improving healthcare for hoosier children jay l. grosfeld, md lafayette f. page professor of...
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![Page 1: Improving Healthcare for Hoosier Children Jay L. Grosfeld, MD Lafayette F. Page Professor of Pediatric Surgery Indiana University School of Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062716/56649dff5503460f94ae7db7/html5/thumbnails/1.jpg)
Improving Healthcare for Hoosier Children
Jay L. Grosfeld, MDLafayette F. Page Professor of
Pediatric SurgeryIndiana University School of Medicine
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Provision of Health Care in Indiana
• State population: 6,120,000 in 2002
• 20% are children (1,574,396 in 2001)
• 83,000 annual births
• 70 % of children are covered by private healthcare insurance
• Others: Medicaid (475,464)
Hoosier Health Care
CHIPS - Programs A, C
Uninsured (11%)
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Population Demographics
Ethnicity Indiana US
White (non-latino)
85% 69%
Afro-American 8.4% 12.3%
Hispanic-Latino
3.5% 12.5%
Asian 1.0% 3.6%
Native American
0.3% 0.9%
Population 6.12 million 284.8 million
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National and State Health DataParameter US Indiana Nat’l. Rank
% low birth weight babies
7.6% 7.4% 22nd
Death rate/100k 22 25 33rd
Teen deaths by accident, suicide and homicide/100K
51 58 29th
Infant mortality/1,000 live births
6.9 (14.2) 7.6 (13.6) 36th
Teen birth rate 15-17 yrs
27/1,000 26/1,000 30th
Single parent 28% 24% 6th
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National and State Health Data
Parameter US Indiana Nat’l rank
Children in poverty
17%
(extreme 7%)
12%
(extreme 5%)
10th
Smoking mothers
12.9% 20.3% 46th
Unemployed parent(s)
24% 21% 17th
Female head of family –receiving child support
36% 54% ?
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Demographics
Parameter Indiana US
< 5 yrs 7.0% 6.4%
< 18 yrs 25.9% 25.7%
> 65 yrs 12.4% 12.4%
< FPL 9.5% 12.4%
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Medicaid
• Office of Medicaid Planning and Policy (OMPP) designated state agency for Medicaid. 475,464 covered by MK
• Hoosier Healthwise Program managed by the managed care division of the OMPP
• Children’s Health Insurance Program (CHIPS) Joint Federal-State funded program with State receiving federal matching dollars.
• Indiana matching rate = 74.43%
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Medicaid funding(n = 738,240) 3.85 billion (2003)
Aid category Enrollment % total expense
TANF-adult 101,212 9%
Children 475,464 (64.3%) 22%
Aged 61,310 26%
Blind/disabled 97,902 41%
Unclassified 2,352 1%
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MedicaidChildren’s age groupings
Age group
Under 1 yr
1- 5 yrs
6 - 12 yrs
12 - 18 yrs
Enrollment
39,657
152,648
169,539
113,610
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Medicaid/CHIPS
• CHIPS – two phases
• Phase I (Medicaid expansion) provides medicaid to children birth to < 19 yrs old with family incomes no more than 150% FPL($27,150 for family of 4) n = 54,050
• Phase II (non-Medicaid expansion) State defined - not an entitlement. Monthly premium share program provides care from birth -18 yrs with family incomes 200% FPL ($36,200 for family of 4) n = 12,900
• Total 66,950 children Phase I and II
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Hoosier Healthcare for ChildrenMedicaid delivery system
Based on monthly income, family sizeFamily size $/mo “A” $/mo “C”
1 1,044.00 1,392.002 1,407.00 1,875.003 1,769.00 2,359.004 2,132.00 2,842.005 2,494.00 3,325.006 2,857.00 3,809.007 3,219.00 4,292.008 3,582.00 4,775.00
no insurance monthly premiumno co-pay 1 child $11-16.50
FPL= $ 18,100 for 2 or more $16.50-24.75 a family of 4 Up to 250% of FPL
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Medicaid/CHIPAge distribution 2001/2002
Age group CHIP I CHIP II Medicaid
0-5 yrs 12%/13% 36%/36% 47%/46%
6-12 yrs 46%/52% 41%/40% 35%/34%
13-18 yrs 42%/35% 23%/24% 18%/20%
Average age (yrs)
11.8/11.0 8.6/8.7 8.6/7.5
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Utilization
• CHIP expenses are less than MK for primary care MD services, non-primary care MD services, in-patient and outpatient hospital services
• CHIP uses more dental services , and Pharmacy costs were similar to MK
• CHIP II has a higher MD use and Dental use than CHIP I
• 37% CHIP II and 39% CHIP I patients are in risk based managed care (RBMC). 9/10 CHIP I children have a single coordinator of primary care case management.
