Population-Based Payment Models Can Streamline Care And Reduce Inequities For Children With Medical Complexity

Paige Bhansali, Adam Boehler, Alison Curfman, Health Affairs Forefront, October 12, 2022. DOI: 10.1377/forefront.20221011.793673

Children with medical complexity (CMC) represent a small but growing population and a disproportionate amount of pediatric health care costs. While exact definitions of CMC continue to evolve, prior studies estimate CMC to represent fewer than 1 percent of children and more than 30 percent of pediatric health care costs. Broadly, CMC have at least one complex chronic condition; severe functional limitations, often requiring technology dependence; increased health care service needs; and increased health care costs. The prevalence of CMC continues to grow as life-saving advances in medical technology have enabled the survival of many with childhood-onset diseases.

Unfortunately, the health care system and supporting policy infrastructure have not kept pace with the needs of CMC and their families. CMC experience fragmented, uncoordinated, or unavailable outpatient health care; inadequate home health services; high admission and readmission rates; and large health care costs. As a result, families experience high out-of-pocket expenses, higher rates of employment instability, financial issues, dissatisfaction, and stress. Prior work has suggested that the presence of pediatric medical complexity itself is a primary determinant of health care inequity.

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