Tufts isn’t the only hospital to shift focus away from children’s care. Across the nation, pediatric units are being shuttered in favor of more lucrative units for adult care. Hospitals like Tufts are quick to point out the need for more beds for critically ill adults but fail to mention that this also improves their profit margins. The impacts of this switch are compounded by the surge in respiratory viruses which has caused the remaining children’s beds to fill up quickly. While increased adult beds may meet the COVID-centric moment we’re still in, the closing of children’s units and hospitals across the nation will have wide-ranging, long-term impacts that we will have to reckon with over the coming years.

Why hospital beds for kids are less lucrative

Many hospitals, especially those that are smaller and in rural areas, are struggling financially. When budgets get tight, we see more profitable specialties like oncology and surgery prioritized, while less lucrative specialties like obstetrics and pediatrics are cut. Access to maternal health care, for example, has dropped precipitously due to cuts and has resulted in larger swaths of the country being classified as “maternity care deserts.”

Why is pediatrics a drain on hospital finances? One reason is reimbursement. Medicaid, the state-run health insurance program for low-income patients, covers more than ⅓ of children in the US, and Medicaid reimbursement rates are typically lower than those from other insurers.

But even kids covered under commercial insurance are often less profitable than adults because they have little need for elective surgeries. Elective procedures like joint replacements or heart surgeries, which are profitable for hospitals, are much more common among older adults. Low-value imaging tests are also less common for kids because pediatricians often try to avoid unnecessary radiation — that’s less money for the hospital too. 

The consequences of underinvesting in pediatric care

When no kids’ hospital beds are available, parents may be guided to bring their children to the emergency room instead. This increases the patient flow through already-overcrowded emergency departments, slowing down the rate of care and increasing the burden on staff as the unit becomes progressively more overcrowded. Alternatively, parents can go to the next closest pediatric hospital. In a metropolitan area like Boston, there is still Boston Children’s Hospital and, if necessary, Hasbro Children’s Hospital in Providence. But in rural areas like northeast Oklahoma, choices are limited. And if it takes hours to reach the nearest pediatric specialist with access to the necessary equipment, what are parents to do in an emergency?

Consider the long-term impacts of pediatric unit closures on children with chronic conditions. According to the New York Times, patients in Oklahoma are forced to drive to Memphis, St. Louis, and Rochester just to get their kids the care they need. Hours of travel time, thousands of dollars spent on gas and housing, and the stress of making regular appointments can be too much for patients and lead them to ration or abstain from care altogether. Postponing care can obviously exacerbate sick children’s health problems, but without support for travel, many families have no choice. This can have obvious and immediate consequences, but what other choice do families have? 

We’re headed in the wrong direction. The fact that hospitals feel forced to close down crucial units is indicative of the broken system in which we’re operating. Children are supposedly the most prized population among us, they’re supposed to be protected and cared for all the way through their development. What does it say about our true priorities if even the youngest, most vulnerable members of society are deprioritized for financial reasons? If children are the future, our health system needs to treat them like they matter.

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The study’s findings were reassuring to those who advocate for expanding newborn genetic sequencing. However, just because sequencing has not been shown to cause psychosocial harms doesn’t mean it is worth pursuing. The potential harms and benefits of sequencing the genome of every infant has to be examined much more closely, to find out whether this medical service should be expanded.

The promise of genetic sequencing

The history of genetic sequencing has been one of promises and disappointment. At the turn of the 21st century, former director of the genome agency at the National Institutes of Health Francis Collins predicted a “complete transformation in therapeutic medicine” in the next decades, led by genetic sequencing of diseases and treatments. Twenty years later, this “genetic revolution” has not come to pass, and in fact, life expectancy has been on the decline.

Why has it been harder than expected to harness the power of genetic sequencing? In perspective piece in the Journal of Clinical Investigation, Dr. Michael Joyner at the Mayo Clinic and Dr. Nigel Paneth at Michigan State University explained some of the obstacles.

“Extensive analyses of thousands of potential gene-health outcomes often fail to match, let alone exceed, the predictive power of a few simply acquired and readily measured characteristics such as family history, neighborhood, socioeconomic circumstances, or even measurements made with nothing more than a tape measure and a bathroom scale.”