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Medicaid/CHIPS
• State supported recipients: Medicaid 85%;CHIPS 15%
• 86% Medicaid recipients and 81% CHIPS children live in urban communities
• Hoosier Health Care Program is mandatory in Marion, Lake, Allen, Elkhart and St. Joseph counties
• Indiana children have a higher rate of IP & OP hospital utilization, pharmacy and dental services when compared to national averages and the highest utilization rates in the region for IP, physician and dental services.
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Medicaid recipientstop 5 counties
MarionLakeAllenSt. JosephVandenburgh
137,092* 80,143 39,535 35,149 23,749
*4X increase in HispanicChildren enrolled since
1997(2.5%) now 9.3%
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Highest % of county population enrolled in Medicaid
County
Orange
Crawford
Scott
Lake
Marion
Percent
18.2%
17.8%
17.0%
16.3%
15.7%
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Children’s Special Healthcare Services (CSHCS*) Program
• Primary Care benefit
• Dental care benefit
• Specialty care (qualified serious chronic medical diagnosis - CP, CF**, M/M, Asthma, CHD, Cancer etc. “eligible medical conditions” only)
• Slightly more than 8,300 patients statewide
• Used as a supplemental program (birth - 21yr**) – eligibility 250% of FPL
– Private insurance
– Hoosier Healthwise for Children/Medicaid using CSHCS providers and obtaining prior authorization
*formerly Crippled Children’s Program **CF on program for life
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CSHCS - exclusions
• Over the counter drugs and supplies
• Mental health and substance abuse services
• Prenatal or other pregnancy related care
• ER visits or hospitalization un-associated with specific eligible diagnosis (fracture, appendicitis, hernia etc.)
• Organ transplantation
• Eyeglasses, earplugs, diapers,
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Childhood deaths ages 1-14 yrs
All causes
• 1] Accidents
• 2] Cancer
• 3] Cong. Anomalies
• 4] Homicide
• 5] Cardiac disease
• 6] Resp. disease
• 7] Suicide
12,392 (22/100,000)
4,805 (8.5/100,000)
1,434 (2.5/100,000)
894 (1.6/100,000)
727 (1.3/100,000)
452 (0.8/100,000)
380 (0.6/100,000)
307 (0.3/100,000)
Nat’l Center for Health Statistics 2002
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Obstetrical/Perinatal Problems
• Appropriate Prenatal Care
• Pre-eclampsia
• Pitocin related Uterine rupture
• Minority disparity infant mortality (2.5X)
• Prematurity
• Sepsis
• Progeny of Diabetic mothers – IUGR, SGA
• Birth Depression - neuromorbidity
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Advances in neonatal care
• High frequency ventilators – oscillators, more patient friendly (less barotrauma)
• ECMO
• Nitric oxide – pulmonary hypertension
• Surfactant
• Immunomodulation – enhance immune response (Monoclonal antibodies)
• Stem cell alteration of immature tissues – replacement of damaged tissues
• Gene therapy
• Neuromorbidity – response to inflammatory cascade in premature infants
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Very low birth rate survival
Birth weight
1,000-1,500 gms
750-999 gms
550-600 gms
Survival
>95%
80%
50%
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Neonatal SurgeryOngoing problems
• Necrotizing enterocolitis
• Congenital diaphragmantic hernia
• Giant omphalocele
• Gastroschisis with loss of intestine
• Short bowel syndrome–Extensive aganglionosis
–Malrotation with midgut volvulus
–Multiple atresias
–Pseudo-obstruction
–Microviullus disease
–Trauma
–Crohn’s disase
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Obstacles to improved care
• Managed Care
• De-regionalization of Care
• Unnecessary duplication of services in same community – competition for $$$
• Physician and hospital resistance
• Identification of high risk pregnancies, prenatal diagnosis and referral of selected mothers to high risk centers with appropriate personnel, resources and programs in place (access)
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Future Programs
• Improved access to prenatal care
• Reduce minority disparity in child mortality
• Identify high risk pregnancies-selective referral of mothers prior to delivery
• Categorize facilities regarding level of care – focus patients in facilities that provide the appropriate level of care according to severity
• Continued research to solve ongoing problems with premature labor and delivery and high mortality conditions (prematurity, NEC, CDH, Neuro-morbidity, sepsis
• Indiana Perinatal Network
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Childhood Trauma
• Leading cause of death in children
• No statewide trauma System in Indiana
• No uniform pre-hospital standards
• Patients taken to nearest facility – that may not be appropriate for trauma care
• Local hospital may transfer patient to a parent hospital that is a non-trauma center facility
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Vehicular Accidents in Children
• In 2001 there were 42,116 traffic fatalities in the US. 5% were children (4-14 yrs). 4% of vehicle occupant fatalities were children. Children represented 9% of all those injured (267,000).
