This approach requires close and consistent contact with a primary-care physician and on-going education to keep people out of hospitals. A relationship with a physician ensures better coordination of care with other providers and less costly utilization of often duplicative tests.
Most important, the patient receives good general care and prevents an untreated condition from becoming an emergency requiring an inpatient admission. Massachusetts and Wisconsin have shown good results with medical homes for children. Right now, New York has eight pilot programs under way for adults, according to the Nelson A. Rockefeller Institute of Government.
A second group of children, rather than one medical issue, have multiple problems that simultaneously require specialized management. These children often are referred to as “medically complex” and frequently have multiple tests, emergency room visits and admissions in a single year. Before they reach adulthood, some of these children were known to consume their entire lifetime private insurance benefit, causing the family to fall back on Medicaid as a safety net and insurer of last resort. Lifetime insurance benefit limits were eliminated in national healthcare reforms precisely because of these types of cases.
Unfortunately, the medical home, based in the primary-care model, does not adequately address the needs of these children. A medically complex child can consume hours of time in a primary-care setting. The providers must review the results of tests, reports from consultant specialists, schedule tests and procedures, and coordinate inpatient care if the child is hospitalized.
Most primary-care physicians require moderate- to high-volume practices to be economically viable and simply cannot devote the time these children require. So, medically complex children may be better managed through a team of specialists in a children's hospital.
Unlike adults who often see specialists in a private practice, pediatric specialists tend to be concentrated at children's hospitals, and are often employed by them or their affiliated medical schools. The specialists a child needs are all in one place, simplifying coordination of care.
The specialists use a common medical record, often electronic, to make the flow of information and communication more efficient. If the child needs tests, they are interpreted by pediatric specialists in pathology, radiology, cardiology, neurology or other disciplines who have extensive training and years of experience with childhood conditions.
The specialists have admitting privileges at the children's hospital, so they can provide care and direct it for the child during hospitalization. The concentration of expertise and experience in one location offers the best opportunity to deliver not only care of the highest quality, but also to do so as efficiently as possible.
Medicaid can test these models of care through demonstration projects to see if they make sense throughout the state of New York and the rest of the country. The Medicaid database is a rich source of information that can confirm or refute the fragmentation of services that currently exists. Demonstration projects for children with chronic or medically complex needs can prove or disprove the model of care that works best, improve coordination and implement the most effective delivery of care.
If we can prove that these changes improve the delivery of care, keep children healthy and hold down costs, everybody benefits. This is in line with New York's and the nation's bold efforts to address the hardest issues in healthcare: access to care, quality of care and cost of care.
Kevin Hammeran is chief operating officer of the Morgan Stanley Children's Hospital of NewYork-Presbyterian.