Children’s hospitals are being pushed to the brink as they confront a surging respiratory disease outbreak in addition to rising COVID-19 cases and a mental health epidemic. It's a multifaceted threat that may recur without policy fixes.
Children’s hospitals were spared from the worst of the pandemic because pediatric COVID-19 case numbers had been low relative to adults. But COVID-19 and respiratory syncytial virus diagnoses among children have climbed in recent months. Those patients are going to hospitals where capacity is already strained by the skyrocketing number of children and young adults with behavioral health conditions.
“Pediatric hospitals are in crisis mode right now,” said Lisa O’Connor, senior managing director at FTI Consulting. “They are pulling out emergency preparedness policies and activating everything functionally possible from a policy and regulatory standpoint.”
Policy experts say it is up to healthcare providers and the government to invest in pediatric care and prevent future crises.
“It has been a perfect storm,” said Dr. Daniel Rauch, a pediatrics professor at Tufts University and chair of the American Academy of Pediatrics committee on hospital care. “If most smaller and safety-net hospitals are, at best, breaking even on Medicaid, they can’t afford to keep pediatric beds open.”
Pediatric care is typically a small element of health system operations so, for units with fewer resources, a viral outbreak can be overwhelming. For instance, Orange County in California declared a health emergency this week as healthcare providers there battle COVID-19, RSV and influenza.
At the same time, hospitals are still struggling to hire workers. Health systems trained lower-level practitioners to treat less-acute patients during the COVID-19 pandemic, but that approach isn’t viable for most pediatric care because it is so specialized.
“Despite the efforts put into place regarding recruitment and retention, we just need a lot more bodies,” said Carrie Kroll, vice president of advocacy, public policy and political strategy at the Texas Hospital Association.
Weathering the ‘perfect storm’
The RSV surge hit earlier than expected this year, which forced hospitals to adapt their operations to accommodate an influx of pediatric patients.
In California, the Santa Barbara area is seeing a striking rise in RSV infections. Cases doubled three weeks ago and have since doubled again, said Dr. Lynn Fitzgibbons, infectious diseases physician at Santa Barbara Cottage Hospital. There have been as many RSV infections in the past week as there were in the preceding month, she said.
Dr. Elizabeth Meade, medical director of quality for pediatrics at Providence Swedish in Seattle, said inpatient pediatric units are at capacity in that region. Between 50% and 75% of the pediatric patients at Providence Swedish are being treated for RSV, which is more than the facility would see in a typical winter.
As a result, the hospital is working on a contingency plan that applies lessons from the pandemic. Shifting workers from adult care to pediatrics is another potential solution, Meade said. And the Providence Swedish emergency department is assessing where to place children when no beds are available, she said.
Hospitals elsewhere have canceled non-urgent procedures and set up outdoor tents to deal with the wave of sick kids.
RSV patients are grouped together at Providence Swedish, where the pediatric and pediatric intensive care units are on the same floor, Meade said. If they require additional space, adolescent patients with non-infectious ailments, such as behavioral health issues or post-surgery needs, would be transferred, she said.
The North Carolina Healthcare Association has deployed a centralized contact system, which it used to facilitate patient transfers before Hurricane Florence hit in 2018 and more recently during COVID-19 surges, to place patients in beds that are harder to find, such as in pediatric ICUs.
Compounding the RSV crisis is the escalating rate of mental health cases among children and young adults, which further strains capacity at children’s hospitals. Kids with mental health issues are staying in hospital emergency departments longer — sometimes for week s— because residential or outpatient services have been cut or facilities are full.
Pediatric providers’ mental health capacity constraints are symptoms of longstanding and often neglected shortfalls. Access to pediatric mental healthcare has historically been limited because of low reimbursement rates, scant financial incentives for students to choose the specialty and narrow insurance networks.
“Part of the solution needs to be upstream. What are we doing on the prevention side and how can we make sure children are getting the appropriate care in the home or outpatient settings, which are not always available?" said Anne Dwyer, associate research professor at the Georgetown University Center for Children and Families.
Policy experts and healthcare trade associations have proposed short-term solutions to boost capacity and long-term fixes to stabilize the pediatric sector.
The Centers for Medicare and Medicaid Services should codify the looser rules enacted during the coronavirus public health emergency that facilitate telehealth access, such as not requiring clinicians to be licensed in the same states as their patients, Rauch said.
Extending the public health emergency’s facilities waiver would allow hospitals to convert space that is not usually used for patient care, said Bob Garrett, CEO of Edison, New Jersey-based Hackensack Meridian Health. Over the long term, adding more graduate medical education slots for pediatrics and pediatric psychology students would increase the pool of specialists, he said.
The Texas Hospital Association is developing a $65.5 million legislative proposal to increase loan repayments for nursing students, fund training programs to replace retiring nurse professors and increase nursing school capacity. Last year, Texas nursing schools turned away more than 15,000 qualified applicants because of insufficient resources, Kroll said.
“Anytime you are looking for a pediatric specialist, the pool of candidates narrows,” Kroll said. “The only real way to flip the boat around is to put more people into the workforce.”
Congress should lift the caps on graduate medical education payments to teaching hospitals and the federal government and states should raise pediatric Medicaid reimbursements to match Medicare rates, Rauch said. Otherwise, more pediatric beds will disappear, he said.
The number of pediatric inpatient beds declined from 2008 to 2018, according to an analysis of American Hospital Association data published in the journal Pediatrics last year.
CMS notified state Medicaid agencies in August about the Early and Periodic Screening, Diagnostic and Treatment benefit, which funds preventive pediatric mental healthcare. CMS encouraged states to promote prevention by eliminating diagnosis requirements to access treatment, expanding provider capacity by training primary care providers or community health workers in behavioral health, and boosting payment for primary care that integrates behavioral health.
States can also tap into additional funding through the American Rescue Plan Act, which provides $12 billion for home and community-based services under Medicaid. Qualifying states can receive a 10 percentage point increase in the Medicaid matching rate for related services.
“Pediatric care in general is not as profitable as adult care,” said Dr. Larry Kociolek, medical director of infection prevention and control at Lurie Children’s Hospital of Chicago. “Hospitals are businesses and hospitals need a margin to stay open, and so hospitals are making business decisions about how to staff those beds in order for them to be able to recoup the costs of providing healthcare.”
Pediatrics should focus on primary care, which would lighten the burden hospitals bear, said Dr. Keith Jensen, regional medical director of pediatric emergency medicine for the Woman’s Hospital of Texas and HCA Houston Healthcare. Higher pay for primary care also would encourage more people to choose pediatrics as a specialty, he said.