Health Care Reform and Children with Chronic Conditions
James M. Perrin, M.D.Professor of Pediatrics, Harvard Medical School
Director, Division of General PediatricsMassGeneral Hospital for Children
Changing Patterns of Childhood Chronic Conditions
Children and Adolescents with Limitation of Activity
012345678
Per
cent
1960 1969-70 1974-75 1979-81 1992-94 1996-98
Newacheck, NHIS Analyses
Disability from Childhood Chronic Health Conditions
0
5
10
15
20
25
30
35
Speech problems
Asthma
Dvlptl Retardation
Other Mental Condition
ADHDLearning Disability
<5 yo5-11 yo12-17 yo
Per 1,000 population; NHIS, 2002-2003
Overall Growth in Childhood Chronic Conditions
0
5
10
15
20
25
30
1988-1994 1994-2000 2000-2006
Initial Prev
End Prev
Cohorts of 2-8yo followed for six years; initial and end chronic condition prevalence; Van Cleave, Gortmaker, Perrin, JAMA, 2010; 303: 623-630
Trajectories of Chronic Conditions
Children in the National Longitudinal Survey of Youth (NLSY)
1988, 1994, 2000, and 2006 comparisons
40-50% of children with chronic conditions in 1988 do not have them in 1994 (same in 2000 and 2006)
>60% of those with chronic conditions in 1994 (or 2000 or 2006) did not have them six years earlier
Chronic Conditions: Children and Adults
Adult conditions: small number of common conditions
Child conditions: large number of (mainly) rare conditions
Most conditions more common in males, especially before puberty
Most children survive, although developmental, physical, and psychological outcomes vary
New Epidemics: Mainly among school-age children
and youthOverweight
Asthma
ADHD
Depression
Autism Spectrum Disorder
11,250,000*
5,250,000
4,000,000
3,200,000
500,000
*population estimates, early-2000s
“Other” Chronic Conditions
Cystic fibrosis
Spina bifida
Sickle cell anemia
Hemophilia
22,500
60,000
37,500
7,500
Growth in Rates of Chronic Conditions
1960-1980: Improvements in survival led to increases in rate of a number of chronic conditions (>80% survival in 1980; >95% survival currently)Marginal impact of newer conditions (eg, VLBW, in utero toxins, AIDS)1980-2006: New epidemics of common chronic conditions
Growth of Child and Adolescent Health Conditions, 1980-1995
0%
2%
4%
6%
8%
10%
12%
14%
16%
Obese(>95%ile)
ExtremeObesity
(>99%ile)
Asthma ADHD
early 1980smid 1990s
Long-term Implications
Major (public) health burdens fromRising cardiovascular disease (overweight and
diabetes) Increased pulmonary disabilityHigher rates of mental health conditions
Decreased workforce participation and quality of lifeIncreased reliance on disability programs
Childhood Chronic ConditionsIncreasing Prevalence
Several developments have led to dramatic increases in childhood chronic conditions: Amazing biomedical advances
Children with chronic conditions live longer (eg, CF, leukemia) More children survive (eg, NICU, surgical)
Genetics (?) Toxins – known and unknown Autoimmune conditions on the rise Regressive social changes
Factors affecting New Epidemics
Increasing rates of VLBW
Poverty Increases rates of most conditions Increases severity of many conditions
Little evidence for changes in poverty ratesBut certainly little improvement in 40 years!
Changes in Children’s Social Environment
Parenting
Media (incl., phones)
Physical activity and indoor time
Diet
Parental Stress
Changing employment patterns
Changing geography, esp. in urban areas
Children have less time and attention from consistent adults
Television and Media
60% of all children with TVs in rooms; 30% of children <2 yo Advertising for fast and high calorie foodsChildren indoor and sedentaryPassive entertainmentFast-paced, rapid cycling visual and auditory stimulationAggression and violence presented as harmless; gratification immediateTracks from preschool years to adolescenceReplaces tasks requiring more attention (e.g., reading; model building)
Impact of Television
Fattening children in front of TV (Gortmaker, Dietz)
Dose-related effects of TV on initiation of smoking among 10-14 year olds (Gidwani et al.)
Physical activity
Limited recreation (playgrounds, parks, sports programs)
Dangerous neighborhoodsEffects on social interactions
Decreased school physical education
Lower rates of walking and bicycling
More Time Indoors
More exposure to indoor pollutants
Less time socializing with peers
(More time with TV and other media)
(More sedentary behaviors)
Diet
Increased fast food and take out restaurantsIncreased portion sizeNutrients from fortified drinks – sodas in schools
Clear association with overweight and diabetesAssociation of asthma with Low levels of omega-3 fatty acids and antioxidant vitamins High levels of trans fatty acids
Sugar and ADHD (??)
Health Care Reform
Health Care Reform Benefits for Children
Improved Medicaid reimbursement To Medicare floor for primary care by 2013 Potential limitations!
