General hospitals increasingly seek specialists for children’s care

If state regulators approve, Yale-New Haven Children’s Hospital will soon take over operation of the pediatrics department at Bridgeport Hospital–the sort of arrangement that could become increasingly common across Connecticut.

The arrangement is the first for Yale, but Connecticut Children’s Medical Center in Hartford has been running the pediatrics unit at St. Mary’s Hospital in Waterbury for two years and, next month, will begin operating the neonatal intensive care unit at UConn’s John Dempsey Hospital. It’s also in discussions with other general hospitals about forming relationships that could include the children’s hospital taking over pediatric beds or providing outpatient subspecialty care.

children's hospital

Connecticut Children’s Medical Center

“We are in conversations with quite a few in the state,” Connecticut Children’s Chief Operating Officer Theresa Hendricksen said. She said confidentiality agreements prevented her from naming them.

The changes in pediatrics in part reflect a larger move toward affiliations between hospitals. But they’re also the result of factors unique to pediatrics.

Some of it is rooted in progress: Many of the illnesses that once put children in the hospital are being prevented through immunization. Others can be managed or treated on an outpatient basis. Only 5 percent of children end up in the hospital in a given year, most before turning 1, said Lawrence McAndrews, president and CEO of the National Association of Children’s Hospitals and Related Institutions. That means it takes a larger population base for a general hospital to run a pediatrics program with enough volume to be economically viable and to keep up the staff’s expertise, he said.

At the same time, the field has become more specialized, and caring for the children that end up in the hospital can require subspecialists that community hospitals don’t have the volume to justify having on staff. Increasingly, surgeons are less comfortable operating on children and are sending them to children’s hospitals, where they can have pediatric anesthesiologists, surgeons and radiologists, Hendricksen said.

“The irony is, you have fewer inpatients but you need more specialists,” said Dr. Leonard Banco, a pediatrician who serves as senior vice president and chief medical officer at Bristol Hospital.

And there’s another challenge: A significant portion of pediatric patients are covered by Medicaid, which tends to pay health care providers less than commercial insurance and Medicare. Hospitals looking to trim costs as they adapt to health reform and other changes could see pediatrics as a place to cut back, experts said.

McAndrews noted that as the population ages, hospitals will have the opportunity to cater to older patients needing more services and higher paying procedures that will get covered by Medicare. Pediatrics, with low patient volume, lower reimbursement and challenges in recruiting specialists, probably wouldn’t win from a business perspective.

“In some ways, I think it’s more likely that the adult systems will drop pediatrics and just a few will offer it,” McAndrews said.

The affiliations between children’s hospitals and general hospitals have taken on different forms. Some general hospitals have outsourced just their neonatal intensive care units or pediatric emergency departments to children’s hospitals, while some have outsourced all their pediatric programs. Nationwide, only about half the general hospitals have pediatric programs, McAndrews said.

Under the plan between Bridgeport and Yale, pediatric services would continue to be offered at Bridgeport Hospital’s P.T. Barnum Pediatric Center. But it would become a campus of Yale-New Haven Children’s Hospital. 

“We’re not eliminating anything,” Bridgeport Hospital President and CEO William Jennings said. “This really is an integration.”

Jennings said the plan–which must be approved by the state Office of Health Care Access–is intended to improve safety and quality by sharing best practices and having a single standard of care. Bridgeport is already part of the Yale-New Haven network.

The memorandum of understanding between the two hospitals alludes to a larger trend, noting that “the parties seek to address a national shift in pediatric hospital care to larger integrated pediatric networks.”

“In the face of decreasing use rates for inpatient facilities, which is the right thing for the kids in all of our communities, it gives us the opportunity to integrate these services and keep them very, very strong,” Jennings said.

Connecticut Children’s was formed in 1996 from Newington Children’s Hospital and the pediatrics departments of Hartford Hospital and John Dempsey Hospital. Hartford and Dempsey hospitals then closed their pediatrics programs. The hospital has multiple types of relationships with other hospitals. In Waterbury, it operates a 12-bed unit at St. Mary’s Hospital as part of an agreement that also includes Waterbury Hospital, which closed its pediatrics program.

In addition, the children’s hospital provides outpatient subspecialists at Danbury Hospital, which has its own inpatient unit. Hendricksen said the arrangement allows children in Western Connecticut to see a pediatric surgeon, hematologist or oncologist without having to travel to Hartford.

“The expertise around pediatrics is becoming more and more centralized, with centers that specialize in the care of children,” Banco said. “So I think it’s going to be logical over time that to the extent that there’s going to be care for kids, it’s going to be woven into a network.”

Banco said hospitals that deliver babies will always need to have people on staff to take care of them. But there is are now a limited number of hospitals in the state that admit a substantial number of children, he said.

Bristol Hospital has pediatric hospitalists who staff the hospital around the clock, and cares for about 150 children a year as inpatients. Those with problems that require one or two nights in the hospital stay there, while those with more complicated conditions are generally taken to Connecticut Children’s, which has an affiliation with Bristol.

McAndrews said the decisions Congress makes about funding Medicaid, part of the larger debate over federal spending, will have a major role in the future of pediatrics programs at general hospitals.

“The children’s hospitals are getting a larger share of the shrinking pie,” he said.