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A Health System That Can’t Care for Children :

December 27, 2019

The field of pediatrics has made incredible strides over the past century in its ability to care for critically ill children.

The field of pediatrics has made incredible strides over the past century in its ability to care for critically ill children. The fields of pediatric critical care medicine and pediatric emergency medicine have been board-certified subspecialties for over 30 years now and technical reports from the American Academy of Pediatrics have outlined guidelines for pediatric care in the Emergency Department since 2001, with the most recent report in 2018. Despite these advances, a recent trend threatens the well-being of children–community hospital pediatric closures and consolidation at regional children’s hospitals.

An important article by Michelson et. al (10.1542/peds.2019-2203) in Pediatrics adds to the prior reports from Franca and McManus1 and Khare and Rauch2 noting the recent trend of children not receiving definitive care in the community. Using data from the Healthcare Utilization and Costs (HCUP) Nationwide Emergency Department system (NEDS) database from 2008-2016, the authors demonstrated that in 8 years fewer hospitals were able to care for children in inpatient settings and the number of transfers for definitive care increased 28%. An accompanying commentary by Dr. Guache-Hill (10.1542/peds.2019-3372) highlights the “perfect storm” that’s occurring in the US–fewer hospitals are caring for children with inpatient conditions and have to wait longer in emergency departments that have gaps in their capability to care for them. The consolidation and regionalization of care potentially could be successful, but not only would this take a coordinated response, but also a payment structure that currently doesn’t exist in our country.

Given the pressure to reduce costs of hospital care, alternative payment models have been implemented in many hospitals around the country. While most focus on the Medicare population, these models have impacts on the delivery and payment of care to children as well. Hospitals in value-based payment models such as global budgets, bundling, or value-based care are incentivized to provide quality, reduce readmissions, and keep ambulatory sensitive conditions out of the hospital setting. As general community hospitals begin to focus on how to survive in this new environment, the focus turns to the care of adults. Given the low payment for pediatric care in general, maintaining a 24/7 unit staffed by pediatricians and pediatric trained nurses with low and variable censuses creates a large financial deficit. Thus, the decision to close a “lost leader” non-profitable, high-risk service as inpatient pediatrics becomes easier and more common. Unless we follow Dr. Gauche-Hill’s recommendation to intentionally address both the structural issues around regionalization of care and transport as well creating adequate payment structures for pediatric care, we will continue to see a decline in quality and access. Unfortunately, it will be the children who will pay the consequence and the sickest won’t get the care they need in a timely manner.


  • França UL, McManus ML. Availability of Definitive Hospital Care for Children. JAMA Pediatr. 2017;171(9):e171096. doi:
  • Trends in National Pediatric Bed Census. Manaswitha Khare, Daniel A. Rauch. Pediatrics. September 2017, VOLUME 140 / ISSUE 1 MeetingAbstract
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