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The costs of children with sickle cell anemia: preparing for managed care
J H Bilenker1, W E Weller, T J Shaffer
1School of Medicine, Johns Hopkins University, Baltimore, Maryland 21205, USA.
Insights
Children with sickle cell anemia (SCA) incur significantly higher healthcare costs. Without adequate capitation rates, the quality of care for these children may be compromised.
Area of Science:
- Pediatric Health Economics
- Chronic Illness Management
- Managed Care Policy
Background:
- Children with chronic illnesses, like sickle cell anemia (SCA), present unique challenges in managed care.
- Capitation models may not adequately account for the high costs associated with complex pediatric conditions.
Purpose of the Study:
- To identify clinical and financial risks for healthcare providers managing children with SCA under capitation.
- To analyze expenditure patterns for children with SCA to inform managed care strategies.
Main Methods:
- Cross-sectional analysis of claims data from Washington State Medicaid and Federal Employees Health Benefits Program.
- Comparison of expenditure patterns for children with SCA versus the general pediatric population.
Main Results:
- Children with SCA had 8.8 times higher mean expenditures than all children.
- Expenditures for SCA patients were highly variable, with 10% accounting for 56% of costs.
- Inpatient care dominated expenditures (72%), followed by outpatient care and physician payments.
Conclusions:
- Inadequate capitation rates risk compromising access and quality of care for children with SCA.
- Newborn screening, specialty access, and education programs are vulnerable to cuts under capitation.
- Managed care organizations need adjusted payment rates to cover higher costs for pediatric chronic illnesses.
Purpose:
To anticipate the clinical challenges and financial risks facing physicians and managed care organizations who care for children with chronic illnesses, such as sickle cell anemia (SCA), under capitated managed care arrangements.
Patients And Methods:
A cross-sectional study based on claims data from the Washington State Medicaid Program (WSMP) and the Federal Employees Health Benefits Program (FEP). Expenditure patterns were compared for children 18 years of age or younger for whom a claim with a diagnosis of SCA was submitted and paid in the State of Washington during fiscal year 1993 (FY1993) or by the FEP during FY1992 to expenditure patterns for all children.
Results:
Children with SCA had mean expenditures 8.8 times the mean expenditures for all children in WSMP. There was wide variation in the annual expenditures among children with SCA; the most expensive 10% of children accounted for 56% of total expenditures. Ninety-seven percent of the expenditures were concentrated in four broad categories: 72% for inpatient care, 11% for outpatient care, 11% for physician payments, and 3% for prescription drugs. Examination of expenditure and utilization patterns for children with sickle cell anemia enrolled in the FEP yielded similar results.
Conclusions:
Unless managed care organizations and capitated pediatricians receive payment rates that reflect the higher expected expenditures of caring for these children, access to and quality of care may suffer. Analyses of practice guidelines and utilization patterns suggest that newborn screening, regular access to specialty facilities, and comprehensive education programs are critical areas that are vulnerable to reductions under capitation.