On March 13, 2020, the president of the United States declared a national emergency in response to the coronavirus disease 2019 (COVID-19) pandemic.(1) Since the start of the COVID-19 pandemic, over 380,000 children have tested positive, representing approximately 9.1% of the population in the U.S.(2) The overall rate of positive pediatric cases is 501/100,000.(3)
The incidence of severe illness due to COVID-19 in the pediatric population is rare among children; however, the financial effect that COVID-19 has had on pediatric care and moreover, children’s hospitals is critical.(4)
The American Academy of Pediatrics (AAP) advises:
- Children’s hospitals have taken equivalent financial damage as hospitals serving adults due to the COVID-19 response and have not received comparable relief.
- Year to date, 2020 damages have exceeded $5 billion—against only $1.3 billion of Health and Humans Services (HHS) relief provided through August 7, 2020— children’s hospitals project to experience similar levels of revenue losses through at least the end of year.
- Total support to children’s hospitals to date has amounted to less than 1% of what has been provided to all U.S. hospitals.
- Protecting children’s health care requires supporting children’s hospitals and avoiding policy changes destabilizing the pediatric health care infrastructure.(5)
In addition to the risk of routine well child care not being maintained during the pandemic, the risk for COVID-19 among chronically medically complex children is unclear but presumed to be higher than among children without medical complexity.(6) Typically, these children have multiple chronic conditions, functional limitations, medical technology dependence and a complex network of service providers and caregivers critical to maintain day-to-day health.(7) As primary and specialty health care access is reduced, guidance for home health and medical equipment agencies is needed on in-home practices, including conserving personal protective equipment and expanding the home health workforce with pediatric expertise.(8) The Centers for Disease Control (CDC) addresses these issues at Information for Pediatric Healthcare Providers.(9)
Telehealth reimbursable services are essential to preserve access to tertiary care center–based multispecialty medical care. Similar to caregivers of other at-risk child groups, chronically medically complex children caregivers will need support as their usual care networks shrink because of social distancing and/or COVID-19 illness.(10) The AAP follows the Federation of State Medical Boards waivers of in state licensure telehealth requirements during COVID-19.(11)
The AAP has also developed specific clinical guidance for pediatric care during the COVID-19 pandemic:
Interim Guidance Disclaimer: The COVID-19 clinical interim guidance provided here has been updated based on current evidence and information available at the time of publishing. Guidance will be regularly reviewed with regards to the evolving nature of the pandemic and emerging evidence. All interim guidance will be presumed to expire in December 2020 unless otherwise specified.
- Family Presence Policies for Pediatric Inpatient Settings During the COVID-19 Pandemic: Guidance on family presence policies developed to support family-centered care for all children and particularly for children with special health care needs, including those with disabilities, medical complexity, and serious illness. (8/7/2020)
- Breastfeeding Guidance Post Hospital Discharge for Mothers or Infants with Suspected or Confirmed SARS-Co V-2 Infection: Guidance developed to support pediatricians providing direct care for breastfeeding families after discharge from the newborn hospital stay. Post-discharge guidance and education are essential to support families, ensure the health of mothers and infants, and ensure mothers are able to reach their breastfeeding goals. (Updated 7/29/2020)
- Guidance for Children and Families Involved with the Child Welfare System During the COVID-19 Pandemic: guidance for pediatricians and others who care for children in the child welfare system that affirms that a stable home and caregiver are important to nurturing a child’s development and preventing trauma that can affect a child across the lifespan. (7/27/2020)
- COVID-19 Interim Guidance: Return to Sports: New guidance for pediatricians to inform families on how to mitigate risk and prevent the spread of SARS-CoV-2 to others both within sport and within families and the community. (7/22/2020)
