Enhanced medical home benefits high-risk children with chronic illness

Compared with usual care, comprehensive care provided to high-risk children with chronic illness substantially increased access to care and parent satisfaction and decreased by 55% the number of such children with a serious illness, a recent study showed. Comprehensive care also reduced clinic and hospital costs by $10,258 a year per child (not including savings to parents), largely because of reductions in hospital costs.

The randomized clinical trial was conducted in 201 children being treated at a high-risk clinic at the University of Texas in Houston (UTH). The children, more than 90% of whom were on Medicaid, were followed for a median of 1.83 years.

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Children in the usual care group were treated by pediatricians in private offices or in the UTH general pediatrics clinic as well as at UTH subspecialty clinics and at a twice-weekly clinic for children with special healthcare needs. Children in the comprehensive care group received care at the UTH High-Risk Children’s Clinic, which was open 40 hours a week and staffed by the medical director and 2 pediatric nurse practitioners. Parents of children in this group could reach a primary care clinicians at any time, and each clinician could access clinic records from home. Children in this group also could see as needed various subspecialists, who attended the clinic once a month.

Compared with usual care, comprehensive care reduced per 100 child years total episodes of serious illness (from 44 to 16), emergency department visits (from 190 to 90), hospitalizations (from 131 to 69), number of days in the hospital (from 635 to 276), intensive care unit (ICU) admissions (from 26 to 9), and days in the ICU (from 103 to 28). The probability that comprehensive care improved each outcome ranged from 94% to 99%, with the exception of death, which comprehensive care did not reduce significantly (Mosquera RA, et al. JAMA. 2014;312[24]:2640-2648).

Commentary: The researchers report a 42% reduction in the annual cost of care for these high-risk children, a savings of more than $10,000 per patient per year. This, along with a reduction in serious illness and improved quality of life for the patients and their families, makes a strong argument for an enhanced medical home model for some children with complex medical needs. Now, payers and healthcare providers need to work on a system that rewards the providers for this improved care. Until financial incentives are shifted away from a fee-for-service model, the providers and their hospital employers will bear the cost of this enhanced service, which decreases their revenues by keeping children out of the hospital. However a realignment of incentives will provide a win for patients, parents, providers, and payers. -Michael G Burke, MD

Ms Freedman is a freelance medical editor and writer in New Jersey. Dr Burke, section editor for Journal Club, is chairman of the Department of Pediatrics at Saint Agnes Hospital, Baltimore, Maryland. The editors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.