Costs and Use for Children With Medical Complexity in a Care Management Program

Pediatrics. 2020 Apr;145(4):e20192401. doi: 10.1542/peds.2019-2401.


Background and objectives: Children with medical complexity (CMC) comprise only 6% of the pediatric population, account for ∼40% of pediatric health care spending, and provide an important opportunity for cost saving. Savings in this group can have an important impact on pediatric health care costs. The objective of this study was to assess the impact of a multicenter care management program on spending and use in CMC.

Design and methods: We conducted a prospective cohort analysis of a population of 4530 CMC enrolled in a learning collaborative designed to improve care for CMC ages 0 to 21 years identified using 3M Clinical Risk Group categories 5b through 9. The primary outcome was total per-member per-year standardized spending; secondary outcomes included inpatient and emergency department (ED) spending and use. We used a 1:1 propensity score match to compare enrolled patients to eligible nonenrolled patients and statistical process control methods to analyze spending and usage rates.

Results: Comparison with the matched group showed a 4.6% (95% confidence interval [CI]: 1.9%-7.3%) decrease in total per-member per-year spending (P < .001), a 7.7% (95% CI: 1.2%-13.5%) decrease in inpatient spending (P = .04), and an 11.6% (95% CI: 3.9%-18.4%) decrease in ED spending (P = .04). Statistical process control analysis showed a decrease in hospitalization rate and ED visits.

Conclusions: CMC enrolled in a learning collaborative showed significant decreases in total spending and a significant decrease in the number of hospitalizations and ED visits. Additional research is needed to determine more specific causal factors for the results and if these results are sustainable over time and replicable in other settings.

Publication types

  • Comparative Study
  • Multicenter Study
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adolescent
  • Child
  • Child, Preschool
  • Cost Savings
  • Emergency Service, Hospital / economics*
  • Female
  • Follow-Up Studies
  • Health Care Costs / statistics & numerical data*
  • Health Expenditures
  • Hospitalization / economics*
  • Humans
  • Infant
  • Infant, Newborn
  • Male
  • Managed Care Programs / economics*
  • Primary Health Care / economics*
  • Prospective Studies
  • Young Adult