What’s behind an increase in closures of pediatric units

This week, the New York Times reported a nationwide wave of hospitals shutting down their pediatric units. Though the pandemic, loss of staff and more profitable adult patients are a few key factors, the problem has been decades in the making. Dr. Scott Krugman, vice chair of the Department of Pediatrics at Herman and Walter Samuelson Children's Hospital, joins Geoff Bennett to discuss.

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  • Geoff Bennett:

    We're going to shift our focus now to another crisis of care, this one involving children brought to our attention by reporting this past week by the New York Times, a nationwide wave of hospitals closing the doors of their pediatric units. The COVID-19 pandemic loss of staff and more profitable adult patients are just a few of the key factors. But this problem is decades in the making, from 2008 to 2018, there was a 20% decline in the number of hospitals with inpatient pediatric care units, leaving many families to travel far to find care for their children.

    Joining us now to talk about this is Dr. Scott Krugman. He's Vice Chair of the Department of Pediatrics at Herman and Walter Samuelson Children's Hospital at Sinai Hospital in Baltimore. And he's also Professor of Pediatrics at Georgetown University School of Medicine. Thanks for being with us.

    Scott Krugman, Herman & Walter Samuelson Children's Hospital: Thank you for having me.

  • Geoff Bennett:

    So, what exactly is driving the pediatric unit closures at hospitals across the country, and just how widespread of an issue is this?

  • Scott Krugman:

    So, you mentioned a lot of the key drivers and really the biggest one really is money, our healthcare system, unfortunately, is set up for profit. And most hospitals try to make enough money to keep investing and survive. So, hospitals are prioritizing things that make money which is adult services, like surgeries, and oncology, and orthopedics. And that shuts out the low yield specialties like pediatrics. And when you have something that costs a lot, and there's low volume, there's very little incentive to keep it going.

  • Geoff Bennett:

    Why is it so critical to have doctors trained in pediatric care, and not just have experienced generalists who can also provide care for children?

  • Scott Krugman:

    So, a lot of us who go into pediatrics job because we really like taking care of kids and not adults, and people who go into adult medicine like to go take care of adults and not kids, and they really are very different physiologies, different disease conditions. And we've demonstrated over the years that when kids are taken care of by nurses and doctors and staff trained to be pediatric friendly, and pediatric skilled, they do a much better job. And while the General Hospital with adult providers and emergency room or family physicians can do a good job to stabilize kids, those with really significant illnesses and chronic conditions, often need pediatric specialists. And we train three to six years sometimes more to be able to do these things.

  • Geoff Bennett:

    What have you seen in your own experience? I mean, how does the loss of pediatric beds and hospitals affect children and their families directly?

  • Scott Krugman:

    So, the biggest thing we're seeing across the country is kids having to wait or travel long distances to get definitive care. And by definitive care means you show up to a place and you have a condition that gets treated and the child gets discharged and is better. And what's happening now is, in rural areas, they have to travel very long distances to children's hospitals. And even in urban areas, and states like Massachusetts and Maryland, many community in hospitals in the suburbs have shut down. So even if a child shows up, not that far from the Children's Hospital, they still might have significant wait times and have to sit in, in general ER, for hours and hours waiting for transport to that Children's Hospital. And that delay and care has risk, it has a potential of the child getting worse, or maybe a potential outcome like they didn't make it when they should have.

  • Geoff Bennett:

    So why doesn't that factor into the decision making of these hospitals when they decide to close these pediatric units?

  • Scott Krugman:

    Well, it does for some, and you got to give a lot of hospitals credit that they keep their pediatric units open, despite losing money. And despite the challenges of finding staff and keeping staff trained, and many hospitals still do that across this country. But more and more hospitals are looking around the area and saying, you know what, it's only 10 miles to the Children's Hospital. Why are we bothering do this? It's too hard. It's costing too much money. So, every hospital makes their own decision.

  • Geoff Bennett:

    What does the solution look like that?

  • Scott Krugman:

    So, I think there's a couple things that we need to look at as a country. One is how are we paying for medical care for kids in general. So, we have Medicare, which is a safety net program for adults over 65. And that sort of sets the floor for payment. So, if you're a hospital taking care of adults, you at least know you're getting Medicare rates. And usually when you have adults with other types of insurance, they're actually getting more than Medicare rates.

    The floor for kids is actually Medicaid. And Medicaid pays much less than Medicare. Sometimes it's like 70% on the dollar, so 70 cents for each dollar. And that's just not covering the costs. And that doesn't cover the cost of kids who don't even have insurance and it doesn't cover the cost of what it takes to have a fully trained staff and 24/7 pediatricians and child life and all the other ancillary services you need to take for kids. So, we really need to have a system that prioritizes care for kids. And sets up what is done in rural hospitals like a guaranteed payment. If you take care of kids, you will be paid as a hospital and be kept total so that we can keep these places open and have the people needed to do what needs to be done.

  • Geoff Bennett:

    Dr Scott Krugman, thanks so much for your insights and for your time, I appreciate it.

  • Scott Krugman:

    Thank you for having me.

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