This is because few health conditions are connected to just one gene variant, making them difficult to assess disease risk using genetic information alone. Common health conditions such as high blood pressure, diabetes, cardiovascular disease, and many cancers, are each “linked to many hundreds of gene variants that individually and even collectively explain only a small fraction of the variance in disease frequency,” they write.

Josephine Johnston, director of research at the Hastings Center, and colleagues provided similar caveats in their 2018 report on newborn genetic sequencing. They have concerns that sequencing will lead to children being labeled as “patients in waiting,” exposing children to unnecessary interventions, monitoring, and stigma. Other experts have pointed out that genetic testing results could make parents overcautious, preventing children from pursuing certain activities. An exaggerated perception of a child’s health risks, known as “vulnerable child syndrome” can lead to “overuse of medical services, possible unnecessary interventions, and poor parenting practices, parent-child attachment, and child development.”

Assessing risk is more difficult than it seems. Even clinicians consistently overestimate the prevalence of medical conditions. How can parents interpret what an elevated risk of certain medical conditions means for their child, or what they are supposed to do about it? What if parents want to make changes for the sake of their child’s health, but they are unable to because of environmental or economic constraints? So much of our health is determined by the social and environmental conditions in the communities in which we grow up, and knowing the results of a genetic test can’t change these conditions.

Where do we put our resources?

Even if newborn genetic sequencing does not lead to psychosocial costs, there is still a significant opportunity cost to making this service widespread. Should we even be investing in genetic sequencing for newborns when are crises in infant and maternal health that need our attention?

Around the same time the JAMA Pediatrics article, I also saw an article in Pediatrics on newborn complications at New York hospitals. Researchers looked at 40 hospitals in the New York City area, and compared the rates of unexpected complications for low-risk births, controlling for patient risk. The rates of complications ranged from 3% in some hospitals to more than 16% in others. Black and Hispanic/Latina women were much more likely to give birth in a hospital with high complication rates, compared to white or Asian American women.

Such a large gap in quality of care for newborns is unacceptable. We need much more resources invested in hospitals that lack the infrastructure or processes to reach the level of quality similar to other hospitals. During the Covid-19 pandemic, the danger of maternal death for Black women has become even more stark. Expanding Medicaid coverage, increasing awareness and programming to reduce bias against Black mothers, reducing unnecessary procedures, and many other policies included in the Black Maternal Health Momnibus Act are necessary to reduce these disparities.

We have to direct our resources to addressing the twin crises of maternal mortality and newborn complications that are so prevalent for women of color, before we turn to genetic sequencing of healthy babies.

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Deimplementation refers to “the process of reducing care that is harmful, ineffective, overused, or not cost-effective.” How do we “de-implement” harmful or unnecessary tests and procedures? The authors identify several forces that have driven reductions in low-value care in the recent past.

One is the decreased prevalence of childhood diseases through vaccination and public health campaigns; as more children are vaccinated, there is less need to test for certain diseases. Another is the rise of evidence-based pediatric care: the development of criteria to evaluate evidence, more funding for rigorous trials, and a growing evidence base around pediatric treatments. With more evidence comes the knowledge that some interventions are not as effective as we thought. And lastly, campaigns to raise awareness about the harms of low-value care have pushed clinicians and specialty groups to stop certain low-value services in pediatrics.

The authors acknowledge that there is still a long way to go toward “deimplementing” low-value services in children’s health. Despite changes in clinical guidelines, “there are many factors at the level of the patient (parental pressures, direct-to-consumer advertising), clinician (fear of missing a diagnosis, malpractice suits), and health care system (fee-for-service reimbursement, short visit times) that continue to drive pediatric overuse,” they write.

What changes do we need? Dr. Wolf says there are four main next steps: Developing benchmarks for low-value care for specific conditions, so that doctors can be evaluated on their progress; measuring the harms of overuse for children; understanding the best ways to stop each type of low-value care; and considering any potential unintended consequences of de-implementation.

