CVC care and pediatrics• But, they had no specialty pharmacy to provide the drug• So, the child stayed an extra 5 days while a single case agreement was completed

with a different pharmacy

• An 18 month old required complex wound care • The payer insisted that this could be done in a SNF• There were no in-network SNFs that took 18 month old babies

Some practical examples

26

• Specialty drug compounding• If a commercially available drug is available, a specially compounded

version is not permitted

• But, children often require liquid formulations, that may not be in an appropriate dilution for very small babies

• Sildenafil is branded as Revatio for pulmonary hypertension• Infant dose is 0.5-1 mg/kg/dose

• The liquid formulation is 10 mg/ml

Some practical examples

27

• Limited providers in certain neighborhoods/rural areas

• Daytime vs. nighttime coverage

• Non-uniform coverage of type/duration of home health services

• Inadequate payments

• Some agencies don’t permit the home nurse to be the only adult at home

Other barriers

https://www.healthychildren.org/English/family-life/health-management/health-insurance/Pages/Paying-for-Your-Childs-Home-Health-Care.aspx

28

• 12-month, multisite prospective study of children with medical complexity discharging with home health

• Delayed discharge occurred in 68.5% of new patients and 9.2% of existing patients, most frequently due to home care nursing

• Average length of stay increase of 53.9 days (new pts) and 35.7 days (existing patients)

• Estimated cost for each hospital day was $3932 vs $40.72/hour for home care nursing ($651.52/16 hour per day coverage)

What are some consequences?

Maynard R, et al. Pediatrics. 2019 Jan;143(1). pii: e20181951. doi: 10.1542/peds.2018-1951. Epub 2018 Dec 3.PMID: 30509929

29

• A 53 yo with end stage kidney disease s/p kidney transplant in 2008

• Admitted with viral respiratory infection requiring two weeks in the hospital including noninvasive ventilation, IV antibiotics, IV antihypertensives, frequent labs, IV pain management

• A 5 yo with prune belly syndrome s/p kidney transplant at age 3

• Admitted with viral respiratory infection requiring two weeks including noninvasive ventilation, IV antibiotics, IV antihypertensives, frequent labs, IV pain management

An example as the patient prepares for discharge

30

• Nephrology follow up• Hypertension

management/education, ptdoes this independently

• Medication adjustments

• Weekly Epogen, teaching for home use

• Dialysis education, access to dialysis center

• Home BP cuff, purchase at retail pharmacy

• Same follow up, BP cuff• Digital options are very

expensive• Digital retail options may not

be accurate or the right size• Caregiver must be trainable

and reliable

• Dialysis center – extremely limited

• Home dialysis – caregiver must be trainable/competent

Outpatient Needs

Adult patient Pediatric patient

31

• Transportation –independent

• Support – independent, minimal assistance

• Transportation – caregiver dependent

• Appointments – caregiver dependent

• Home health support –limited

• Transitional care facilities –limited, and…

• General support – must consider growth, development

Outpatient Needs

Adult patient Pediatric patient

32

• Determining observation vs. inpatient status

• Network adequacy, resources, and fragmentation

• Evidence-based clinical care

• Culture of pediatric care

What sorts of challenges arise?

33

• Some care is extrapolated from adult studies, particularly if definitive evidence is lacking in children

• Some conditions affect a small number of pediatric patients, making it difficult to perform a pivotal RCT

• A review of studies in 6 leading generalist and specialist journals showed that studies involving adults were significantly more likely than those in children to be RCT’s (23.8% vs 8.8%) and systematic reviews, and less likely to be cross sectional studies (16.9% vs 40.9%)1

Evidence-based clinical care

1Martinez-Castaldi C, et al. Pediatrics 2008;122:52-57

34

• There are few standard treatment algorithms for many pediatric conditions

• Some treatments are overwhelmingly used in pediatric rather than adult care (such as a ketogenic diet for seizure control)

• Many drugs are considered ‘off label’ either because they are not approved in children less than a specific age or the indication is different*

Evidence-based clinical care

*About 79% of discharges have at least one drug used off labelShah SS, et al. Arch Pediatr Adoles Med 2007;161:282-290

35

• 15 yo with high risk AML with a mutation in the FLT-3 gene. A new drug which is a multi-target kinase inhibitor is FDA approved for patients with high risk, FLT-3 mutated AML, but…

• The pivotal phase 3 trial had a minimum age of 18 years

• Ultimately approved but a typical problem

An example

36

• Determining observation vs. inpatient status

• Network adequacy, resources, and fragmentation

• Evidence-based clinical care

• Culture of pediatric care

What sorts of challenges arise?

37

• We care for the child within the family, and the family has a large role in every decision

• We must continually focus on both the physiologic and behavioral/developmental aspects of care

• Minimal emphasis on LOS optimization in days past

• No Hospital-Issued Notice of Noncoverage (HINN) process• What do you do if the family refuses to be transferred to a lower level of care or

discharged?

• Often defer to parent comfort level as a precondition of discharge

• We care for a vulnerable population and appropriately err on the side of protecting the child, but this can lead to “unnecessary” prolongation of stay

Culture of pediatric care

38

• Teach-back parental education – what is the best timing?

• Contingency planning post discharge

• Follow up care

• Care coordination

• Challenges of family engagement and family-centeredness if parents must go to work or care for other children

• Aligning family expectations with care team expectations• Does the child need to be afebrile or improving? For how long?

Discharge readiness – much written, much still to learn

39

Ultimately, it’s all worth it

www.acpadvisors.org

40

dgoodman@luriechildrens.org

Questions?