• Six children are killed and 732 injured daily in MVA. 23% that die are in alcohol related crashes.
• The number of childhood pedestrian fatalities have decreased in the past decade from 789 in 1991 to 444 in 2001. 85% of non-occupant fatalities. 69% occur in urban areas. 65% were boys. 50% on weekends, 45% between 3-7:00 PM. 47% alcohol related.
• 728 pedalcyclists were killed by MVA in 2001. 19% (n=137) were children < 15 yrs. 13% of non-occupant fatalities. Others 2% (Roller-skates, skate boards).
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Childhood traffic accidents
• Child Safety seats reduced the risk of fatal injury in infants < 1 yr by 71% and for toddlers (1- 4 yr) by 54%. Half of the children that died were unrestrained.
• Fewer children are restrained in rural settings than in urban areas and on weekends compared to weekday travel.
• Mortality is higher in rural areas because of ↓access to care
• School bus transportation is relatively safe: 26 deaths annually , only 6 were occupants of the bus and 19 were pedestrians (5-7 yr old group)
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Young drivers 15-20 yrsRisky group
• 190.6 million licensed drivers in US. 6.8% (12.9 million) are between 15-20 yrs old.
• 8,137 of 57,480 fatal crashes involved drivers 15-20 years old (14%). 3,608 drivers were killed. 1% decrease for boys but 15% increase for girlsgirls. This age group also involved in 17% of the car crashes (1.8 million of 11.1 million crashes).
• 33% invalid license, 31% drinking alcohol
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Fatality Rates in Indiana 1999-2002
YEAR
• 1999
• 2000
• 2001
• 2002
# Fatalities
1,020
886
909
792
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Vehicular typeOccupants killed in Indiana
Vehicle
• Cars
• Light trucks
• Large trucks
• Motorcycles
# %
425 (58.2 %)
198 (27.1 %)
17 (2.3 %)
88 (12.1 %)
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Alcohol related crashes (Indiana)
• 171 of 546 (31%) driver fatalities were related to alcohol
• 269 of 792 total persons killed (34%)
were related to alcohol
• Only 12% of drivers survived alcohol related crashes that involved fatalities
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Childhood Trauma System
• Develop pre-hospital standards of care
• Develop EMS Hospital triage system – for patients defined as having a significant injury going to dedicated level 1 or 2 trauma center
• Develop hospital standards and performance guidelines
• Cost-effective
• Decreases mortality
• Improves outcomes
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Indiana Trauma Centers
• Verified by the Committee on Trauma- American College of Surgeons
• Level 1 (n=3) Methodist Hospital, Wishard Memorial Hospital, Riley Children’s Hospital (all in Indianapolis)
• Level 2 (n = 1) Fort Wayne
• None verified in South, East or West sectors of the state (South Bend, Evansville trying for Level 2)
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Trauma System
• Permits triage to appropriate care facility based on severity of injury.
• Permits injury pattern surveillance
• Documents where injuries are occurring – urban vs. rural
• Allows development of childhood (specific) injury prevention programs
• Trauma education: ATLS, ACLS, BCLS, EMSC-program, ER/ICU Nurses program
• Indiana State Committee on Trauma (ACS)
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Statewide “Safe-Kids” Program
•Coordinated program-main base in Indianapolis
•Lots of local chapters – South Bend, Fort Wayne, Evansville, Porter County,
•Car seats, Fire-prevention, MVA, Pedestrian, water-safety, Falls, bicycle safety (helmets), fire-arms
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Child Abuse
• A growing problem (1 million/yr abused)
• 5,000 deaths/yr in the US (27@day)
• Riley Hospital: 200 cases/yr (most < 2yrs)
10 deaths/yr (5%)
• Lower socio-economic groups and younger parents more prone to commit abuse (financial and social stress)
• Some die at home (risk: ↑ 6-12 mo old group)
• Increased societal exposure to violence ?
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Child Abuse: Patterns of injuryOrder of Frequency
• Repetitive soft tissue injuries
• Contusions, abrasions, lacerations, burns
• Evidence of repetitive fractures (long bones, ribs, skull)
• Solitary head injury, subdural hematoma, retinal hemorrhage
• Visceral injuries – spleen, liver, duodenal hematoma, pancreatic injury, renal, bowel perforation (often (50% ) fatal)
• < 3yrs = abuse until proven otherwise
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Child abuse
• Physical abuse– battered child syndrome, shaken baby syndrome
• Boys >> girls: mother, boyfriend, battering sibling, babysitter etc.