This may be more difficult in pediatrics than in other fields, because acknowledging the harms of overuse has been slower in pediatrics, says Wolf. Historically, more attention has gone toward making sure that children receive care they need, like vaccines.

“There has been attention given to some examples of overuse, such as unnecessary treatment of bronchiolitis or antibiotics for upper respiratory infections, but very little attention given to other areas of overuse,” says Wolf.

However, pediatricians also recognize that because most children are healthy or just have an acute illness (rather than chronic conditions), the bar has to be higher to subject them to tests, medications, or other therapies than for adults for whom the prevalence of chronic conditions is much greater. Conducting more research on the potential harms of overuse in children and raising awareness should help pediatricians better understand which medical treatments clear that high bar– and which ones don’t.

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Low-value pediatric care

A recent study in Pediatrics dives into the issue of overuse in pediatrics by estimating the rate at which American children covered by private insurance or public insurance (Medicaid) received a low-value service. The authors measured the prevalence of 20 different low-value services in pediatrics, including vitamin D screening, sinus imaging, cervical cancer screening, overuse of antibiotics and cold medication, and more. 

They found that overall, 10.6% of the children received at least one low-value service in a single year. There was a small difference between the two groups, with 11% of publicly-insured children and 9% of privately-insured children receiving at least one low-value service.

For parents trying to avoid low-value care, Lown Insitute president Vikas Saini suggests asking the doctor questions before a procedure to make sure it’s really necessary. For example, when considering doing a test, ask the doctor what she or he would do differently given the results the test. Sometimes doctors order tests to rule out a diagnosis, but the diagnosis would not change the course of action.

“Asking questions is helpful — and it does, I think, moderate what’s otherwise an automatic tendency,” said Saini in an interview with MarketWatch about the study.

Unnecessary cervical cancer screening in adolescents

Another recent study in JAMA Internal Medicine examined the prevalence of cervical cancer screening in women age 15-20. In their analysis of survey data from the National Survey of Family Growth, they found that 12.5% of young women received a potentially unnecessary bimanual pelvic examination in the past year, and 13.8% received a potentially unnecessary Pap test in the past year. Of all the women who received pelvic exams, a little more than half were unnecessary. Of the Pap tests received, more than 70% were unnecessary.

Women under 21 who don’t have symptoms and aren’t pregnant do not need pelvic exams or pap tests; leading professional organizations do not recommend cervical cancer screening in this population. Yet because of standards of care that are difficult to change, these tests are still prevalent. Historically, gynecologists have performed pelvic exams before prescribing birth control or screening for STIs, although there is no medical reason why this is necessary. 

It is incredibly concerning that one in eight young women receive unnecessary cervical cancer screening, because overscreening often leads to overdiagnosis, anxiety, and unnecessary costs. The bimanual pelvic examination in particular is very intrusive. “Many young women associate the examination with fear, anxiety, embarrassment, discomfort, and pain,” the authors write. While some argue that requiring annual pelvic examinations prompts women to visit their clinician regularly, there is no evidence to support this claim. In fact the opposite is likely true; women may delay a visit to the gynecologist for STI testing or birth control if they are nervous about getting a pelvic exam. 

Pediatric professional groups have known for years that certain tests and procedures are unnecessary and potentially harmful. Yet one in ten children overall and an even greater proportion of women age 15-20 are receiving low-value care. These studies indicate that “we have a lot of educating to do” to get pediatricians and ob-gyns on the same page, says Dr. George Sawaya, professor of obstetrics at the University of California, San Francisco, and author of the cervical cancer screening study. In an NPR interview, Sawaya said that he hopes that the study will “cause physicians to be a little shocked — and then be reflective about their own practice.” 

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A new report from the Dartmouth Institute examined rates of NICU admissions for infants of various birth weights across the country. They found that most very low-weight infants are being admitted to the NICU regardless of geography, but for infants of moderately low birth weight or normal birth weight, there is wide regional variation in NICU admission rates. For example, 1.6% of newborns of normal weight in Richmond, VA were admitted to the NICU, but in El Paso, TX, 8.9% of these infants were admitted. Overall, almost half of all newborns admitted to NICUs in the U.S. are of normal birth weight, the Dartmouth report found. At the same time, nearly 15% of very low birth weight infants are not getting the NICU care they need. 

