ASSESSING HEALTH CARE USE, COSTS, AND QUALITY FOR CENTERS OF EXCELLENCE FOR PEDIATRIC CONGENITAL HEART DISEASE CARE FOR THE MILITARY BENEFICIARY POPULATION

Abstract

Background: For the military beneficiary population with cardiac or congenital anomalies, the Fiscal Year 2019 health care costs were $83 million, including $55 million for newborns who were less than one year of age and $28 million for youth ages 1 to 17 (Kennell and Associates Inc., 2020). The 2019 Military Health System (MHS) costs were approximately $50 billion (Mendez, 2019) and are expected to increase significantly through 2028 (Congressional Budget Office, 2014). In an attempt to close the gap between cost and benefit for its 9.6 million beneficiaries, the MHS has considered targeted inclusion of Centers of Excellence (CoE) for purchased care within TRICARE insurance coverage and MHS policies. In general, a CoE produces consistent outstanding measurable outcomes for a specific medical condition. A Congenital Heart Defect (CHD) is the presence of abnormalities in the heart structure that develop in the uterus during pregnancy. CHDs are the most common types of birth defects and the principal cause of illness and death for birth defect conditions. CHDs are associated with comorbidities and repeat surgical interventions resulting in significant use of health care services during infancy, childhood, and adulthood, making CHDs a great candidate for CoE use.Objective: To compare health care use, costs, and quality of care for pediatric CHD care at CoEs and non-CoEs for the military beneficiary population. Data Sources: Retrospective claims data from the MHS Data Repository for MHS beneficiaries aged 0 to 17 years who received CHD care from 2016 to 2020. Study Design: Using an instrumental variable approach to estimate the impact of CoE use on clinical outcomes (annual admissions, annual emergency room use, and mortality) and health care costs (total costs and hospitalization costs) for pediatric CHD care within the military beneficiary population. Results: A total of 10,865 patients were included, of which 82.9% used a CoE at some point for CHD care. Results suggested that racial disparities in CoE use were not significant for CHD care for the military beneficiary population. There were disparities noted in CoE use by military rank, suggesting that Senior Enlisted and Other ranks were associated with lower odds of CoE use than Junior Enlisted ranks. Results of the IV approach proved that the causal effect of CoE use was a lower probability (-14.1) of emergency room use post one-year CHD diagnosis for the military beneficiary population (p<0.01). The causal effect of CoE use on annual admissions and mortality was insignificant at the .05 significance level but proved that CoE use did not increase annual admissions nor jeopardize patients’ survival post one-year CHD diagnosis for the military beneficiary population. The causal effect of CoE use on CHD related annual costs was a $40,898 decrease in annual costs (p=.059). Although the relationship was not significant at the .05 level, the magnitude of the reduction was approximately 53% of the mean annual cost. When stratified by complexity of CHD diagnosis, the causal effect of CoE use on CHD related annual costs was a statistically significant reduction of $84,852 in annual costs post one-year CHD diagnosis for patients diagnosed with a moderate-complex or single ventricle CHD diagnosis, equating to an approximate 76% reduction in mean annual costs. The causal effect of CoE use on CHD related hospitalization costs was a $33,170 decrease in hospitalization costs (p=.087). Although the relationship was not significant at the .05 level, the magnitude of the reduction was approximately 47% of the mean hospitalization costs. When stratified by CHD diagnosis complexity, the causal effect of CoE use on CHD related hospitalization costs was a statistically significant reduction of $73,084 in hospitalization costs post one-year CHD diagnosis for patients diagnosed with a moderate-complex or single ventricle CHD, equating to an approximate 76% reduction in the mean admission costs. Conclusions: Patients with more severe CHD diagnoses were more likely to use CoEs. After adjusting for selection bias due to disease severity, CoE use improved clinical outcomes, reduced health care resource utilization, and reduced costs for CHD care for the military beneficiary population.