• Sexual abuse – girls > 10 yrs: rape, incest
• Psychological and emotional abuse
• Child neglect: failure to thrive, nutritional deficiency/starvation, lack of supervision and hygienic neglect
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Special types of child abuse
•Growing International problem
•Childhood slavery
•Childhood soldiers (Africa, Middle East, Indonesia)
•Adolescent prostitution (Asia, India, Africa)
•Munchausen syndrome
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Child abuseIntervention
• Verification of diagnosis – physician protected in reporting process
• Breaking the cycle – immediate intervention, prevent subsequent injury
• Treat child and the family
• “family” rehabilitation, social services , long-term psychiatric care
• 10% taken from the home permanently
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Obesity in children
• Prevalence is rising - has become an important public health issue referred to as the “obesity epidemic”
• Defined as a BMI (body mass index kg/m2) of >95 percentile for age and sex. Overweight = BMI >85 percentile
• Indiana ranks 6th in the nation . Obesity is observed in 14% of children nationally while 19-20% of the children in Indiana are obese.
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Childhood obesity
• Strong genetic predisposition that facilitates storage of fat
• Easy access to calorically dense foods
• Low levels of physical activity that characterizes modern societies (couch potato, TV, “game-boy”mentality)
• Psychosocial stigma and medical consequences
• Hypertension, cardiovascular disease, metabolic, diabetes, sleep-apnea, orthopedic problems (osteoporosis, joint degeneration), neurologic, and increased risk of cancer in later life.
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Childhood obesity
• There is a definite association between birth weight and attained BMI. Higher birth weight has a tendency toward obesity.
• Parental adiposity is directly associated with offspring’s birth weight; Mom>>Dad
• Maternal diabetes and fetal hyperinsulinism? Effect on fat cell size and number?
• Reduced size at birth associated with central (truncal) obesity and increased cardiovascular risk, hypertension, dyslipidemia, diabetes and insulin resistance (“metabolic syndrome”)
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Prevention of obesity
• An immediate Public Health challenge
• No specific nationwide or Statewide policy or programs in place
• Prevention starting in childhood is critical
• Can have a life-long and perhaps multigenerational impact
• Interventions directed toward improving diet, physical activity and sedentary activities is essential.
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Childhood obesityInterventional strategies
• Psychological and family therapy
• Lifestyle and behavior modification
• Nutritional education and dietary modification
• Regular physical exercise
• Drugs not recommended in children
• Surgical intervention for extremely obese patients (adolescents) the treatment of last resort (BMI >45-50kg/m2)
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Childhood obesitySurgical management
• Bariatric surgery is effective in managing severely obese adolescent patients that fail conservative treatment programs.
• Gastric by-pass procedure effective
• Laparoscopic minimally invasive approach is safe, reduces morbidity, fewer wound infections, avoids scars, ventral hernias, reduces postoperative pain requirements, shortens hospital stay, more rapid recovery
• Treatment should be carried out in centers with comprehensive, multidisciplinary childhood obesity prevention/management programs.
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Future Goals• Improve health care quality, utilization
and outcomes
• Statewide Trauma System – optimal trauma care and injury prevention programs
• Perinatal Statewide Network
• Health Maintenance Programs
• Electronic records and tracking system for outreach and outcomes studies. Telemedicine and informatics.
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Programs
• Chronic disease management programs
–Children with Special Health Care Needs
–Coalition for Childhood Obesity
–Childhood Type 2 Diabetes Studies
–Statewide Asthma Coalition
–Childhood Cancer
• Need more adequate funding specifically for children to integrate new information, technology, treatment and education into the health care package for children
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Medicaid Funding
• Three top expenditures: nursing homes(25%), pharmacy and hospital care
• Indiana has a significant overcapacity of nursing home beds. With a cost based reimbursement scheme – paying for empty beds instead of needed services. Medicaid covers 2 out of 3 nursing home beds in the state.
• Children represent 64.3 % of the recipients but only receive 22% of the Medicaid funding
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Medicaid funding
• Estimated projected expenses $4.3 billion in 2004 and $4.75 billion in 2005. But MK frozen at the 2003 rate despite adding more recipients (mainly adults).
• Disproportionate share also reduced by $19 million in 2003.
• As the population ages their expenditures will threaten other areas of the program i.e. the children.
• The system needs to change – our children represent our future. We need to improve their care.
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About change
• Adversity often opens new windows of opportunity to improve upon the past.
• Failure to adapt appropriately to change may lead to extinction.
• We must embrace change with open arms but never change our values.
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Response to change
“ Change is the law of life, and those who look only to the past or the present are certain to miss the future”
John F. Kennedy