What’s the problem with infants of moderately low or normal birth weight being placed in the NICU? One would think that intensive care would be safer for all infants. However, the NICU also exposes newborns to the risk of overtreatment and hospital-acquired infection, and can disrupt their sleep and maternal bonding. For very sick infants, the benefits of the NICU outweigh the risks, but it’s not clear that healthier infants benefit from being in the NICU — and they may in fact be harmed by it.

Given the potential risks, why are so many infants being admitted to the NICU unnecessarily? The authors of the Dartmouth report point out that the supply of NICU beds increased by 69% nationwide from 1995-2013, and the number of neonatologists per live births has increased as well. However, this increase in resources does not appear related to the level of need in each region. In 2013, the number of NICU beds per newborn was unrelated to the region’s c-section rate or low-weight birth rate.

Variation in NICU admissions likely has more to do with financial incentives and institutional culture than medical need. NICU services are highly profitable for hospitals, giving hospitals incentives to build and expand their NICUs. Once these units are built, there is even more pressure to keep the NICU beds full, which may lead to healthier infants being placed in the NICU. Doctors may not be aware of the impact of financial incentives, but the abundance of NICU beds (as with the oversupply of other medical services) can lead to patterns of overuse within the institution. In other words, “It’s there, so we might as well use it.”

In a perfect world, all infants would be placed in the hospital newborn unit most appropriate for their health status. Unfortunately, the Dartmouth report reveals that there is significant variation in NICU admissions that appears unrelated to newborn health. While some infants of very low birth weight are not getting the NICU care they need, many other infants of normal birth weight are being placed in the NICU unnecessarily, at an enormous financial cost to the health care system. As other clinicians have pointed out, the financial resources spent on filling NICU beds could be used to help seriously ill infants and their parents after they leave the NICU, services that are crucial but often poorly reimbursed. This research from the Dartmouth Institute provides a first step toward reducing overuse and underuse in newborn care. 

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Is our health care system adequately prepared to treat more behavioral health problems in younger people? So far, the answer is no. Amid the growing need for mental health treatment, mental health care remains inaccessible for many people who need it, particularly low-income people.

Take Massachusetts, for example. Although Massachusetts has more mental health care providers per capita than any other state, only about half accept Medicaid or even private insurance, making it extremely difficult to find affordable care. According to a survey of Massachusetts residents by the Blue Cross Blue Shield of Massachusetts Foundation, more than half of respondents who sought mental health or addiction treatment had difficulty getting care, and 39 percent went without treatment.

“Mental health care has become, in large measure, a private-pay business that operates outside the insurance system,” wrote journalist Liz Kowalzyk in The Boston Globe.

Psychiatrists in particular are less likely to accept insurance, compared to physicians in other specialties, according to a 2014 study in JAMA Psychiatry. Only about 55 percent of psychiatrists accepted private insurance, compared to 89 percent of other doctors, and just 43 percent of psychiatrists accepted Medicaid, compared to 73 percent of other physicians.

However, even when mental health care providers accept insurance, insurers are finding ways not to cover needed services. According to an investigation in Bloomberg News, insurers are skirting around the Mental Health Parity law by “padding their directories” with clinicians who are no longer in network, requesting “piles of paperwork” before approving treatment, and giving smaller reimbursements to mental health clinicians than to other clinicians for the same services. Insurers have been able to get away with this in part because the law is ambiguous in setting parity rules, and because enforcement efforts by government agencies are meager and disjointed.

To put it simply, when it comes to mental health, “we have a lousy system of care,” said Dr. Wun Jung Kim, a child psychiatrist and professor at Rutgers University, in USA Today.

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In the newest edition of the American Family Physician, members of the Right Care Alliance Children’s Health Council Dr. Matthew Schefft, Dr. Alan R. Schroeder, Dr. Diane Liu, Dr. Daniel Nicklas, Dr. Justin Moher, and Dr. Ricardo Quinonez present their final list of top “Do’s and Don’ts” for preventing both overuse and underuse in pediatrics. 