- Newborn Care: Guidance for the care of infants whose mothers have suspected or confirmed COVID-19: Includes precautions for birth attendants, rooming-in, breastfeeding, testing, neonatal intensive care, visitation and hospital discharge. (Updated 7/22/2020)
- Newborn Screening During the COVID-19 Pandemic: Guidance recommending that pediatricians continue to follow federal and state guidelines on newborn bloodspot screening, newborn hearing screening, and critical congenital heart disease screening. (7/16/2020)
- Multisystem Inflammatory Syndrome in Children (MIS-C) Interim Guidance: Clinical guidance for pediatricians including signs, symptoms, diagnosis and management of this rare but serious complication associated with COVID-19. (7/13/2020)
- Responding to the Needs of Youth Involved With the Justice System During the COVID-19 Pandemic: Guidance for juvenile justice agencies to address the unique challenges to the health and well-being of youth involved with the justice system. As federal, state and local governments work to respond to the COVID-19 pandemic, actions must be taken to protect the health and well-being of vulnerable youth and promote resilience in justice-involved youth. (7/6/2020)
- Child Care During COVID-19: Guidance for early education and child care programs that are operating during the COVID-19 pandemic. (6/29/2020)
Return to School Considerations: AAP guidance developed in support of collaborative decision-making among school districts and local and state public health departments about when it is safe to open schools. (6/25/2020)
- Guidance for Families and Pediatricians on Camp Attendance During the COVID-19 Pandemic: guidance for pediatricians and families as they make informed decisions on sending children to overnight/sleep away or day camp this summer. (6/5/2020)
- Guidance on Providing Pediatric Well-Care During COVID-19: Guidance on the continued provision of health care, specifically well-child care and timely immunizations, for newborns, infants, children and adolescents during the COVID-19 pandemic. (5/8/2020)
- Guidance on the Necessary Use of Telehealth During the COVID-19 Pandemic: Guidance on the use of telehealth to provide appropriate elements of health supervision visits or acute and chronic care visits by pediatricians, pediatric medical subspecialists and pediatric surgical specialists. (5/8/2020)(12)
Risk, Quality and Safety Considerations
Though there are challenges providing care at children’s hospitals during a pandemic, there are opportunities to maintain and further promote quality and safety while managing risk. The West Virginia University (WVU) Medicine Children’s Hospital approached the pandemic as an opportunity to advance their high-reliability agenda.(13)
WVU moved forward with the following initiatives:
Increased the use of telemedicine
due to pandemic increased the goal of telemedicine expansion to a proportion of total visits to 178%.
Daily safety huddle
this was part of a planned roll out but initiated during the pandemic which resulted in improved and more frequent communication and resolution of issues.
long a part of increasing visibility and approachability, this format was instrumental in staff believing that leadership truly cares and is now is an excepted way for staff and clinicians to voice concerns and questions.
a daily support group as well as newsletter informing employees of what the issues and concerns are, but also to provide an interruption to daily stress and offer reassurance.
quality projects that pre-pandemic would have taken months to activate were fast tracked to see the effectiveness of new initiatives that were pandemic specific.
Spread the work
the system worked together to develop opportunities to learn from and expand pandemic practices throughout the system via virtual learning sessions. (14)
WVU feels strongly that they have addressed the six domains of quality health care as defined by the Institute of Medicine by pushing this agenda, specifically in the face of COVID-19.(15) These domains are:
- Safe: Avoiding harm that originates from care that is meant to help patients.
- Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing those services to patients not likely to benefit (avoiding underuse and misuse, respectively).
- Patient-centered: Providing care that is responsive to and respectful of individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.
- Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care.
- Efficient: Avoiding waste including waste of equipment, supplies, ideas and energy.
- Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status.(16)
Currently, there is a bipartisan effort to appeal to Health and Human Services (HHS) to allocate more money to children’s hospitals so that they can continue to serve this most vulnerable population during and post the COVID-19 pandemic.(17)
The foremost concern regarding COVID-19 and healthcare professional liability (HPL) insurance often focuses on the attachment of exclusions related to COVID-19, communicable disease, and/or pandemics. To date exclusions such as these, have not been widely utilized regarding pediatrics, but may be more specifically encountered in individual circumstances. Other HPL policy language in consideration should include mold exclusions, and batch clauses. Similarly, these terms have not been widely amended for pediatrics, but are still under scrutiny by professional liability carriers as they assess the impact of the 2020’s pandemic on their loss portfolios. In addition to policy terms, pricing has become a significant insurance consideration, as the market continues to harden, and capacity shrinks further. The withdrawal of two HPL carriers in Q3 of 2020 will compound capacity challenges throughout 2020 and into 2021. Increased pricing and retentions will further stress the financial picture for pediatric facilities.
While children have not experienced the physical repercussions from COVID-19 at the same rate that adults have, children have experienced interruption in both routine and chronic care as a result of the pandemic. Children’s hospitals have also suffered financially, and care needs to be taken to avoid damaging pediatric care in general. The AAP has come forward with specific guidelines to help with the care of children during the pandemic, the use of telemedicine has broadened, and organizations are coming up with creative ways to mitigate risk and practice safe, quality care during these difficult times. Keeping abreast of market changes and knowing what policy changes have been made or may occur is an important part of successfully navigating through these challenging and uncertain times for children’s hospitals, pediatric and healthcare in general.
Authors: Doris Fischer-Sanchez is a Senior Clinical and Enterprise Risk Management Consultant at Willis Towers Watson. Maryann McGivney is a Healthcare Industry Practice Leader at Willis Towers Watson.
(1) Advocacy Efforts for Children’s Hospitals’ COVID-19 Relief Funding. Accessed at: https://www.childrenshospitals.org/Issues-and-Advocacy/Medicaid/Talking-9Points/COVID19-Relief-Talking-Points
(2) Adams S, Nicholas D, Mahant S, et al. Care maps for children with medical complexity. Dev Med Child Neurol. 2017;59(12):1299–1306. https://doi.org/10.1111/dmcn.13576
(5) Advocacy Efforts for Children’s Hospitals’ COVID-19 Relief Funding. Accessed at: https://www.childrenshospitals.org/Issues-and-Advocacy/Medicaid/Talking-Points/COVID19-Relief-Talking-Points
(6) Adams S, Nicholas D, Mahant S, et al. Care maps for children with medical complexity. Dev Med Child Neurol. 2017;59(12):1299–1306. https://doi.org/10.1111/dmcn.13576
(8) Foster CC, Agrawal RK, Davis MM. Home health care for children with medical complexity: workforce gaps, policy, and future directions. Health Aff (Millwood). 2019;38(6):987–993. https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2018.05531
(10) Charlene A. Wong, David Ming, Gary Maslow, Elizabeth J. Gifford Mitigating the Impacts of the COVID-19 Pandemic Response on At-Risk Children. Pediatrics July, 2020, 146 (1) e20200973; DOI: 10.1542/peds.2020-0973
(11) Accessed at: https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf
(12) Accessed at: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/
(13) Brant, R.(2020). Growing a Safety Culture During the COVID-19 Pandemic. Accessed at: https://www.childrenshospitals.org/Newsroom/Childrens-Hospitals-Today/Articles/2020/07/Growing-A-Safety-Culture-During-the-COVID-19-Pandemic
(15) Six Domains of Health Care Quality. Accessed at: https://www.ahrq.gov/talkingquality/measures/six-domains.html
(16) Agency for Healthcare Research & Quality. The Six Domains of Health Care Quality. Accessed at: https://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/create/sixdomains.html
(17) Federal Lawmakers Advocate for Children’s’ Hospitals COVID-19 Needs (July, 2020). https://www.childrenshospitals.org/Issues-and-Advocacy/Medicaid/Letters-and-Testimony/2020/COVID19-funding-for-childrens-hospitals-support-letters
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