Utilization and costs for children who have special health care needs and are enrolled in a hospital-based comprehensive primary care clinic.

OBJECTIVE: When deciding how much hospital resources should be allocated to comprehensive primary care clinics for children with multisystem disorders, it is important to consider all of the non-primary care revenue streams associated with these children as well as the effects of a comprehensive primary care program on access and quality. The objectives of this study were, first, to determine costs as well as the payments associated with hospital ambulatory and inpatient services for children with multisystem disorders followed by a comprehensive primary care clinic; and, second, to determine the effect of enrollment in a hospital-based comprehensive primary care clinic on ambulatory and inpatient utilization patterns and expenditures for children with multisystem disorders.

METHODS: The study population for the payment analysis consisted of 1012 children of all ages who were seen in the Special Primary Care Clinic (SPCC) in 2001. For these children, outcomes included direct costs, total (direct plus allocated overhead) costs, and payments per patient per 365 days after their first SPCC visit in 2001. A total of 175 of these patients were 4 years of age or older and had no SPCC visit before their first visit in 2001. We compared utilization and expenditures for the 175 children during the year before enrollment in SPCC with those in the year after enrollment. The Children's Hospital administrative database was used to document direct costs, total costs, and payments by type of service for 365 days after an index visit. Ambulatory services included medical and surgical ambulatory, inpatient, emergency department (ED), and ancillary services. We determined the proportion of children who had visits; the visit rates per 100 child-years; and the average total and direct costs per visit, per child with a visit, and per child-year. Inpatient services data included non-intensive care and intensive care hospitalization rates per 100 child-years; the proportion of children hospitalized; their average length of stay; and the average total and direct costs per hospitalization, per patient hospitalized, and per child-year of total patients in the cohort.

RESULTS: For 1012 children who were seen in SPCC in 2001, the hospital overall loss per child-year was $956. The loss per child-year for outpatient services was $1554. This loss was partially offset by a gain from inpatient services of $598. For the 175 patients for whom data were available to compare costs before and after enrollment in the SPCC, there were no significant differences in hospitalization or in direct costs per patient for patients who were hospitalized. The average length of non-intensive care stay was lower after enrollment (4.8 vs 11.7). In the surgical specialty analysis, children were more likely to see a surgeon after enrollment (41% vs 21%) and had a higher rate of visits per 100 child-years (102.3 vs 51.4). Differences in medical subspecialty, ancillary, and ED services did not achieve statistical significance.

CONCLUSION: This study suggests that children with multisystem disorders are medically fragile and require frequent hospitalizations and ED visits even with improved primary care. Enrollment in a comprehensive primary care program was associated with a decreased length of stay for non-intensive care hospitalizations and with increased use of surgical services.