The Right Care Top Ten has been years in the making. In 2016, each of the Right Care Alliance councils began developing a list of 10 evidence-based recommendations for health care value in their specialty. Through a modified Delphi panel process, the Children’s Health council voted for what they considered the most important recommendations, based on how much the recommendation matters for patients, its potential for positive impact, and how well it illustrates broader system failures.

Here are a few highlights from the top ten list:

• Making sure that children with attention-deficit/hyperactivity disorder have access to behavioral therapies such as cognitive behavior therapy, parent training, classroom behavioral management, peer interventions, can help avoid the expense and side effects of medication.
• Providing free, age-appropriate books to parents at the doctor’s office or hospital can help improve childhood literacy, which is linked to better long-term health outcomes. 
• Routine prescribing of antibiotics for children with a middle ear infection provides only a minimal benefit in pain reduction and should be avoided.
• For children with minor head trauma, clinicians should consider that computed tomography (CT) scans may cause more harm than benefit, because it increases radiation exposure. Incidental findings from head CTs can also lead to overdiagnosis and overtreatment.

For the full list of Do’s and Don’ts for Right Care in Children’s Health, see the AFP article here!

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Below are some highlights from this year’s update, from researchers Eric R. Coon, Ricardo A. Quinonez, Daniel J. Morgan, Sanket S. Dhruva, Timmy Ho, Nathan Money, and Alan R. Schroeder. 

• Two meta-analyses found that for children with uncomplicated appendicitis, treatment with antibiotics instead of appendectomy was successful in over 90% of cases. Starting with antibiotics instead of appendectomy could reduce the risks of surgery and anesthesia for patients.
• On the other hand, studies also found cases in which antibiotics are commonly used but not always necessary or beneficial. For children with recurrent urinary tract infections, a research review found that providing antibiotic treatment did not prevent renal scarring compared to a placebo. Another study found that broad-spectrum antibiotics did not have a benefit compared to narrow-spectrum antibiotics when treating respiratory tract infections, and actually led to more adverse events.
• Are there ways we could lessen the potential for harm in infant care? Several studies provided important information on treatment for infants, including the benefits of using a laryngeal mask for anesthesia; providing less invasive treatment for respiratory distress; and the need to further evaluate the benefits of giving high doses of Docosahexaenoic acid (DHA) to preterm infants.
• When childrens’ lives and health are on the line, our instinct may be to take the most aggressive approach. But this may not be better for the patient in the long run. For patients being treated for childhood cancer, a large cohort study found that reducing the intensity of radiation therapy decreased the risk in secondary malignancies without lowering cure rates.

What’s the big takeaway? “This is a generalizable lesson for all pediatricians: efforts should be made to limit medical harms, even among effective, life-saving interventions,” the authors write.

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• Children’s health is traditionally under-resourced. Our health care system spends much more on older adults than on children, so pediatricians are used to fighting for more resources for children’s health. Advocating for less care goes very much against the grain.
• Pediatrics has less available evidence on overused services. The knowledge we have on overused services in adult care took many randomized trials with thousands of participants. These types of large trials are not typically conducted for children’s health, which makes it harder to identify which pediatric services are being overused.
• Children’s health emphasizes prevention. Pediatricians have tried to emphasize the importance of prevention in recent years – including vaccinations, preventing child obesity, and screening for developmental delays. Addressing these problems in childhood has positive effects on health for that child’s whole lifetime, so it makes sense that pediatricians are focusing more on underuse than overuse.

“The problem of unnecessary health care in this country does not simply involve children—it actually starts with them.”

Dr. Shawn Ralston and Dr. Alan Schroeder

And yet, it is imperative that pediatricians recognize the harm of overuse, Ralston and Schroeder write. From unnecessary tonsillectomies, to overprescription of psychotropic drugs, to overdiagnosis of behavioral disorders, overuse in children’s health is prevalent. And, as the authors point out, too many scans or antibiotics in childhood can have negative effects on health later in life. They conclude, “We must acknowledge that the problem of unnecessary health care in this country does not simply involve children—it actually starts with them.”

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