States to maintain Medicaid eligibility levels thru end of 2014; CHIP thru Sept 2019
Required coverage of pre-existing conditions
Use of Bright Futures in well child and preventive care – with no copays
Medicaid, SCHIP, and Health Care Reform
Broad payment reform experiments Substantial emphasis on primary care medical
home
Center for Medicare and Medicaid Innovation – encouraging new patient care modelsOpportunities for blended payment models
Exchange plans and SCHIP
What Is a Medical Home?What Is a Medical Home? An approach to providing health care services in a An approach to providing health care services in a high-quality, comprehensive, and cost-effective high-quality, comprehensive, and cost-effective mannermanner
Provision of care through a primary care physician Provision of care through a primary care physician through partnership with other allied health care through partnership with other allied health care professionals and the familyprofessionals and the family
Acts in best interest of children and youth to Acts in best interest of children and youth to achieve maximum family potentialachieve maximum family potential
Many notions tested among children and youth Many notions tested among children and youth with special health care needs – but principles and with special health care needs – but principles and characteristics apply broadly to all characteristics apply broadly to all children/familieschildren/families
Medical HomeFamily-centered vs primary care
Characteristics Patient registries, with severity assessment Electronic medical records Practice standards and
decision supportDevelopment of clinical information to enhance
guideline development Care coordination Clinical teamwork Patient information and involvement in decisions
Medical Home: Does it Work?
33 articles from 30 distinct studies 6 RCTs 1 pre-post with comparison; 4 without 3 cohort 16 cross-sectional
Evidence for improved Health status Timeliness of care Family-centeredness Family functioning
Homer et al., Pediatrics, October 2008
Medical Home “Definition” in Legislation*
Personal physicianWhole person orientationCoordinated and integrated careSafe and high quality care Evidence-informed medicine Appropriate use of health information technology Continuous quality improvement
Expanded access to carePayment that recognizes added value of primary care components
From the Medical Home Joint Principles
Joint Principles of the Joint Principles of the Patient-Centered Medical Patient-Centered Medical
HomeHomeAmerican Academy of PediatricsAmerican Academy of Pediatrics
American Academy of Family PhysiciansAmerican Academy of Family Physicians
American College of PhysiciansAmerican College of Physicians
American Osteopathic AssociationAmerican Osteopathic Association
Medical Home Joint Medical Home Joint Principles: Pediatric Principles: Pediatric
PreamblePreamble
Family centered careFamily centered care
Community based system of careCommunity based system of care
TransitionsTransitions
ValueValue
The Medical Home and The Medical Home and Community Service SystemCommunity Service System
Children and families receive services from Children and families receive services from many community sourcesmany community sources EducationEducation RecreationRecreation TransportationTransportation OthersOthers
Medical home helps to coordinate key health-Medical home helps to coordinate key health-related servicesrelated services
Perrin, J. M. et al. Arch Pediatr Adolesc Med 2007;161:933-936.
Family-Centered Community-Based System of Services Family-Centered Community-Based System of Services for Children and Youthfor Children and Youth
Additional coverage and insurance reforms
No lifetime or unreasonable annual benefit limits
Prohibits discriminatory premium rates
Guaranteed availability of coverage
Prohibits pre-existing condition exclusions
Includes dependent coverage up to age 26 years
Increased access to home/community-based services in Medicaid
Community health
Major expansion (double #s of patients seen in three years) of community health centersMedical home extension service – state hubs with community-based services to aid in transformation Support for transformation to primary care medical homesIncreased scholarships and loan forgiveness to PCPs in Natl Health Service Corps sites
Quality
Section 2717 recognizes medical home as way to improve health outcomes
Exchange payment structures have incentives to improve health outcomes, including use of medical home
Specific Medical Home efforts
$25 million in state planning grants to develop amendments to provide “health homes”
Substantial (90%) Federal match for health homes development
Pediatric accountable care organization demonstrations (within 3 years)
Various experiments
Medical Home Experiments
Broad payment and practice reform in primary care, including PCMH models, “for high-need applicable individuals, women’s unique health care needs, and models that transition PCPs from FFS to capitated payments or salaried careCommunity-based teams (esp., in smaller communities) to enhance patient self-management Collaborate with local PCPs to coordinate disease prevention , chronic
disease management, transitions among health providers, and case management (including children), with priority given to conditions amenable to prevention, chronic conditions, or conditions identified by the Secretary
Center for Medicare and Medicaid Innovation – encouraging new patient care models Opportunities for blended payment models
Summary
Medical home prominent in health care reform legislation – in large part related to patients with chronic health conditions
Much focused on primary care for adults
Opportunities to improve primary care-subspecialty care referral and collaboration
How does HCR affect children with chronic conditions?
Opportunities
Universal health care coverageNeed to assure adequate benefit package
Emphasis on prevention of chronic conditionsParticularly relevant for childrenPrimary and secondary prevention
Improving coverage for subspecialty care?
Thank you!
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